São Tomé and Príncipe (STP) uses a selective hepatitis B birth-dose vaccination (HepB-BD) strategy targeting infants born to mothers who test positive for hepatitis B virus (HBV) surface antigen. We conducted a field assessment and economic analysis of the HepB-BD strategy to provide evidence to guide development of cost-effective policies to prevent perinatal HBV transmission in STP. We interviewed national stakeholders and key informants to understand policies, knowledge, and practices related to HepB-BD, vaccine management, and data recording/reporting. Cost-effectiveness of the existing strategy was compared with an alternate approach of universal HepB-BD to all newborns using a decision analytic model. Incremental cost-effectiveness ratios (ICERs) were calculated in 2015 USD per HBV-associated death and per chronic HBV case prevented, from the STP health-care system perspective. We found that STP lacked national or facility-specific written policies and procedures related to HepB-BD. Timely HepB-BD to eligible newborns was considered a high priority, although timeliness of HepB-BD was not monitored. Compared with the existing selective vaccination strategy, universal HepB-BD would result in a 19% decrease in chronic HBV infections per year at overall cost savings of approximately 44% (savings of USD 5,441 each year). We estimate an ICER of USD 5,012 saved per HBV-associated death averted. The existing selective HepB-BD strategy in STP could be improved through documentation of policies, procedures, and timeliness of HepB-BD. Expansion to universal newborn HepB-BD without maternal screening is feasible and could result in cost savings if actual implementation costs and effectiveness fall within the ranges modeled.

Background: Newborn mortality in Sao Tome and Principe (STP) is overwhelmingly high and the antenatal healthcare (ANC) is one of the strategies to achieve its reduction. This study aimed to know which antenatal screenings are done in STP and which antenatal problems are detected. Methods: A retrospective study in which 518 pregnant women antenatal cards were reviewed between July 2016 and November 2018. Information analysed included clinical factors, laboratory tests, ultrasounds, results, and treatment. Results: Mothers’ mean age was 26.6 (SD=7.1) years old. At least one ANC visit occurred in 98.6% pregnant women and 38.7% had 8 or more. Regarding laboratory screenings, blood group was done in 64.4%, haemoglobin tested in 62.5% (first trimester) and in 29.3% (second trimester) and, urine once in 57.1% and twice in 12.2%. Antenatal problems identified in the pregnant women studied were: i) a RhD-negative phenotype (5.8%); 2) anaemia 1st trimester (36.4%) and 2nd trimester (35.5%); 3) bacteriuria (43.2%); 4) intestinal parasites (55.5%); 5) sickle cell solubility test positive (13%). Overall, 161 (53.7%) out of the 300 ultrasounds were done before the 20th week. Conclusion: In Sao Tome and Principe many pregnant women do not have access to the full spectrum of ANC recommended screenings. Maternal anaemia and bacteriuria are the main health problems that should be urgently addressed to prevent newborn morbidity and mortality in the country. Other preventive interventions as anthelmintic drugs should be debated as intestinal parasites were diagnosed in more than half of the women. Alloimmunization to RhD is also a concern due to the unaffordability of anti-D immunoglobulin in the country.