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Jones AV, Manasyan A, Xue Y, Kapesa H, Mwendafilumba K, Nalwamba L, Mzumara M, Mubiana-Mbewe M, Dionne JA. Benzathine penicillin G stockouts and other barriers to documented syphilis treatment in pregnancy in Zambia. PLoS One 2024; 19:e0304576. [PMID: 38829879 PMCID: PMC11146727 DOI: 10.1371/journal.pone.0304576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 05/15/2024] [Indexed: 06/05/2024] Open
Abstract
OBJECTIVE The prevalence of syphilis in Zambia remains high and is a critical public health concern. The Zambian Ministry of Health recommends universal screening and same-day treatment for syphilis in pregnancy, yet the syphilis screening rate is low, and treatment is poorly documented. The goal of this study was to document syphilis treatment rates and associated factors among pregnant women in care in Zambia. METHODS This retrospective cohort study included pregnant women diagnosed with syphilis according to rapid plasma reagin (RPR) screening during routine antenatal care (ANC) in Lusaka, Zambia in 2018-2019. The main outcome of interest was lack of documented BPG treatment during pregnancy. Additional information about pregnancy and neonatal outcomes, partner referral for therapy, and facility level stockout data were included. Patient characteristics were compared by treatment status using Pearson Chi-Square Test and logistic regression models were created to estimate the association between individual level-factors, facility type, and lack of BPG treatment. A Cochran-Mantel-Haenszel test was used to evaluate facility-level data with significance set at p<0.05. RESULTS Among 1,231 pregnant women who screened positive for syphilis at clinic, 643 (52%) lacked documented antibiotic treatment at the facility. BPG was the only antibiotic used to treat syphilis in the cohort and 8% of sex partners had evidence of referral for therapy. Preterm delivery rates were higher in women without documented BPG (43% vs 32%; p = 0.003). In adjusted models, only calendar year and hospital facility type were associated with lack of treatment. At the facility level, annual syphilis screening rates ranged from 37-65% and most (7/10) clinics reported at least one stockout of BPG. CONCLUSION Treatment rates for syphilis in pregnancy in Zambia were low and BPG medication stockouts at the facility level were common. A consistent supply of BPG at all ANC facilities is needed to facilitate timely treatment and improve birth outcomes.
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Affiliation(s)
- Anna V. Jones
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Albert Manasyan
- Department of Pediatrics, University of Alabama at Birmingham, Children’s of Alabama Hospital, Birmingham, Alabama, United States of America
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Yumo Xue
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Herbert Kapesa
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | | | - Maureen Mzumara
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Jodie A. Dionne
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, University of Alabama at Birmingham Hospital, Birmingham, Alabama, United States of America
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, University of Alabama at Birmingham Hospital, Birmingham, Alabama, United States of America
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Zhang M, Zhang H, Hui X, Qu H, Xia J, Xu F, Shi C, He J, Cao Y, Hu M. The cost-effectiveness of syphilis screening in pregnant women: a systematic literature review. Front Public Health 2024; 12:1268653. [PMID: 38577277 PMCID: PMC10993388 DOI: 10.3389/fpubh.2024.1268653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 02/23/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction The cost-effectiveness study of syphilis screening in pregnant women has not been synthesized. This study aimed to synthesize the economic evidence on the cost-effectiveness of syphilis screening in pregnant women that might contribute to making recommendations on the future direction of syphilis screening approaches. Methods We systematically searched MEDLINE, PubMed, and Web of Science databases for relevant studies published before 19 January 2023 and identified the cost-effectiveness analyses for syphilis screening in pregnant women. The methodological design quality was appraised by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist. Results In total, 17 literature met the eligibility criteria for a full review. Of the 17 studies, four evaluated interventions using different screening methods, seven assessed a combination of syphilis testing and treatment interventions, three focused on repeat screening intervention, and four evaluated the interventions that integrated syphilis and HIV testing. The most cost-effective strategy appeared to be rapid syphilis testing with high treatment rates in pregnant women who were positive. Discussion The cost-effectiveness of syphilis screening for pregnancy has been widely demonstrated. It is very essential to improve the compliance with maternal screening and the treatment rates for positive pregnant women while implementing screening.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Mengcai Hu
- Department of Health Care, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Miao P, Terris-Prestholt F, Fairley CK, Tucker JD, Wiseman V, Mayaud P, Zhang Y, Rowley J, Gottlieb S, Korenromp EL, Watts CG, Ong JJ. Ignored and undervalued in public health: a systematic review of health state utility values associated with syphilis infection. Health Qual Life Outcomes 2024; 22:17. [PMID: 38350925 PMCID: PMC10863090 DOI: 10.1186/s12955-024-02234-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/29/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Syphilis is a sexually transmitted infection causing significant global morbidity and mortality. To inform policymaking and economic evaluation studies for syphilis, we summarised utility and disability weights for health states associated with syphilis. METHODS We conducted a systematic review, searching six databases for economic evaluations and primary valuation studies related to syphilis from January 2000 to February 2022. We extracted health state utility values or disability weights, including identification of how these were derived. The study was registered in the international prospective register of systematic reviews (PROSPERO, CRD42021230035). FINDINGS Of 3401 studies screened, 22 economic evaluations, two primary studies providing condition-specific measures, and 13 burden of disease studies were included. Fifteen economic evaluations reported outcomes as disability-adjusted life years (DALYs) and seven reported quality-adjusted life years (QALYs). Fourteen of 15 economic evaluations that used DALYS based their values on the original Global Burden of Disease (GBD) study from 1990 (published in 1996). For the seven QALY-related economic evaluations, the methodology varied between studies, with some studies using assumptions and others creating utility weights or converting them from disability weights. INTERPRETATION We found a limited evidence base for the valuation of health states for syphilis, a lack of transparency for the development of existing health state utility values, and inconsistencies in the application of these values to estimate DALYs and QALYs. Further research is required to expand the evidence base so that policymakers can access accurate and well-informed economic evaluations to allocate resources to address syphilis and implement syphilis programs that are cost-effective.
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Affiliation(s)
- Patrick Miao
- Central Clinical School, Monash University, Melbourne, Australia
- Melbourne Sexual Health Centre, 580 Swanston Street, Carlton, Victoria, 3053, Australia
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- UNAIDS, Geneva, Switzerland
| | - Christopher K Fairley
- Central Clinical School, Monash University, Melbourne, Australia
- Melbourne Sexual Health Centre, Melbourne, Australia
| | - Joseph D Tucker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Philippe Mayaud
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ying Zhang
- Central Clinical School, Monash University, Melbourne, Australia
| | - Jane Rowley
- Global HIV, Hepatitis and Sexual Transmitted Infections Programme, World Health Organization, Geneva, Switzerland
| | - Sami Gottlieb
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Caroline G Watts
- Kirby Institute, University of New South Wales, Sydney, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
| | - Jason J Ong
- Central Clinical School, Monash University, Melbourne, Australia.
- Melbourne Sexual Health Centre, Melbourne, Australia.
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Kiemde F, Compaore A, Koueta F, Some AM, Kabore B, Valia D, Rouamba T, Bocoum FY, Sawadogo S, Nana M, Some DY, Kone NA, Pagbeleguem V, Sangare I, Bere AW, Bonko MDA, Tougri G, Youl SY, Schallig H, Tinto H. Development and evaluation of an electronic algorithm using a combination of a two-step malaria RDT and other rapid diagnostic tools for the management of febrile illness in children under 5 attending outpatient facilities in Burkina Faso. Trials 2022; 23:779. [PMID: 36109766 PMCID: PMC9476427 DOI: 10.1186/s13063-022-06717-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/06/2022] [Indexed: 11/29/2022] Open
Abstract
Background In Sub-Saharan Africa (SSA), febrile illnesses remain a major public health problem in children. However, the persistence of hrp2 antigen and the low sensitivity of pLDH RDT negatively affect antimalarials and antibiotics prescription practices. These limitations lead to poor management of febrile diseases and antimicrobial resistance (AMR). To improve the diagnosis of these febrile diseases and subsequent prescription of antimicrobials, it is hypothesized that the implementation of an algorithm including a two-step malaria RDT PfHRP2/pLDH supported by point-of-care (PoC) tests for bacterial infections could significantly improve the management of febrile diseases and thereby tackling AMR. Methods To assess the value of the proposed algorithm, an open-label randomized controlled trial with three arms, enrolling febrile children from 6 to 59 months is proposed. In the control arm, febrile children will be managed according to the Integrated Management of Childhood Illnesses (IMCI), which is part of the standard of care in Burkina Faso. Treatment will be done according to national guidelines. In the RDT decisional algorithm (RDT-DA) arm (intervention), the clinical examination based on IMIC will be supported by a two-step malaria RDT and bacterial infections RDTs. Prescription will be left to the discretion of the healthcare workers based on clinical examination and PoC test results. In the e-algorithm arm (intervention), artificial intelligence integrating multiple layers of clinical information such as clinical examination, signs/symptoms and medical history, and biological information such as biomarkers (CRP and WBC) and pathogen-specific PoC tests, and oximetry will be developed. The e-algorithm will serve to guide the diagnostic and management of febrile infections in children. In the 3 arms, the case report forms will be digitalized. A final follow-up visit (day 7) will be scheduled for all participants. Patients will be asked to come back to the health facilities before the scheduled visit if the symptoms persist or in case of health condition worsening. Discussion If successful, this study could contribute to improve the management of febrile diseases and reduce inappropriate use of antimicrobials. Trial registration The trial is registered at ClinicalTrial.gov, NCT05285657. Enrolment started on 4 March 2022 with long-term outcome being assessed completely by 2023.
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Angel-Müller E, Grillo-Ardila CF, Amaya-Guio J, Torres-Montañez N. Diagnostic Accuracy of Rapid Point-of-Care Tests for Detecting Active Syphilis: A Systematic Review and Meta-Analysis. Sex Transm Dis 2021; 48:e202-e208. [PMID: 34618785 DOI: 10.1097/olq.0000000000001498] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Syphilis represents an important cause of morbidity and mortality. Point-of-care (POC) test offers the advantages of diagnosing the condition and the possibility of starting treatment immediately. METHODS MEDLINE, Embase, CENTRAL, LILACS, World Health Organization International Clinical Trials Registry Platform, Web of Science, OpenGrey, and DARE were searched without language restrictions from inception to September 30, 2020. Diagnostic test accuracy studies that enrolled men and nonpregnant women of reproductive age under field conditions were analyzed. Only studies wherein all the patients had undergone a rapid POC test and those that included the reference standard (treponemal plus nontreponemal test) were eligible for inclusion. Studies were independently assessed for inclusion, data extraction, and bias risk. The data from these studies were extracted for meta-analyses. The quality of the evidence was assessed using the GRADE approach. Registration Prospero CRD42018107532. RESULTS Nine studies with 9666 participants were included. Nine POC brands were assessed. Sensitivities of the tests ranged from 0.67 to 1.00 and specificities from 0.93 to 1.00. The mean sensitivity and specificity of all the included studies was 0.86 (95% confidence interval, 0.79-0.91) and 0.98 (95% confidence interval, 0.96-0.99), respectively. CONCLUSIONS Based on the results of this systematic review, the POC test for syphilis showed good sensitivity and excellent specificity.
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Affiliation(s)
- Edith Angel-Müller
- From the Department of Obstetrics and Gynecology, School of Medicine, Universidad Nacional de Colombia
| | | | - Jairo Amaya-Guio
- From the Department of Obstetrics and Gynecology, School of Medicine, Universidad Nacional de Colombia
| | - Nicolas Torres-Montañez
- From the Department of Obstetrics and Gynecology, School of Medicine, Universidad Nacional de Colombia
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Batura N, Saweri OP, Vallely A, Pomat W, Homer C, Guy R, Luchters S, Mola G, Vallely LM, Morgan C, Kariwiga G, Wand H, Rogerson S, Tabrizi SN, Whiley DM, Low N, Peeling RW, Siba PM, Riddell M, Laman M, Bolnga J, Robinson LJ, Morewaya J, Badman S, Kelly-Hanku A, Toliman PJ, Peter W, Peach E, Garland S, Kaldor J, Wiseman V. Point-of-care testing and treatment of sexually transmitted and genital infections during pregnancy in Papua New Guinea (WANTAIM trial): protocol for an economic evaluation alongside a cluster-randomised trial. BMJ Open 2021; 11:e046308. [PMID: 34385236 PMCID: PMC8362726 DOI: 10.1136/bmjopen-2020-046308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 07/09/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Left untreated, sexually transmitted and genital infections (henceforth STIs) in pregnancy can lead to serious adverse outcomes for mother and child. Papua New Guinea (PNG) has among the highest prevalence of curable STIs including syphilis, chlamydia, gonorrhoea, trichomoniasis and bacterial vaginosis, and high neonatal mortality rates. Diagnosis and treatment of these STIs in PNG rely on syndromic management. Advances in STI diagnostics through point-of-care (PoC) testing using GeneXpert technology hold promise for resource-constrained countries such as PNG. This paper describes the planned economic evaluation of a cluster-randomised cross-over trial comparing antenatal PoC testing and immediate treatment of curable STIs with standard antenatal care in two provinces in PNG. METHODS AND ANALYSIS Cost-effectiveness of the PoC intervention compared with standard antenatal care will be assessed prospectively over the trial period (2017-2021) from societal and provider perspectives. Incremental cost-effectiveness ratios will be calculated for the primary health outcome, a composite measure of the proportion of either preterm birth and/or low birth weight; for life years saved; for disability-adjusted life years averted; and for non-health benefits (financial risk protection and improved health equity). Scenario analyses will be conducted to identify scale-up options, and budget impact analysis will be undertaken to understand short-term financial impacts of intervention adoption on the national budget. Deterministic and probabilistic sensitivity analysis will be conducted to account for uncertainty in key model inputs. ETHICS AND DISSEMINATION This study has ethical approval from the Institutional Review Board of the PNG Institute of Medical Research; the Medical Research Advisory Committee of the PNG National Department of Health; the Human Research Ethics Committee of the University of New South Wales; and the Research Ethics Committee of the London School of Hygiene and Tropical Medicine. Findings will be disseminated through national stakeholder meetings, conferences, peer-reviewed publications and policy briefs. TRIAL REGISTRATION NUMBER ISRCTN37134032.
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Affiliation(s)
- Neha Batura
- Institute for Global Health, University College London, London, UK
| | - Olga Pm Saweri
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew Vallely
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - William Pomat
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Caroline Homer
- The Burnet Institute, Melbourne, Victoria, Australia
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Rebecca Guy
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Stanley Luchters
- The Burnet Institute, Melbourne, Victoria, Australia
- Department of Public Health and Preventive Medicine, Ghent University, Ghent, Belgium
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
- Department of Epidemiology and Preventive Medicine, Monash University, Monash, Victoria, Australia
| | - Glen Mola
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Lisa M Vallely
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | | | - Grace Kariwiga
- Milne Bay Provincial Health Authority, Alotau, Papua New Guinea
| | - Handan Wand
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Rogerson
- Department of Medicine, The Doherty Institute, University of Melbourne, Melbourne, Victoria, Australia
| | | | - David M Whiley
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Rosanna W Peeling
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter M Siba
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Michaela Riddell
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Moses Laman
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - John Bolnga
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Leanne J Robinson
- The Burnet Institute, Melbourne, Victoria, Australia
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Jacob Morewaya
- Milne Bay Provincial Health Authority, Alotau, Papua New Guinea
| | - Steven Badman
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Angela Kelly-Hanku
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Pamela J Toliman
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Wilfred Peter
- Madang Provincial Health Authority, Madang, Papua New Guinea
| | | | - Suzanne Garland
- Microbiology and Infectious Diseases Department, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - John Kaldor
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Saweri OPM, Batura N, Al Adawiyah R, Causer LM, Pomat WS, Vallely AJ, Wiseman V. Economic evaluation of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low- and middle-income countries: A systematic review. PLoS One 2021; 16:e0253135. [PMID: 34138932 PMCID: PMC8211269 DOI: 10.1371/journal.pone.0253135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 05/30/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Sexually transmitted and genital infections in pregnancy are associated with adverse pregnancy and birth outcomes. Point-of-care tests for these infections facilitate testing and treatment in a single antenatal clinic visit and may reduce the risk of adverse outcomes. Successful implementation and scale-up depends on understanding comparative effectiveness of such programmes and their comparative costs and cost effectiveness. This systematic review synthesises and appraises evidence from economic evaluations of point-of-care testing and treatment for sexually transmitted and genital infections among pregnant women in low- and middle-income countries. METHODS Medline, Embase and Web of Science databases were comprehensively searched using pre-determined criteria. Additional literature was identified by searching Google Scholar and the bibliographies of all included studies. Economic evaluations were eligible if they were set in low- and middle-income countries and assessed antenatal point-of-care testing and treatment for syphilis, chlamydia, gonorrhoea, trichomoniasis, and/or bacterial vaginosis. Studies were analysed using narrative synthesis. Methodological and reporting standards were assessed using two published checklists. RESULTS Sixteen economic evaluations were included in this review; ten based in Africa, three in Latin and South America and three were cross-continent comparisons. Fifteen studies assessed point-of-care testing and treatment for syphilis, while one evaluated chlamydia. Key drivers of cost and cost-effectiveness included disease prevalence; test, treatment, and staff costs; test sensitivity and specificity; and screening and treatment coverage. All studies met 75% or more of the criteria of the Drummond Checklist and 60% of the Consolidated Health Economics Evaluation Reporting Standards. CONCLUSIONS Generally, point-of-care testing and treatment was cost-effective compared to no screening, syndromic management, and laboratory-based testing. Future economic evaluations should consider other common infections, and their lifetime impact on mothers and babies. Complementary affordability and equity analyses would strengthen the case for greater investment in antenatal point-of-care testing and treatment for sexually transmitted and genital infections.
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Affiliation(s)
- Olga P. M. Saweri
- The Kirby Institute, University of New South Wales, Sydney, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- * E-mail:
| | - Neha Batura
- University College London, London, United Kingdom
| | | | - Louise M. Causer
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - William S. Pomat
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew J. Vallely
- The Kirby Institute, University of New South Wales, Sydney, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, Australia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Romero CP, Marinho DS, Castro R, de Aguiar Pereira CC, Silva E, Caetano R, Silva Elias FT, Chilcott J, Dixon S. Cost-Effectiveness Analysis of Point-of-Care Rapid Testing Versus Laboratory-Based Testing for Antenatal Screening of Syphilis in Brazil. Value Health Reg Issues 2020; 23:61-69. [PMID: 32841902 DOI: 10.1016/j.vhri.2020.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 12/27/2019] [Accepted: 03/25/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Severe consequences of mother-to-child transmission of syphilis and high increasing incidence of congenital syphilis remains an important public health problem in Brazil. Our objective was to assess the cost-effectiveness of a rapid point-of-care test (RT) and treatment of positive mothers immediately compared with a laboratory-based standard test (ST) with treatment at next follow-up visit. METHODS A decision analytic model was developed to estimate the incremental cost-effectiveness ratio (ICER) between antenatal syphilis screening strategies. The model was built with lifetime horizon from Brazilian health system perspective using 3% and 5% discount rates. A hypothetical cohort of pregnant women at reproductive age were used in the model. Health outcomes: low birth weight, stillbirths, neonatal deaths and congenital syphilis were estimated in disability-adjusted life-years (DALYs) lost. Microcosting study and secondary data provided parameters of direct medical costs. Probabilistic sensitivity analysis was undertaken. RESULTS For base case, the mean cost per pregnant woman screened was $2.63 (RT) and $2.48 (ST), respectively. Maternal syphilis was associated with a loss of 0.0043 DALYs (RT) and 0.0048 DALYs (ST) per mother screened. Expected value of incremental cost per DALY averted was $298.08. After 10 000 probabilistic sensitivity analysis model runs, incremental cost and health benefits were $0.15 (95% credible interval -1.56 to 1.92) and 0.00042 DALYs (95% credible interval -0.0036 to 0.0044), respectively, with a mean ICER of $357.44 per DALY. Screening with RT has a 58% chance of being the optimal strategy at a threshold of $3,200 per DALY. CONCLUSIONS In Brazil, antenatal screening with syphilis RT and immediate treatment is likely to be cost-effective compared with standard screening and must be prioritized in local settings.
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Affiliation(s)
- Carmen Phang Romero
- Centro de Desenvolvimento Tecnológico em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil; Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas do Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil.
| | - Daniel S Marinho
- Centro de Desenvolvimento Tecnológico em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil; Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas do Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil
| | - Rodolfo Castro
- Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas do Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil; Instituto de Saúde Coletiva, Universidade Federal do Estado do Rio de Janeiro, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Claudia Cristina de Aguiar Pereira
- Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas do Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil; Escola Nacional de Saúde Pública "Sérgio Arouca," Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | | | - James Chilcott
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Simon Dixon
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
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Perez F, Mayaud P. One step in the right direction: improving syphilis screening and treatment in pregnant women in Africa. LANCET GLOBAL HEALTH 2019; 7:e550-e551. [PMID: 30910530 DOI: 10.1016/s2214-109x(19)30064-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Freddy Perez
- Department of Communicable Diseases and Environmental Determinants of Health, HIV, Hepatitis, Tuberculosis and Sexually Transmitted Infections Unit, Pan American Health Organization, Washington, DC 20037, USA.
| | - Philippe Mayaud
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine (LSHTM), London, UK; Medical Research Council/Uganda Virus Research Institute and LSHTM Unit in Uganda, Entebbe, Uganda
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Toward Improving Accessibility of Point-of-Care Diagnostic Services for Maternal and Child Health in Low- and Middle-Income Countries. POINT OF CARE 2019; 18:17-25. [PMID: 30886544 PMCID: PMC6407818 DOI: 10.1097/poc.0000000000000180] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Point-of-care (POC) testing can improve health care provision in settings with limited access to health care services. Access to POC diagnostic services has shown potential to alleviate some diagnostic challenges and delays associated with laboratory-based methods in low- and middle-income countries. Improving accessibility to POC testing (POCT) services during antenatal and perinatal care is among the global health priorities to improve maternal and child health. This review provides insights on the availability of POC testing designed for diagnosing HIV, syphilis, and malaria in pregnancy to improve maternal and child health. In addition, factors such as accessibility of POC testing, training of health work force, and the efficiency of POC testing services delivery in low- and middle-income countries are discussed. A framework to help increase access to POC diagnostic services and improve maternal and child health outcomes in low- and middle-income countries is proposed.
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Angel-Müller E, Grillo-Ardila CF, Amaya-Guio J, Torres-Montañez NA, Vasquez-Velez LF. Point of care rapid test for diagnosis of syphilis infection in men and nonpregnant women. Hippokratia 2018. [DOI: 10.1002/14651858.cd013036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Edith Angel-Müller
- Faculty of Medicine, Universidad Nacional de Colombia; Department of Obstetrics and Gynecology; Cra 30 # 45-03 Bogota Colombia
| | - Carlos F Grillo-Ardila
- Faculty of Medicine, Universidad Nacional de Colombia; Department of Obstetrics and Gynecology; Cra 30 # 45-03 Bogota Colombia
| | - Jairo Amaya-Guio
- Faculty of Medicine, Universidad Nacional de Colombia; Department of Obstetrics and Gynecology; Cra 30 # 45-03 Bogota Colombia
| | - Nicolas A Torres-Montañez
- Faculty of Medicine, Universidad Nacional de Colombia; Department of Obstetrics and Gynecology; Cra 30 # 45-03 Bogota Colombia
| | - Luisa F Vasquez-Velez
- Faculty of Medicine, Universidad Nacional de Colombia; Department of Obstetrics and Gynecology; Cra 30 # 45-03 Bogota Colombia
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Lazarini FM, Barbosa DA. Educational intervention in Primary Care for the prevention of congenital syphilis. Rev Lat Am Enfermagem 2017; 25:e2845. [PMID: 28146181 PMCID: PMC5288867 DOI: 10.1590/1518-8345.1612.2845] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/23/2016] [Indexed: 11/24/2022] Open
Abstract
Objectives: to evaluate the efficiency of educational interventions related to the knowledge
of health care professionals of Primary Care and to verify the impact on the
vertical transmission rates of congenital syphilis. Method: a quasi-experimental study conducted in the city of Londrina, Paraná, between 2013
and 2015. An educational intervention on diagnosis, treatment and notification was
carried out with 102 professionals with knowledge measurement before and after the
intervention. Incidence and mortality data from congenital syphilis were taken
from the system for notifiable diseases (SINAN) and the Mortality Information
System (SIM). Excel tabulation and statistical analysis was done in the
Statistical Package for Social Sciences, version 2.1. A descriptive and
inferential analysis was performed. Results: the mean number of correct responses increased from 53% to 74.3% after the
intervention (p < 0.01). The adherence to professional training was 92.6%.
There was a significant reduction in the vertical transmission rate of syphilis
from 75% in 2013 to 40.2% in 2015. In 2014 and 2015 there were no records of
infant mortality from this condition. Conclusion: the educational intervention significantly increased the knowledge of health
professionals about syphilis and collaborated to reduce the rate of vertical
transmission of the disease.
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Affiliation(s)
- Flaviane Mello Lazarini
- PhD, Assistant Professor, Departamento de Saúde Coletiva, Universidade Estadual de Londrina, Londrina, PR, Brazil
| | - Dulce Aparecida Barbosa
- PhD, Associate Professor, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Abstract
PURPOSE OF REVIEW Syphilis in pregnancy continues to be a worldwide threat to mothers and their fetuses, and in recent years has been increasing in prevalence. The purpose of this short review is to address current issues in the diagnosis and management of syphilis complicating pregnancies. RECENT FINDINGS Maternal syphilis infections and congenital syphilis appear to be increasing in both high and low resource settings. Treponema pallidum ssp. pallidum, the causative spirochete of syphilis, remains one of the few human infectious pathogens that has not been successfully cultured, making identification difficult and research in targeted antimicrobial therapies challenging. Fortunately, syphilis remains sensitive to penicillin, which remains the foundational therapy for this infection. Patients with syphilis and significant penicillin allergies remain a specific challenge in treatment. Of concern is the emergence of T. pallidum resistant to macrolides such as azithromycin. This will limit options in patients with penicillin allergies, and potentially contribute to suboptimal treatment. During pregnancy, penicillin is the only known effective treatment for congenital syphilis, and pregnant patients with penicillin allergy should be desensitized and treated with penicillin. Research focusing on protein expression of the genome of T. pallidum may lead to more accurate screening and diagnosis and development of novel antibiotic therapies. SUMMARY Obstetric and pediatric providers, public health organizations, and governments should recognize the re-emergence of syphilis globally and in their local healthcare environments. Screening of all pregnant patients with robust treatment and follow-up represents the most effective method to reduce congenital syphilis currently available.
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Vermund SH. Screening for Sexually Transmitted Infections in Antenatal Care Is Especially Important Among HIV-Infected Women. Sex Transm Dis 2016; 42:566-8. [PMID: 26372928 DOI: 10.1097/olq.0000000000000342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sten H Vermund
- From the Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
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15
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Lago EG. Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis. Cureus 2016; 8:e525. [PMID: 27081586 PMCID: PMC4829408 DOI: 10.7759/cureus.525] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 03/09/2016] [Indexed: 12/21/2022] Open
Abstract
This article aims to provide an update on the prevention of mother-to-child transmission of syphilis by drawing upon some important basic concepts and reviewing the most recent literature on the diagnosis and treatment of syphilis in pregnancy. New technologies, such as automated and point-of-care immunologic tests, are shifting some paradigms, which will certainly be further investigated in the forthcoming years. This is the time to carefully evaluate traditional as well as new strategies to prevent congenital syphilis. Adverse outcomes of mother-to-child transmission of syphilis can be prevented with antenatal screening and penicillin therapy, which proved to have an excellent cost-benefit ratio even in populations with a low prevalence of syphilis. However, syphilis epidemiology is influenced by socioeconomic and cultural factors, and major challenges are faced by poor and developing countries in which the severity of the problem is extremely alarming. On the other hand, the emergence of new technologies has raised doubts about the best algorithm to be used when proper laboratory resources are available. Conditions are quite heterogeneous across populations, and some procedures should not be generalized while there is no evidence that supports some changes and while in-depth studies about local conditions are not conducted. Official organizations need to be alert in order to avoid isolated decisions and ensure that evidence-based guidelines be used in the management of syphilis in pregnancy.
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Affiliation(s)
- Eleonor G Lago
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS ; Edipucrs University Publisher, Pontifícia Universidade Católica do Rio Grande do Sul - PUCRS
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Rapid Syphilis Testing Is Cost-Effective Even in Low-Prevalence Settings: The CISNE-PERU Experience. PLoS One 2016; 11:e0149568. [PMID: 26949941 PMCID: PMC4780822 DOI: 10.1371/journal.pone.0149568] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 02/01/2016] [Indexed: 11/19/2022] Open
Abstract
Studies have addressed cost-effectiveness of syphilis testing of pregnant women in high-prevalence settings. This study compares costs of rapid syphilis testing (RST) with laboratory-based rapid plasma reagin (RPR) tests in low-prevalence settings in Peru. The RST was introduced in a tertiary-level maternity hospital and in the Ventanilla Network of primary health centers, where syphilis prevalence is approximately 1%. The costs per woman tested and treated with RST at the hospital were $2.70 and $369 respectively compared with $3.60 and $740 for RPR. For the Ventanilla Network the costs per woman tested and treated with RST were $3.19 and $295 respectively compared with $5.55 and $1454 for RPR. The cost per DALY averted using RST was $46 vs. $109 for RPR. RST showed lower costs compared to the WHO standard costs per DALY ($64). Findings suggest syphilis screening with RST is cost-effective in low-prevalence settings.
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De Schacht C, Lucas C, Sitoe N, Machekano R, Chongo P, Temmerman M, Tobaiwa O, Guay L, Kassaye S, Jani IV. Implementation of Point-of-Care Diagnostics Leads to Variable Uptake of Syphilis, Anemia and CD4+ T-Cell Count Testing in Rural Maternal and Child Health Clinics. PLoS One 2015; 10:e0135744. [PMID: 26308345 PMCID: PMC4550242 DOI: 10.1371/journal.pone.0135744] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 07/26/2015] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Anemia, syphilis and HIV are high burden diseases among pregnant women in sub-Saharan Africa. A quasi-experimental study was conducted in four health facilities in Southern Mozambique to evaluate the effect of point-of-care technologies for hemoglobin quantification, syphilis testing and CD4+ T-cell enumeration performed within maternal and child health services on testing and treatment coverage, and assessing acceptability by health workers. METHODS Demographic and testing data on women attending first antenatal care services were extracted from existing records, before (2011; n = 865) and after (2012; n = 808) introduction of point-of-care testing. Study outcomes per health facility were compared using z-tests (categorical variables) and Wilcoxon rank-sum test (continuous variables), while inverse variance weights were used to adjust for possible cluster effects in the pooled analysis. A structured acceptability-assessment interview was conducted with health workers before (n = 22) and after (n = 19). RESULTS After implementation of point-of-care testing, there was no significant change in uptake of overall hemoglobin screening (67.9% to 83.0%; p = 0.229), syphilis screening (80.8% to 87.0%; p = 0.282) and CD4+ T-cell testing (84.9% to 83.5%; p = 0.930). Initiation of antiretroviral therapy for treatment eligible women was similar in the weighted analysis before and after, with variability among the sites. Time from HIV diagnosis to treatment initiation decreased (median of 44 days to 17 days; p<0.0001). A generally good acceptability for point-of-care testing was seen among health workers. CONCLUSIONS Point-of-care CD4+ T-cell enumeration resulted in a decreased time to initiation of antiretroviral therapy among treatment eligible women, without significant increase in testing coverage. Overall hemoglobin and syphilis screening increased. Despite the perception that point-of-care technologies increase access to health services, the variability in results indicate the potential for detrimental effects in some settings. Local context needs to be considered and services restructured to accommodate innovative technologies in order to improve service delivery to expectant mothers.
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Affiliation(s)
| | - Carlota Lucas
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique
| | - Nádia Sitoe
- Instituto Nacional de Saúde, Maputo, Mozambique
| | - Rhoderick Machekano
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, United States of America
| | | | - Marleen Temmerman
- International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, Ghent, Belgium
| | - Ocean Tobaiwa
- Clinton Health Access Initiative, Maputo, Mozambique
| | - Laura Guay
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, United States of America
- Department of Epidemiology and Biostatistics, The George Washington University, Milken Institute School of Public Health, Washington DC, United States of America
| | - Seble Kassaye
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, United States of America
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Shelley KD, Ansbro ÉM, Ncube AT, Sweeney S, Fleischer C, Mumba GT, Gill MM, Strasser S, Peeling RW, Terris-Prestholt F. Scaling Down to Scale Up: A Health Economic Analysis of Integrating Point-of-Care Syphilis Testing into Antenatal Care in Zambia during Pilot and National Rollout Implementation. PLoS One 2015; 10:e0125675. [PMID: 25970443 PMCID: PMC4430530 DOI: 10.1371/journal.pone.0125675] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 03/25/2015] [Indexed: 11/20/2022] Open
Abstract
Maternal syphilis results in an estimated 500,000 stillbirths and neonatal deaths annually in Sub-Saharan Africa. Despite the existence of national guidelines for antenatal syphilis screening, syphilis testing is often limited by inadequate laboratory and staff services. Recent availability of inexpensive rapid point-of-care syphilis tests (RST) can improve access to antenatal syphilis screening. A 2010 pilot in Zambia explored the feasibility of integrating RST within prevention of mother-to-child-transmission of HIV services. Following successful demonstration, the Zambian Ministry of Health adopted RSTs into national policy in 2011. Cost data from the pilot and 2012 preliminary national rollout were extracted from project records, antenatal registers, clinic staff interviews, and facility observations, with the aim of assessing the cost and quality implications of scaling up a successful pilot into a national rollout. Start-up, capital, and recurrent cost inputs were collected, including costs of extensive supervision and quality monitoring during the pilot. Costs were analysed from a provider’s perspective, incremental to existing antenatal services. Total and unit costs were calculated and a multivariate sensitivity analysis was performed. Our accompanying qualitative study by Ansbro et al. (2015) elucidated quality assurance and supervisory system challenges experienced during rollout, which helped explain key cost drivers. The average unit cost per woman screened during rollout ($11.16) was more than triple the pilot unit cost ($3.19). While quality assurance costs were much lower during rollout, the increased unit costs can be attributed to several factors, including higher RST prices and lower RST coverage during rollout, which reduced economies of scale. Pilot and rollout cost drivers differed due to implementation decisions related to training, supervision, and quality assurance. This study explored the cost of integrating RST into antenatal care in pilot and national rollout settings, and highlighted important differences in costs that may be observed when moving from pilot to scale-up.
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Affiliation(s)
- Katharine D. Shelley
- Department of Epidemiology & Biostatistics, George Washington University School of Public Health, Washington, DC, United States of America
- * E-mail:
| | - Éimhín M. Ansbro
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Colette Fleischer
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America
| | - Susan Strasser
- Elizabeth Glaser Pediatric AIDS Foundation, Lusaka, Zambia
| | - Rosanna W. Peeling
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Terris-Prestholt F, Vickerman P, Torres-Rueda S, Santesso N, Sweeney S, Mallma P, Shelley KD, Garcia PJ, Bronzan R, Gill MM, Broutet N, Wi T, Watts C, Mabey D, Peeling RW, Newman L. The cost-effectiveness of 10 antenatal syphilis screening and treatment approaches in Peru, Tanzania, and Zambia. Int J Gynaecol Obstet 2015; 130 Suppl 1:S73-80. [PMID: 25963907 PMCID: PMC4510253 DOI: 10.1016/j.ijgo.2015.04.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective Rapid plasma reagin (RPR) is frequently used to test women for maternal syphilis. Rapid syphilis immunochromatographic strip tests detecting only Treponema pallidum antibodies (single RSTs) or both treponemal and non-treponemal antibodies (dual RSTs) are now available. This study assessed the cost-effectiveness of algorithms using these tests to screen pregnant women. Methods Observed costs of maternal syphilis screening and treatment using clinic-based RPR and single RSTs in 20 clinics across Peru, Tanzania, and Zambia were used to model the cost-effectiveness of algorithms using combinations of RPR, single, and dual RSTs, and no and mass treatment. Sensitivity analyses determined drivers of key results. Results Although this analysis found screening using RPR to be relatively cheap, most (> 70%) true cases went untreated. Algorithms using single RSTs were the most cost-effective in all observed settings, followed by dual RSTs, which became the most cost-effective if dual RST costs were halved. Single test algorithms dominated most sequential testing algorithms, although sequential algorithms reduced overtreatment. Mass treatment was relatively cheap and effective in the absence of screening supplies, though treated many uninfected women. Conclusion This analysis highlights the advantages of introducing RSTs in three diverse settings. The results should be applicable to other similar settings.
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Affiliation(s)
| | - Peter Vickerman
- London School of Hygiene and Tropical Medicine, London, UK; University of Bristol, Bristol, UK
| | | | | | - Sedona Sweeney
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Rachel Bronzan
- Health and Development International, Newburyport, MA, USA
| | - Michelle M Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | | | - Teodora Wi
- World Health Organization, Geneva, Switzerland
| | | | - David Mabey
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Lori Newman
- World Health Organization, Geneva, Switzerland
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