Finding a Needle in the Haystack: The Costs and Cost-Effectiveness of Syphilis Diagnosis and Treatment during Pregnancy to Prevent Congenital Syphilis in Kalomo District of Zambia

Abstract

BackgroundIn March 2012, The Elizabeth Glaser Pediatric AIDS Foundation trained maternal and child health workers in Southern Province of Zambia to use a new rapid syphilis test (RST) during routine antenatal care. A recent study by Bonawitz et al. (2014) evaluated the impact of this roll out in Kalomo District. This paper estimates the costs and cost-effectiveness from the provider's perspective under the actual conditions observed during the first year of the RST roll out.MethodsInformation on materials used and costs were extracted from program records. A decision-analytic model was used to evaluate the costs (2012 USD) and cost-effectiveness. Basic parameters needed for the model were based on the results from the evaluation study.ResultsDuring the evaluation study, 62% of patients received a RST, and 2.8% of patients tested were positive (and 10.4% of these were treated). Even with very high RST sensitivity and specificity (98%), true prevalence of active syphilis would be substantially less (estimated at <0.7%). For 1,000 new ANC patients, costs of screening and treatment were estimated at $2,136, and the cost per avoided disability-adjusted-life year lost (DALY) was estimated at $628. Costs change little if all positives are treated (because prevalence is low and treatment costs are small), but the cost-per-DALY avoided falls to just $66. With full adherence to guidelines, costs increase to $3,174 per 1,000 patients and the cost-per-DALY avoided falls to $60.ConclusionsScreening for syphilis is only useful for reducing adverse birth outcomes if patients testing positive are actually treated. Even with very low prevalence of syphilis (a needle in the haystack), cost effectiveness improves dramatically if those found positive are treated; additional treatment costs little but DALYs avoided are substantial. Without treatment, the needle is essentially found and thrown back into the haystack.

Educational intervention in Primary Care for the prevention of congenital syphilis

“…In Fortaleza-CE*, half of the interviewed professionals stated that they would request the VDRL for the partner and would only deal with the result 13 . A similar study carried out in Recife-PE* showed a value of 38% for the same index 20 , closer to the one found in Londrina. The data corroborate those pointed out in a similar survey carried in Rio de Janeiro-RJ*, in which approximately 40% of medical professionals and nurses reported having difficulty discussing syphilis with sexual partners 9 .…”

“…Before the training, only 7.8% of the professionals knew this flow, although it had already been in practice for five months. Faced with this reality, it is understood that permanent education actions and changes in the work process must have a planned continuity 18 , because their punctual action informs and updates the professionals, but the change of conduct in practice needs monitoring and correction of errors as learning, not punishment, reinforcing self-analysis and self-management activities of the health teams 19 - 20 . …”

“…The lack of recruitment and orientation of the partners and the difficulty of the health professionals in using the recommended therapeutic scheme for these cases - concomitant with the pregnant women - has been evidenced in several studies 9 , 15 - 16 , leading to the understanding that this protocol standard has not yet been fully assimilated, causing errors at the time of care and provoking inadequate treatments that reflect in the elevation of cases of congenital syphilis 20 .…”

“…It is emphasized that vertical transmission causes serious consequences to these newborn infants, due to the failures in primary prevention 13 - 14 , which have sequelae (largely irreversible), as well as prematurity 7 , 10 and put a burden on the health system 20 - 21 . The understanding of the healthcare network organization with reference institutions directed to the pediatric infectious diseases outpatient clinic and the counter-referral from the maternity to the UBS by e-mail, probably influenced the absence of syphilis infant mortality in the two years following the intervention (2014 and 2015), as a result of improved pre- and postnatal care.…”

The continuing threat of syphilis in pregnancy

“…However, for high-risk populations and for individuals with high-risk behaviors, testing in the third trimester is reasonable and becomes cost-effective when seroconversion rates are 19-fold higher than national averages for primary and secondary syphilis [16]. Especially in emerging countries where syphilis is highly prevalent, screening programs regardless of their construct must be coordinated with effective treatment opportunities to be cost-effective [17].…”