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Antenatal syphilis screening using point-of-care testing in Sub-Saharan African countries: a cost-effectiveness
Andreas Kuznik1, Mohammed Lamorde, Agnes Nyabigambo
1Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda ; Pfizer, New York, New York, United States of America.
Insights
Antenatal syphilis screening using point-of-care tests is highly cost-effective in sub-Saharan Africa. Expanding screening can significantly reduce infant deaths and congenital syphilis cases, averting millions of disability-adjusted life years (DALYs).
Area of Science:
- Public Health
- Health Economics
- Infectious Disease Epidemiology
Background:
- Untreated syphilis in pregnancy leads to severe infant outcomes.
- Sub-Saharan Africa (SSA) faces inadequate antenatal syphilis screening coverage.
- Point-of-care syphilis tests offer high accuracy and potential to improve screening.
Purpose of the Study:
- To evaluate the cost-effectiveness and budget impact of antenatal syphilis screening in 43 SSA countries.
- To estimate the impact of universal screening on stillbirths, neonatal deaths, congenital syphilis, and DALYs averted.
Main Methods:
- A decision analytic model from a national healthcare system perspective.
- Utilized sensitivity (86%) and specificity (99%) of the immunochromatographic strip (ICS) test.
- Incorporated country-specific data on syphilis prevalence, birth rates, antenatal care access, and healthcare costs.
Main Results:
- Syphilis screening is highly cost-effective across all 43 SSA countries, averaging US$11 per DALY averted.
- Screening remains cost-effective even with significantly lower syphilis prevalence.
- Universal screening could prevent up to 64,000 stillbirths, 25,000 neonatal deaths, and 32,000 congenital syphilis cases annually, averting 2.6 million DALYs.
Conclusions:
- Immunochromatographic strip (ICS) tests for antenatal syphilis screening are highly cost-effective in SSA.
- Significant DALY reductions are achievable with a modest budget impact.
- Antenatal programs in SSA should prioritize expanding syphilis screening using ICS tests.
Background:
Untreated syphilis in pregnancy is associated with adverse clinical outcomes for the infant. Most syphilis infections occur in sub-Saharan Africa (SSA), where coverage of antenatal screening for syphilis is inadequate. Recently introduced point-of-care syphilis tests have high accuracy and demonstrate potential to increase coverage of antenatal screening. However, country-specific cost-effectiveness data for these tests are limited. The objective of this analysis was to evaluate the cost-effectiveness and budget impact of antenatal syphilis screening for 43 countries in SSA and estimate the impact of universal screening on stillbirths, neonatal deaths, congenital syphilis, and disability-adjusted life years (DALYs) averted.
Methods And Findings:
The decision analytic model reflected the perspective of the national health care system and was based on the sensitivity (86%) and specificity (99%) reported for the immunochromatographic strip (ICS) test. Clinical outcomes of infants born to syphilis-infected mothers on the end points of stillbirth, neonatal death, and congenital syphilis were obtained from published sources. Treatment was assumed to consist of three injections of benzathine penicillin. Country-specific inputs included the antenatal prevalence of syphilis, annual number of live births, proportion of women with at least one antenatal care visit, per capita gross national income, and estimated hourly nurse wages. In all 43 sub-Saharan African countries analyzed, syphilis screening is highly cost-effective, with an average cost/DALY averted of US$11 (range: US$2-US$48). Screening remains highly cost-effective even if the average prevalence falls from the current rate of 3.1% (range: 0.6%-14.0%) to 0.038% (range: 0.002%-0.113%). Universal antenatal screening of pregnant women in clinics may reduce the annual number of stillbirths by up to 64,000, neonatal deaths by up to 25,000, and annual incidence of congenital syphilis by up to 32,000, and avert up to 2.6 million DALYs at an estimated annual direct medical cost of US$20.8 million.
Conclusions:
Use of ICS tests for antenatal syphilis screening is highly cost-effective in SSA. Substantial reduction in DALYs can be achieved at a relatively modest budget impact. In SSA, antenatal programs should expand access to syphilis screening using the ICS test. Please see later in the article for the Editors' Summary.
