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Screening For Jaundice In Ghanaian Neonates By Smartphone Sclera Imaging

Felix Outlaw1, Miranda Nixon1, Terence S Leung1, Nicola Robertson2, Nana Okai Brako3, Judith Meek4, Christabel Enweronu-Laryea5 
1Dept of Medical Physics and Biomedical Engineering, UCL; 2UCL Institute for Women’s Health and UCLH; 3Greater Accra Regional Hospital; 4The Neonatal Care Unit, Elizabeth Garrett Anderson Wing, UCLH; 5Dept of Child Health, University of Ghana School of Medicine and Dentistry and Korle-Bu Teaching Hospital 
Introduction (include hypothesis) 
Timely identification of jaundice remains problematic. Specialised screening devices such as the transcutaneous bilirubinometer exist but are rarely available in the home setting, particularly in low-income parts of the world. In Sub-Saharan Africa, long-term impairment following kernicterus is eight times more common than in high-income countries [1]. Smartphones may serve as objective and ubiquitous colorimeters. We seek to show that a sclera imaging app could screen for jaundice with comparable accuracy to a transcutaneous bilirubinometer. 
The app was used to image the sclera of 101 newborns in the Greater Accra Regional Hospital before a blood test for determination of total serum bilirubin (TSB) concentration. Pixel values were extracted from manually drawn regions of interest in the sclera. A regression model was used to relate sclera chromaticity to TSB. We call the output of this model the Scleral-Conjunctival Bilirubin (SCB), in analogy with Transcutaneous Bilirubin (TcB). A TcB measurement was also made using the Draeger JM-105. This study is funded by Saving Lives at Birth with ethical approval from Ghana Health Services, UCL, and University of Ghana Ethics Committees. 
A correlation of r=0.79 (p<0.01) was achieved between SCB and TSB. In screening for newborns with TSB greater than 250μmol/L, the NICE-recommended threshold for blood test referral in term infants [2], a SCB decision threshold of 215μmol/L maximised Youden’s Index. The sensitivity (95% confidence interval) was 96% (89% – 99%), with specificity 72% (62% – 81%). The area under the Receiver Operating Characteristic curve (AUROC) was 0.91. With the same subjects and decision criteria, the JM-105 gave correlation 0.76 (p<0.01), sensitivity 89% (81% – 94%), specificity 77% (67% – 85%), and AUROC 0.84. 
We have shown that a colour-based jaundice metric from a sclera image has a screening performance at least as good as the latest generation of TcBs, and that this imaging is feasible with a smartphone in a clinical setting in Ghana. We will integrate analysis into the app for real-time results and improve robustness and usability. 
[1] Bhutani, Vinod K., et al. Pediatric research 74.S1 (2013): 86.  [2] National Institute for Clinical Excellence. “Jaundice in newborn babies under 28 days.” (2016). 

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