Single-Step Universal First-Trimester Cytomegalovirus Screening and Valacyclovir Prophylaxis in Pregnancy: A Cost-Utility Analysis in a High Seroprevalence Setting

OBJECTIVE: To evaluate the cost-effectiveness of first trimester single-step universal cytomegalovirus (CMV) serological screening with valacyclovir as vertical transmission prophylaxis versus routine ultrasound-directed testing.

METHODS: A payer perspective cost-utility analysis was conducted on a hypothetical population of 100,000 pregnant women for a time horizon of 9 month of full-term pregnancy and the lifetime of children. Using a decision-tree and Markov model, we assessed quality-adjusted life years (QALYs) gained by preventing congenital CMV (cCMV) sequelae against the costs of universal screening and valacyclovir prophylaxis.

RESULTS: The ICER for universal screening strategy was USD125,864 (SGD170,087)/QALY-gained compared to routine ultrasound-directed testing. It prevented approximately 54 cCMV infections, 18 cases of symptomatic infections, and 17 cases of sensorineural hearing loss (SNHL) and cognitive impairment by age of 5 per 100,000 mothers screened. The primary factors influencing cost-effectiveness include the effectiveness of VCV in preventing vertical CMV transmission, the prevalence of primary CMV infection during pregnancy, the probability of symptomatic congenital CMV following periconceptional infection, and the cost of serological testing.

CONCLUSIONS: Although the ICER of universal CMV screening appears high in absolute terms, it compares favorably with ICER of commonly offered antenatal screening methods such as first trimester non-invasive prenatal testing for women at intermediate risk of Trisomy 21. Universal screening has the potential for averting childhood morbidity at birth and by 5-years-old. Important variables influencing the ICER include the effectiveness of valacyclovir in preventing vertical transmission, prevalence of primary CMV infection, probability of symptomatic cCMV after periconception primary infection and cost of serology tests.