The cost-effectiveness of targeted screening for congenital cytomegalovirus in newborns compared to clinical diagnosis in the US

Congenital cytomegalovirus screening in neonates born after 35 weeks gestation-is targeted screening beneficial?

Introduction

Congenital Cytomegalovirus (cCMV) is the most common congenital viral infection and leading cause of non-genetic sensorineural hearing loss in children. Timely treatment within the first months of life can prevent hearing loss. We evaluated utility, feasibility, and short-term cost implications of targeted cCMV screening in a tertiary public healthcare institution in Singapore.

Methods

We analyzed data from neonates born at ≥35 weeks gestation from 1st February 2022 to 31st January 2023, at the National University Hospital, Singapore. Screening criteria for CMV testing were neonates who failed hearing screening at birth, had a birth weight <2.5 kg, small for gestational age (SGA), or had clinical suspicion for cCMV. Urine samples were obtained within two weeks of birth for CMV polymerase chain reaction (PCR) testing. We collected clinical, ophthalmological, neuroimaging, laboratory, and audiological data. A limited, short-term cost analysis was performed to compare costs of three cCMV screening strategies (universal, targeted, and no screening) two years after implementation.

Results

Out of 5,277 neonates, 305 (6%) met the screening criteria. Among those screened, 70.5% (215/305) were SGA or had a birth weight <2.5 kg, and 23.3% (71/305) failed the hearing screen. The overall diagnostic yield was 0.06% (3/5,277). There was one false positive result (0.3%; 1/305). Three neonates (0.98%; 3/305) were diagnosed with cCMV by urine PCR. One was SGA without intracranial abnormality, and two had low birth weight with intracranial calcifications. None had cytopenia or transaminitis, and all ophthalmology screenings were normal. All infected neonates were started on Valganciclovir. One neonate failed the hearing test at one month of age but passed repeat assessments by three months. Two neonates exhibited upper motor neuron signs in the lower limbs and are on long-term follow-up. The total estimated direct treatment-related cost without cCMV screening was S$104,445.79. In the targeted screening model, the total cost was S$146,656.30, compared to S$853,890.16 in the universal screening model.

Conclusion

We demonstrated the feasibility of targeted cCMV screening, which complements universal newborn hearing screening in a tertiary neonatal center in Singapore. Targeted cCMV screening can be implemented cost-effectively during the neonatal period, enabling early detection and intervention.

Economic evaluation of newborn screening for congenital cytomegalovirus infection: A systematic review

PURPOSE

This systematic review analyzes economic evaluations of newborn screening for congenital cytomegalovirus (cCMV) infection to identify key factors influencing cost-effectiveness and differences in methodological approaches.

METHODS

Following a pre-registered PROSPERO protocol (CRD42023441587), we conducted a comprehensive literature search across multiple databases on July 4, 2024. The review included both full economic evaluations (cost and outcomes) and partial economic evaluations (cost only). Two reviewers independently performed data extraction and synthesis. Quality assessment used the Consensus Health Economic Criteria extended checklist and the Consolidated Health Economic Evaluation Reporting Standards 2022 Statement.

RESULTS

From 543 records, nine studies met inclusion criteria: four full and five partial economic evaluations. Two full economic evaluations provided the incremental cost-effectiveness ratio per quality-adjusted life year. Full economic evaluations using decision trees and Markov models generally found universal screening more cost-effective than targeted screening, despite higher incremental costs. Partial evaluations focused on direct costs, with varying inclusion of long-term care costs. Most studies adopted a healthcare system perspective, excluding indirect costs. Quality assessment of full economic evaluations revealed high methodological standards but identified common limitations in outcome measurement and reporting.

CONCLUSIONS

Available evidence suggests potential cost-effectiveness of newborn cCMV screening, particularly with early intervention strategies. However, limited full economic evaluations and heterogeneous methodological approaches preclude definitive conclusions, highlighting the need for additional research across diverse healthcare contexts.

WHAT IS KNOWN

• Congenital cytomegalovirus (cCMV) infection is a condition that can be detected through newborn screening, and understanding its economic implications is important for healthcare systems. • Economic evaluations can be categorized into full evaluations (analyzing both costs and outcomes) and partial evaluations (focusing only on costs).

WHAT IS NEW

• Based on a systematic review of 543 records, universal screening appears more cost-effective than targeted screening for cCMV, implementation challenges and healthcare system variations significantly impact its practical adoption. • The review identified significant methodological limitations in existing studies, particularly in outcome measurement and reporting, highlighting the need for more comprehensive research across different healthcare contexts.

Universal newborn screening for congenital cytomegalovirus infection

Congenital cytomegalovirus (CMV) infection is the leading infectious cause of childhood disability, in particular sensorineural hearing loss (SNHL). Timeliness of diagnosis is crucial, since the presence of CMV in any compartment (eg, blood, urine, or saliva) after age 21 days can mean postnatal acquisition of infection, particularly in breastfed infants. Given these issues, there is considerable interest in implementation of screening programmes-either universal screening (where all newborns are tested) or targeted screening. Targeted screening is typically based on the outcome of a newborn hearing screen, and can be influenced in some strategies by findings of other signs suggestive of congenital CMV. Universal screening is likely to have the greatest overall benefit. Early identification of congenital CMV allows for interventions such as antiviral therapy (when indicated) and enables anticipatory audiological monitoring that facilitates timely detection of delayed-onset SNHL. However, there are debates about the effectiveness of screening programmes. Most infants with congenital CMV are unaffected and do not appear to be at risk for adverse neurodevelopment outcomes, except for SNHL. Screening can, therefore, raise unwarranted concern among parents and clinicians in these cases. The best clinical sample for diagnostic testing is unclear. PCR testing of saliva is sensitive but has a risk of yielding false-positive results in infants without congenital CMV. Resolving the technological issues has improved the sensitivity of dried blood spot (DBS) PCR but the technique remains suboptimum. An advantage to DBS PCR testing is that an infrastructure exists to add this test to existing newborn screening programmes. In this Review, the advantages and disadvantages of congenital CMV screening are discussed, along with high-priority areas for future research that will inform and direct this rapidly evolving field.

Congenital and Postnatal Cytomegalovirus: Case Series and State of the Science for Neonatal Providers

Cytomegalovirus (CMV), a beta-herpes virus, is the most common viral infection in infants. Transmission may occur congenitally (cCMV) or postnatally (pCMV). Early detection and intervention are crucial in reducing morbidities, notable developmental delays, and sensorineural hearing loss. However, more than 90% of infants are asymptomatic at birth. Treatment involves intravenous ganciclovir or the oral prodrug, valganciclovir, drugs usually reserved for use with symptomatic infants because of the toxicity profile. Research currently supports standardized antenatal CMV screening and treatment of affected pregnant patients with hyperimmune globulin as well as vaccination against CMV in unaffected pregnant patients, although widespread adoption is lacking. Standardized postnatal CMV screening is a proven, cost-effective way to detect and diagnose CMV and optimize outcomes across the lifespan. This article presents a case series of cCMV and pCMV and a review of the state of science of CMV as well as promising scientific advances that are on the horizon.

Newborn cytomegalovirus screening: is this the new standard?

PURPOSE OF REVIEW

Congenital cytomegalovirus infection (cCMV) is a major cause of childhood hearing loss and neurodevelopmental delay. Early identification of cCMV allows for interventions that improve outcomes, particularly for cCMV-related hearing loss that develops in early childhood. Most cCMV is asymptomatic at birth and is rarely diagnosed without newborn screening. Therefore, various approaches to cCMV screening are increasingly being adopted.

RECENT FINDINGS

Both universal screening (testing all newborns) and targeted screening (testing triggered by failed hearing screening) for cCMV appear valuable, feasible and cost-effective, though universal screening is predicted to have greatest potential overall benefits. CMV PCR testing of newborn oral swabs is sensitive and practical and is therefore widely used in targeted screening programs. In contrast, PCR using dried-blood spots (DBS) is less sensitive but was adopted by current universal cCMV screening initiatives because DBS are already collected from all newborns in high-income countries, which circumvents large-scale oral swab collection.

SUMMARY

Targeted screening is widely recommended as standard of care, while universal screening is less common but is progressively considered as the optimal strategy for identification of children with cCMV. As with all screening programs, cCMV screening requires commitments to equitable and reliable testing, follow-up and services.