Cost-Effectiveness Of Neonatal Screening For Sickle Cell Disease In The Republic Of Angola
Authors: McGann Patrick T. , Santos Brigida , de Oliveira Vysolela , Bernardino Luis , Ware Russell E. , Grosse Scott D 
Published: October 2019

Abstract

Introduction
Sickle cell disease (SCD) is a tremendous global health problem with over 400,000 babies born every year worldwide. Early diagnosis by newborn screening (NBS) reduces mortality, by allowing timely access to lifesaving interventions such as parental education, penicillin prophylaxis, and pneumococcal vaccination. Without early diagnosis and treatment, it has been estimated that 50-90% of babies with SCD in sub-Saharan Africa will die before they reach five years of age. In the United States, a universal NBS approach has been implemented. Despite the relatively low incidence of SCD in the United States (1 in 2,500 per live births) compared to Angola (1 in 66 live births), universal NBS in the US has been demonstrated to be cost-effective. A pilot NBS and treatment program has been ongoing in the capital city of Luanda, Angola since July 2011. Using data from the first two years of this program, we have now performed a cost-effective analysis (CEA) of NBS and treatment for SCD in Angola.

Cost Analysis Methods and Assumptions
Modified WHO-CHOICE methodology was used. Cost and follow-up data from the first two years of the pilot NBS and treatment program in Luanda, Angola were used for this CEA analysis. Based upon our experiences in this pilot NBS program, just over 50% of those testing positive for SCD have been contacted and successfully brought to medical care. Although we anticipate this “find rate” to improve over time with increased overall sickle cell awareness and dedication of national health resources, we have used actual numbers of patients brought to care through this pilot program for these analyses. Estimated costs were calculated for providing routine clinical care, insecticide-treated mosquito nets, and prophylactic penicillin through 5 years of age. The costs of pneumococcal immunization were not included, since these are now available to most sub-Saharan countries (including Angola) through the GAVI Alliance.

Cost-effectiveness analysis
In the first two years of the pilot program in Luanda, a total of 36,453 patients were screened with 550 (1.51%) diagnosed as having SCA (hemoglobin SS disease) and 245 received clinical care. Infants are brought to care by 8 weeks of age; this number represents 50% of age-eligible infants. Up-front investment in laboratory equipment to perform NBS by isoelectric focusing, including delivery, installation and training, was US$53,608. Cost per test, including all materials required for heel stick testing and for laboratory processing by IEF was $4.94. The cost of treating one patient for five years, including prophylactic penicillin and clinical costs for every 3 month visits was $332. The cost to treat 236 patients for five years is $81,340. Total costs for screening all infants and treating those found is $315,026. Assuming that screening and treatment reduces mortality from 80% to the baseline under-5 mortality rate of 15.8%, we estimate that 157 lives will be saved by NBS. The expectation of life at age 5 years in Angola is 55.9 years, or 20 discounted life-years using a 3% discount rate. The cost per life saved is $2,007. If the life expectancy for an Angolan with SCA at age 5 is 60-75% that of other Angolans, 1884 to 2355 discounted life-years are saved and the cost per life-year saved is approximately $134 to $167. Assuming an average disability weight of 0.1 for survivors with SCA, the cost per DALY averted is $150 to $190.

Conclusions
Interventions are defined as “very cost-effective” if the cost per DALY is less than the per capita. This analysis demonstrates that the cost per DALY for NBS and treatment in Luanda appears to be 30 to 40 times lower than the annual per-capita GDP in Angola ($5,475). These data demonstrate that newborn screening and simple preventative treatments are extremely cost effective. With an increasing global burden of SCD, it is essential for governmental and Ministry of Health leaders to recognize and take action in order to reduce the morbidity and mortality of SCD. NBS that is linked to treatment is a logical, cost-effective and high-impact program that should be incorporated into national sickle cell strategies.

Disclosures:
No relevant conflicts of interest to declare.