Cost-benefit analysis of Chlamydia trachomatis screening in pregnant women in a high burden setting in the United States

Ditkowsky, Jared; Shah, Khushal H.; Hammerschlag, Margaret R.; Kohlhoff, Stephan; Smith‐Norowitz, Tamar A.

doi:10.1186/s12879-017-2248-5

Cited by 24 publications

(28 citation statements)

References 30 publications

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“…POCTs will increase the uptake of STI screening in vulnerable populations that are at highest risk and will have an impact on detection and treatment. .…”

Section: Discussionmentioning

confidence: 99%

Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

Ndowa²,

et al. 2019

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Introduction Sexually transmitted infections (STIs) remain prevalent and are increasing in several populations. Appropriate STI diagnosis is crucial to prevent the transmission and sequelae of untreated infection. We reviewed the diagnostic accuracy of syndromic case management and existing point‐of‐care tests (POCTs), including those in the pipeline, to diagnose STIs in resource‐constrained settings. Methods We prioritized updating the systematic review and meta‐analysis of the diagnostic accuracy of vaginal discharge from 2001 to 2015 to include studies until 2018. We calculated the absolute effects of different vaginal flowcharts and the diagnostic performance of POCTs on important outcomes. We searched the peer‐reviewed literature for previously conducted systematic reviews and articles from 1990 to 2018 on the diagnostic accuracy of syndromic management of vaginal and urethral discharge, genital ulcer and anorectal infections. We conducted literature reviews from 2000 to 2018 on the existing POCTs and those in the pipeline. Results and discussions The diagnostic accuracy of urethral discharge and genital ulcer disease syndromes is relatively adequate. Asymptomatic Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections limit the use of vaginal discharge and anorectal syndromes. The pooled diagnostic accuracy of vaginal syndromic case management for CT/NG is low, resulting in high numbers of overtreatment and missed treatment. The absolute effect of POCTs was reduced overtreatment and missed treatment. Findings of the reviews on syndromic case management underscored the need for low‐cost and accurate POCTs for the identification, first, of CT/NG, and, second, of Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV) and NG and MG resistance/susceptibility testing. Near‐patient POCT molecular assays for CT/NG/TV are commercially available. The prices of these POCTs remain the barrier for uptake in resource‐constrained settings. This is driving the development of lower cost solutions. Conclusions The WHO syndromic case management guidelines should be updated to raise the quality of STI management through the integration of laboratory tests. STI screening strategies are needed to address asymptomatic STIs. POCTs that are accurate, rapid, simple and affordable are urgently needed in resource‐constrained settings to support the uptake of aetiological diagnosis and treatment.

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“…POCTs will increase the uptake of STI screening in vulnerable populations that are at highest risk and will have an impact on detection and treatment. .…”

Section: Discussionmentioning

confidence: 99%

Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

Ndowa²,

et al. 2019

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“…There are limited data on the cost-effectiveness of prenatal chlamydia screening and treatment programmes 14. Modelling studies suggest that the effectiveness of chlamydia screening largely depends on the likelihood of developing adverse outcomes 15–17…”

Section: Introductionmentioning

confidence: 99%

Pregnancy and fertility-related adverse outcomes associated withChlamydia trachomatisinfection: a global systematic review and meta-analysis

Tang

Mao

et al. 2019

Sex Transm Infect

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BackgroundGenital chlamydia infection in women is often asymptomatic, but may result in adverse outcomes before and during pregnancy. The purpose of this study was to examine the strength of the relationships between chlamydia infection and different reproductive health outcomes and to assess the certainty of the evidence.MethodsThis review was registered and followed the Cochrane guidelines. We searched three databases to quantitatively examine adverse outcomes associated with chlamydia infection. We included pregnancy and fertility-related outcomes. We performed meta-analyses on different study designs for various adverse outcomes using unadjusted and adjusted analyses.ResultsWe identified 4730 unique citations and included 107 studies reporting 12 pregnancy and fertility-related outcomes. Sixty-eight studies were conducted in high-income countries, 37 studies were conducted in low-income or middle-income countries, and 2 studies were conducted in both high-income and low-income countries. Chlamydia infection was positively associated with almost all of the 12 included pregnancy and fertility-related adverse outcomes in unadjusted analyses, including stillbirth (OR=5.05, 95% CI 2.95 to 8.65 for case–control studies and risk ratio=1.28, 95% CI 1.09 to 1.51 for cohort studies) and spontaneous abortion (OR=1.30, 95% CI 1.14 to 1.49 for case–control studies and risk ratio=1.47, 95% CI 1.16 to 1.85 for cohort studies). However, there were biases in the design and conduct of individual studies, affecting the certainty of the overall body of evidence. The risk of adverse outcomes associated with chlamydia is higher in low-income and middle-income countries compared with high-income countries.ConclusionChlamydia is associated with an increased risk of several pregnancy and fertility-related adverse outcomes in unadjusted analyses, especially in low-income and middle-income countries. Further research on how to prevent the sequelae of chlamydia in pregnant women is needed.Trial registration numberCRD42017056818.

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“…Hepatitis immunoglobulin (HBIG) after rapid diagnostic tests 2. HBIG after confirmatory test Vaccination alone Refugee and migrant population on the Thailand-Myanmar border From first contact to childbirth Healthcare NA USD (no year) Perinatal infection of Hepatitis B Yes HBIG following rapid diagnostic test is CE Wellcome-Trust Major Overseas Programme in SE Asia No Devine et al [ 46 ] Thailand-Myanmar Plasmodium vivax G6PD testing [ 1 ] chloroquine alone [ 2 ] primaquine without screeningz Refugee and migrant population on the Thailand-Myanmar border 1 year Healthcare NA 2014 USD DALYs Yes G6PD RDTs to identify patients with G6PD deficiency before supervised primaquine is likely to provide significant health benefits Welcome-Trust Major Overseas Programme in SE Asia Yes Ditkowsky et al [ 25 ] USA Chlamydia trachomatis Chlamydia screening No Screening Pregnant women aged 15–24 1 year Healthcare NA 2015 USD 2015 USD No Prenatal screening for C. trachomatis resulted in increased expenditure, with a significant reduction in morbidity to woman-infant pairs None Yes Ethgen et al [ 14 ] France Hepatitis C (HCV) 1. IFN + RBV + PI for F2–F4 2.…”

Section: Resultsmentioning

confidence: 99%

Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis

Iragorri

Spackman

2018

Public Health Rev

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BackgroundScreening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools.ObjectiveThis review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them.MethodsA systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized.ResultsFour key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early.ConclusionsTo capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary.

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Cost-benefit analysis of Chlamydia trachomatis screening in pregnant women in a high burden setting in the United States

Cited by 24 publications

References 30 publications

Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

Diagnosing sexually transmitted infections in resource‐constrained settings: challenges and ways forward

Pregnancy and fertility-related adverse outcomes associated withChlamydia trachomatisinfection: a global systematic review and meta-analysis

Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis

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