Over 300,000 infants are born annually with sickle cell anemia (SCA) in sub-Saharan Africa, and >50% die young from infection or anemia, usually without diagnosis of SCA. Early identification by newborn screening (NBS), followed by simple interventions dramatically reduced the mortality of SCA in the United States, but this strategy is not yet established in Africa. We designed and implemented a proof-of-principle NBS and treatment program for SCA in Angola, with focus on capacity building and local ownership. Dried bloodspots from newborns were collected from five birthing centers. Hemoglobin identification was performed using isoelectric focusing; samples with abnormal hemoglobin patterns were analyzed by capillary electrophoresis. Infants with abnormal FS or FSC patterns were enrolled in a newborn clinic to initiate penicillin prophylaxis and receive education, pneumococcal immunization, and insecticide-treated bed nets. A total of 36,453 infants were screened with 77.31% FA, 21.03% FAS, 1.51% FS, and 0.019% FSC. A majority (54.3%) of affected infants were successfully contacted and brought to clinical care. Compliance in the newborn clinic was excellent (96.6%). Calculated first-year mortality rate for babies with SCA compares favorably to the national infant mortality rate (6.8 vs. 9.8%). The SCA burden is extremely high in Angola, but NBS is feasible. Capacity building and training provide local healthcare workers with skills needed for a functional screening program and clinic. Contact and retrieval of all affected SCA infants remains a challenge, but families are compliant with clinic appointments and treatment. Early mortality data suggest screening and early preventive care saves lives. Am. J.

Objective To assess the cost-effectiveness of a pilot newborn screening (NBS) and treatment program for sickle cell anemia (SCA) in Luanda, Angola. Study design In July 2011, a pilot NBS and treatment program was implemented in Luanda, Angola. Infants identified with SCA were enrolled in a specialized SCA clinic in which they received preventive care and sickle cell education. In this analysis, the World Health Organization (WHO) and generalized cost-effectiveness analysis methods were used to estimate gross intervention costs of the NBS and treatment program. To determine healthy life-years (HLYs) gained by screening and treatment, we assumed NBS reduced mortality to that of the Angolan population during the first 5 years based upon WHO and Global Burden of Diseases Study 2010 estimates, but provided no significant survival benefit for children who survive through age 5 years. A secondary sensitivity analysis with more conservative estimates of mortality benefits also was performed. The costs of downstream medical costs, including acute care, were not included. Results Based upon the costs of screening 36 453 infants and treating the 236 infants with SCA followed after NBS in the pilot project, NBS and treatment program is projected to result in the gain of 452-1105 HLYs, depending upon the discounting rate and survival assumptions used. The corresponding estimated cost per HLY gained is $1380-$3565, less than the gross domestic product per capita in Angola. Conclusions These data demonstrate that NBS and treatment for SCA appear to be highly cost-effective across all scenarios for Angola by the WHO criteria.

Severe anemia is an important cause of morbidity and mortality among children in resource-poor settings, but laboratory diagnostics are often limited in these locations. To address this need, we developed a simple, inexpensive, and color-based point-of-care (POC) assay to detect severe anemia. The purpose of this study was to evaluate the accuracy of this novel POC assay to detect moderate and severe anemia in a limited-resource setting. The study was a cross-sectional study conducted on children with sickle cell anemia in Luanda, Angola. The hemoglobin concentrations obtained by the POC assay were compared to reference values measured by a calibrated automated hematology analyzer. A total of 86 samples were analyzed (mean hemoglobin concentration 6.6 g/dL). There was a strong correlation between the hemoglobin concentrations obtained by the POC assay and reference values obtained from an automated hematology analyzer (r=0.88, P<0.0001). The POC assay demonstrated excellent reproducibility (r=0.93, P<0.0001) and the reagents appeared to be durable in a tropical setting (r=0.93, P<0.0001). For the detection of severe anemia that may require blood transfusion (hemoglobin <5 g/dL), the POC assay had sensitivity of 88.9% and specificity of 98.7%. These data demonstrate that an inexpensive (<$0.25 USD) POC assay accurately estimates low hemoglobin concentrations and has the potential to become a transformational diagnostic tool for severe anemia in limited-resource settings.

480 Background: Sickle cell anemia (SCA) is a significant global health problem with >300,000 affected infants born each year in sub-Saharan Africa. Up to 80–90% of all children with SCA in Africa die before five years of age, due to infection or anemia, and usually without the proper diagnosis of SCA. Early identification by newborn screening (NBS), followed by interventions such as pneumococcal immunization and prophylactic penicillin, have dramatically reduced the mortality of children with SCA in the US, but this strategy not yet been established in Africa. A novel public-private partnership involving the Republic of Angola, Chevron Corporation, and Baylor College of Medicine/Texas Children's Hospital was created to develop a pilot NBS and treatment program for SCA, focusing on capacity building and local ownership. Methods: Two large maternity hospitals in the capital city of Luanda, Angola were initially selected for dried blood spot (DBS) collection and analysis, and a third local health center was soon added. Maternity nurses were taught DBS collection and laboratory technicians learned isoelectric focusing (IEF) and capillary electrophoresis (CE) techniques. Identifiers including cell phone numbers are collected onto the Whatman NBS card to facilitate retrieval of affected babies. After collection, DBS were transported to the central NBS laboratory at Hospital Pediátrico David Bernardino (HPDB) for hemoglobin identification by IEF and CE. Demographic data and test results were entered into a unique internet-based electronic data capture system designed with secure password-protection and servers located in Houston, Texas. Results: Since initiation of NBS in July 2011, 17,055 babies have DBS collection and laboratory results: 3,588 (21%) with FAS pattern (sickle cell trait), and 264 (1.55%) with FS (consistent with SCA). Twenty-one samples produced a result other than FA, FAS, or FS, including 10 FAC and 1 FSC. Families of infants with an FS screening result are notified by phone to initiate care and treatment, ideally by age 8 weeks. In the new infant SCA clinic at HPDB, infants receive penicillin prophylaxis and PCV-13 pneumococcal immunization, while parents receive sickle cell education and insecticide-treated bed nets for malaria protection. In the first 6 months, 67.8% of DBS cards had phone numbers documented, but with education and reinforcement, 81.4% of cards had phone numbers in the past 6 months. To date, 220 FS babies are age-eligible for contact and 110 (50%) families have been reached: 104 (47%) have come to the infant SCA clinic, 6 (2.7%) had already died within the first month of life, and 0 refused care. A total of 201 doses of PCV-13 have been provided as per routine vaccination scheduling. After initial visit, the return rate for second immunization is 94% with only 3 babies lost to follow-up including 2 deaths. The calculated first-year mortality rate for all contacted FS babies (6.9%) compares favorably to the national infant mortality rate (9.8%). Conclusions: This prospective pilot study documents that newborn screening for SCA is feasible in a developing country such as Angola. Capacity building and teaching provide local healthcare workers with skills necessary to have a functional NBS program and infant SCA clinic. The sickle cell burden is extremely high in Angola, and contact and retrieval of all affected FS infants remains an ongoing challenge, but families are compliant with clinic appointments and treatment. Early mortality data suggest comprehensive SCA care can save lives, suggesting that expansion of the pilot program is warranted with an eventual national strategy for the diagnosis, care, and treatment of children with SCA in Angola. Disclosures: No relevant conflicts of interest to declare.

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.

Background Sickle cell anemia (SCA) is a significant, under recognized contributor to global childhood mortality, especially in sub-Saharan Africa. Early diagnosis is critical to enable timely access to care and education, before severe and life-threatening complications develop in the first year of life. Unfortunately, such early and comprehensive care remains largely unavailable for many infants across Africa. In an attempt to reduce the high early mortality associated with SCA, an infant SCA clinic was developed and implemented in the capital city of Luanda, Angola. We describe the early experiences and successful outcomes for infants enrolled in this clinic. Methods Infants were enrolled in the clinic if the diagnosis of SCA was made in the first year of life. The clinic was established in the major public pediatric hospital in Angola, Hospital Pediátrico David Bernardino (HPDB). The vast majority of enrolled infants were diagnosed by newborn screening at local maternity hospitals, while some were diagnosed due to clinical suspicion or known family history. Initial clinic visit included intake of demographics such as contact information, family history, and details of basic housing conditions. A dried bloodspot was collected and the diagnosis of SCA was confirmed by isoelectric focusing. All families received sickle cell education and confirmed infants received penicillin prophylaxis (125 mg by mouth twice per day), pneumococcal vaccination series (Prevnar-13), and an insecticide-treated mosquito net for malaria prophylaxis. Results In the first twenty months of the HPDP Infant SCA clinic, 301 infants were enrolled. Eighty-one percent (244/301) were identified through the associated newborn screening program, while the remaining fifty-seven infants presented due to clinical symptoms or known family history. Families live in the urban and poverty-stricken Luanda. The average household has 6.4 people with 2.8 people per bedroom. Only 34.2% of families reported access to water within their household. Despite poverty and difficult housing situations, continued follow-up was extraordinarily high at 97.3%. After the initial visit, only eight families (2.7%) chose not to follow-up – four preferred faith or traditional healing techniques, and four chose follow-up care at a private clinic. With a concentrated effort to track and enable timely follow-up care, there were zero babies truly “lost to follow-up.” For the 167 babies who are now at least one year of age, the calculated infant mortality rate (under 1 year of age) is 6.6%, which compares favorably to the nationally reported infant mortality rate for all children (9.8%). Upon reviewing the 11 deaths, in nearly all cases the families sought appropriate medical care as instructed, and most deaths were likely preventable if appropriate and timely emergency care were available in the community. Conclusions Early mortality associated with SCA can be significantly reduced through early diagnosis and access to care and education, even in countries with few health resources such as Angola. These experiences with a newborn clinic in the urban city of Luanda demonstrate that simple, lifesaving care is feasible and that follow-up and survival is excellent. Although the survival in this Angolan cohort was even better than the national infant mortality rate, the few deaths illustrate gaps in the understanding of emergency SCA care among the healthcare community. It is critical to include education and training of healthcare professionals at all levels of care in any national strategy, so that children with SCA can be promptly triaged and adequately treated for emergent and life-threatening complications. Disclosures: No relevant conflicts of interest to declare.

Background: Severe anemia is a leading cause of morbidity and mortality among children in low-resource countries, particulalrly in sub-Saharan Africa, where malaria is endemic and sickle cell disease is prevalent. In many low-resource regions, particularly more remote areas, laboratory diagnostics are not always readily available. The utility of available equipment can be limited by lack of technical expertise, maintenance, and trained personnel, as well as lack of affordable reagents and reliable power. In a setting where severe, life-threatening anemia is common, it is critical for providers to have access to a rapid and accurate diagnostic tool to determine which patients need acute evaluation and treatment. A simple, rapid, accurate, and disposable point-of-care assay (AnemoCheck¨) has recently been tested and published(Tyburski et al. JCI 2014, in press), Hemoglobin concentration is measured by assessing the color of a chemical solution containing hydrogen peroxide and 3,3',5,5'-tetramethylbenzidine, after mixing with 10μL blood. The AnemoCheck assay is self-contained and does not require electricity, complicated sensors, or additional equipment. The color scale of the original assay correlated well with mild anemia (Hb 9-13 g/dL) but was not designed to discriminate lower hemoglobin concentrations. Accordingly, the test was modified to allow the color scale to detect more severe anemia (Hb 2.5-9.1 g/dL), but needs to be tested in a real-world setting where severe anemia is prevalent. Methods: The primary objective of this study was to determine whether AnemoCheck tests could measure hemoglobin concentrations at least as accurately as currently used standard laboratory techniques in low resource settings where severe anemia is common. The study was performed in the sickle cell clinic at Hospital Pedi‡trico David Bernardino, a large, public pediatric hospital in Luanda, Angola. After receiving informed consent from a parent or guardian, capillary blood was collected by fingerstick as per routine to measure hemoglobin using a BioSystems BTS-350 Hemoglobin Analyzer. A small sample of capillary blood was also collected for the AnemoCheck assay using a 10μL end-to-end capillary tube via capillary action (Sanguis Counting, Germany). Venous blood was also collected to measure hemoglobin using a calibrated hematology analyzer (Sysmex XT-2000i), which was considered the true hemoglobin concentration for comparison purposes. Hemoglobin was determined first by AnemoCheck by placing the 10μL capillary into a 2mL screw cap polypropylene tube containing the chemical reagents. The tube was then vigorously shaken and after 60 seconds, was compared to a standardized color scale and the hemoglobin concentration was determined. The AnemoCheck results were obtained and recorded before any additional machine-determined results were available, to avoid potential bias. Results: For this pilot study, samples were collected from 40 children for hemoglobin determination by all three methods. The range of hemoglobin concentrations, based on results from the Sysmex hematology analyzer, was 4.8 – 9.2 g/dL (median 7.0). As illustrated in the Figure, the hemoglobin values obtained from the AnemoCheck assay correlated well with the Sysmex hematology analyzer results, r=0.74, p<0.0001. The AnemoCheck results were more accurate than the hemoglobin values obtained by the BioSystems Hemoglobin Analyzer (r=0.47, p=0.020), which is the primary mode of hemoglobin determination in the clinic. On average, the hemoglobin obtained by AnemoCheck was within 0.5 g/dL of the Sysmex value (range 0-1.9 g/dL), compared to the Biosystems value (absolute mean difference=0.7 g/dL, range 0-2.2 g/dL). Figure 1 Figure 1. Conclusions: Laboratory diagnosis of anemia is expensive and difficult in low resource settings such as Angola, where severe anemia is common and life-threatening. Our pilot data demonstrate that a novel, point-of-care, color-based assay that does not require electricity or expensive reagents is able to accurately estimate low hemoglobin concentrations. Further refinements of the AnemoCheck assay will include photographic color assessment and automated hemoglobin estimation, which will be helpful in resource-poor settings. This test has the potential to become extremely useful diagnostic tool in low resource hospitals and health centers, where sophisticated equipment and reagents may not be available. Disclosures No relevant conflicts of interest to declare.

2064 Background: Systematic newborn screening (NBS) for sickle cell anemia (SCA) is a practice limited almost entirely to developed countries, which include only a small fraction of annual global SCA births. There are several different laboratory methods used for NBS of hemoglobin disorders, including isoelectric focusing (IEF), capillary electrophoresis (CE), high-performance liquid chromatography (HPLC) and DNA-based testing. However, most NBS occurs in developed countries with standardized specimen collection and storage techniques, advanced laboratory technology and support, and adequate financial resources. For the newly instituted pilot newborn screening program in Angola, IEF and CE were initially selected as the laboratory methods of choice. After the first 12 months of the pilot program, we analyzed the costs of developing the NBS program and compared the reliability and consistency of newborn hemoglobin identification. Methods: After birth, two dried bloodspots (DBS) are collected by heelstick onto a Whatman screening card. Specimens are dried, placed in plastic bags for storage, and transported every 1–3 days to the central NBS laboratory at Hospital Pediátrico David Bernardino, where they are refrigerated until testing. All specimens are initially tested by IEF (RESOLVE neonatal hemoglobin system, PerkinElmer Inc.) within 3–5 days. Hemoglobin identification is performed using a fluorescent glow box and samples are scored according to the presence of HbF, HbA and HbS. The FAS pattern is consistent with sickle cell trait and FS is consistent with SCA. All IEF results with an FAS or FS pattern or an uncertain result are selected for repeat analysis by CE, performed using the CAPILLARYS 2 NEONAT FAST system (Sebia, Inc.). All newborns with an FS result by either method were contacted by telephone to obtain repeat sample for confirmatory testing and enrollment in the newborn sickle cell clinic. Results: Costs: Initial start-up costs included 20,000 DBS cards designed specifically for the Angolan program ($45,000 USD) and lab equipment ($40,330 for IEF, $118,155 for CE, total of $158,485 USD), sufficient for the entire first year of the program. Collection costs (including gloves, lancets and alcohol pads) were calculated at $0.46 USD per sample, while sample collection and transport was $0.09 per sample. Once the DBS samples were received at the central testing laboratory, the reagent costs for sample analysis were $1.06 for IEF and $3.52 for CE, while labor costs were $0.35 for each test. Laboratory Reliability: To date, 17,055 samples have been run by IEF and 100% of these samples have obtained an adequate IEF result regardless of quality of bloodspot. To date, 2,895 samples have been selected for CE analysis, but only 2,031 (70.2%) produced interpretable results by CE. The remaining 29.8% of samples (mostly within the first 6 months of CE training period) did not produce a result due to hemoglobin degradation, inadequate blood spotting technique, mechanical failure, or unclear technical issues. For specimens with a result by both IEF and CE, concordance was greater than 99%. Conclusions: The development of a newborn screening program for SCA in Angola required an initial financial investment to obtain appropriate laboratory testing equipment. After this upfront investment, the total cost of newborn screening for SCA, including costs of collection, processing and laboratory analysis was about $3 USD for each initial IEF screening test and $4–5 USD for each CE result. This per-cost test compares favorably in relation to the public health benefit of identifying and retrieving affected infants. The cost of initiating a program in other countries may be significantly less than in Angola, which has a very expensive economy and resulted in high prices for many of the reagent and equipment costs. Given the variable quality of dried blood spot collection and the unavailability of ideal specimen storage and transport conditions, isoelectric focusing appears to be a more reliable, robust and economical method of newborn screening than capillary electrophoresis for sickle cell anemia in sub-Saharan Africa. Disclosures: No relevant conflicts of interest to declare.