Cost effectiveness of latent tuberculosis screening among asylum seekers in Stockholm

Introduction The burden of tuberculosis (TB) in Sweden is concentrated among migrants from high TB incidence countries. The incident cases in Sweden arise mainly through reactivation of a latent tuberculosis infection (LTBI) acquired in the home country or during transit. Progression from LTBI to active TB disease can be prevented through treatment with anti-tubercular medicines. LTBI screening is therefore offered for asylum seekers and refugees in Sweden as part of a voluntary health examination (HE). Little is known about their experiences of LTBI screening and treatment. In addition, there has been no previous evaluation of the cost-effectiveness of the current LTBI screening policy in Stockholm or Sweden. Aims The overarching aim of this thesis was to determine the cost-effectiveness of the current strategy of screening for LTBI among asylum seekers in Stockholm. This aim was achieved through the following specific objectives: 1) to assess the methodology of previously published economic models of LTBI screening and to develop an analytical framework, 2) to understand the experiences of asylum seekers with HE, 3) to quantify health-related quality of life (HRQoL) of LTBI patients and to explore the factors influencing it, 4) to quantify the HRQoL of TB patients, and 5) to assess the cost effectiveness of LTBI screening through an economic model. Methods A qualitative study was designed to explore the experiences of asylum seekers with HE; semi-structured interviews were conducted based on an interview guide. For the HRQoL studies, a HRQoL instrument, EQ-5D, and a mental health screening instrument, RHS-15, were used. For the LTBI patients, a mixed-method design was used, in which a crosssectional survey using the EQ-5D and RHS-15 instruments was combined with qualitative interviews of a subgroup. For the TB patients, a longitudinal study design was used in which a cohort filled the EQ-5D instrument at the beginning and the end of treatment. A literature review was performed to assess the methodology of published economic modelling studies of LTBI screening. Through this review a framework was developed guiding the development of an economic model (a Markov model) to assess the cost effectiveness of the current LTBI screening in Stockholm compared to a hypothetical scenario of no screening. The analysis adopted the societal perspective, and results were presented in term of incremental costeffectiveness ratios (ICERs); taking 500 000 SEK/QALY as a cost-effectiveness threshold. Results The HE was perceived as available by asylum seekers, with no serious physical or financial accessibility problems. They felt respected and trusted by the healthcare workers. However, information about the Swedish healthcare system was perceived to be incomplete and the HE was seen as non-responsive to their individual needs with main focus on infectious diseases. Among LTBI patients, 38% screened positive for mental health concerns using RHS-15, and 28% scored problems on mental health dimension of EQ-5D. These patients expressed fear of being contagious to others, an ambiguous threat of a vague diagnosis and future uncertainties about developing TB disease. However, LTBI patients had no overall HRQoL decrement. TB patients had a HRQoL utility score of 0,72 at the beginning of treatment, which improved significantly by the end of the treatment to 0,84. The cost effectiveness results showed that ICER is the lowest among the age group 13 to 19 at 303 881 SEK/QALY, which was the only ICER below the 500 000 SEK/QALY threshold. Discussion Asylum seekers had a generally positive attitude towards HE, including TB and LTBI screening, but also emphasized the need to broaden the focus on all health needs rather than solely focusing on infectious diseases. LTBI patients might have a compromised mental health partly linked to fear of TB disease. Therefore, it can be beneficial to address these concerns as part of LTBI management. TB patients had a compromised HRQoL and a decrement of 0,28 for TB patients is recommended to be used in economic evaluations. LTBI screening among asylum seekers in Stockholm is cost effective in the age group 13 to 19 while it is moderately cost-effective in the age groups 0 to 12 and 20 to 34 years. The latter is mainly due to the restrictive practices of offering treatment for persons over the age of 20 years. Conclusions Health examination is an acceptable, accessible health service. However, its quality can be improved by broadening the focus beyond infectious disease control. An LTBI diagnosis can be misunderstood as active TB and linked to stigma. The cost-effectiveness analysis showed that screening is cost effective only when preventive treatment is offered. Therefore, due to ethical and economic reasons, LTBI screening should only be performed for asylum seekers who are potentially eligible for LTBI treatment

Cost-effectiveness of Different Strategies for Screening and Treatment of Strongyloides stercoralis in Migrants From Endemic Countries to the European Union

Background: The best strategy for controlling morbidity due to imported strongyloidiasis in migrants is unclear. We evaluate the cost-effectiveness of six possible interventions. Methods: We developed a stochastic Markov chain model. The target population was adult migrants from endemic countries to the European Union; the time horizon, a lifetime and the perspective, that of the health system. Average and incremental cost-effectiveness ratios (ACER and ICER) were calculated as 2016 EUR/life-year gained (LYG). Health interventions compared were: base case (no programme), primary care-based presumptive treatment (PCPresTr), primary care-based serological screening and treatment (PCSerTr), hospital-based presumptive treatment (HospPresTr), hospital-based serological screening and treatment (HospSerTr), hospital-based presumptive treatment of immunosuppressed (HospPresTrim) and hospital-based serological screening and treatment of the immunosuppressed (HospSerTrim). The willingness to pay threshold (WTP) was ¿32 126.95/LYG. Results: The base case model yielded a loss of 2 486 708.24 life-years and cost EUR 3 238 393. Other interventions showed the following: PCPresTr: 2 488 095.47 life-years (Δ1 387.23LYG), cost: EUR 8 194 563; ACER: EUR 3573/LYG; PCSerTr: 2 488 085.8 life-years (Δ1377.57LYG), cost: EUR 207 679 077, ACER: EUR 148 407/LYG; HospPresTr: 2 488 046.17 life-years (Δ1337.92LYG), cost: EUR 14 559 575; ACER: EUR 8462/LYG; HospSerTr: 2 488 024.33 life-years (Δ1316.08LYG); cost: EUR 207 734 073; ACER: EUR 155 382/LYG; HospPresTrim: 2 488 093.93 life-years, cost: EUR 1 105 483; ACER: EUR -1539/LYG (cost savings); HospSerTrim: 2 488 073.8 life-years (Δ1365.55LYG), cost: EUR 4 274 239; ACER: EUR 759/LYG. One-way and probabilistic sensitivity analyses were undertaken; HospPresTrim remained below WTP for all parameters' ranges and iterations. Conclusion: Presumptively treating all immunosuppressed migrants from areas with endemic Strongyloides would generate cost savings to the health system

sj-docx-1-sjp-10.1177_14034948231160616 – Supplemental material for The burden of disease due to COVID-19 in Sweden 2020–2021: A disability-adjusted life years (DALYs) study

Supplemental material, sj-docx-1-sjp-10.1177_14034948231160616 for The burden of disease due to COVID-19 in Sweden 2020–2021: A disability-adjusted life years (DALYs) study by Jad Shedrawy, Patricia Ernst, Knut Lönnroth and Fredrik Nyberg in Scandinavian Journal of Public Health</p

Diagnostic pathways and delay among tuberculosis patients in Stockholm, Sweden: a retrospective observational study

Abstract Background Asylum seekers in Sweden are offered tuberculosis (TB) screening at a voluntary post-arrival health examination. The role of this screening in improving the TB diagnostic pathway has not been previously evaluated. The aim of this study was to determine diagnostic pathways for active TB cases and compare diagnostic delays between different pathways. Methods Retrospective review of medical records of patients reported with active TB in Stockholm in 2015, using a structured and pre-coded form. Results Seventy-one percent of patients actively sought health care due to symptoms. As for source of referral to TB specialist clinic, 15% came from screening of eligible migrants, of whom the majority were asymptomatic. Among asylum seekers, 69% were identified through screening at a health examination (HE). The main sources of referral to TB clinics were emergency departments (27%) and primary health care centers (20%). Median health care provider delay was significantly longer in patients identified through migrant screening in health examination. Conclusions Screening at a health examination was the main pathway of active TB detection among mainly asymptomatic and non-contagious asylum seekers but contributed modestly to total overall TB case detection. In these patients TB was diagnosed early in a non-contagious phase of the disease. Further research is required to assess the effectiveness and cost-effectiveness of HE TB screening as well as inclusion of other groups of migrants from high incidence countries in the screening program in terms of impact on delay, transmission and treatment outcomes

Cost-effectiveness of different strategies for screening and treatment of Strongyloides stercoralis in migrants from endemic countries to the European Union

The best strategy for controlling morbidity due to imported strongyloidiasis in migrants is unclear. We evaluate the cost-effectiveness of six possible interventions

Estimating costs and health outcomes of publicly funded tick-born encephalitis vaccination: A cost-effectiveness analysis

Background: The number of notified cases of Tick-Borne Encephalitis (TBE) in Sweden has been increasing the past years despite the increased use of TBE-vaccine not subsidized by the healthcare system. Stockholm County is a high endemic area and an earlier study has shown that low-income households have lower vaccination coverage even when they are at high risk. This paper aims to determine the cost-effectiveness of a publicly funded TBE vaccination program in Stockholm. Methods: In three different cohorts with individuals aged 3, 40 or 50 years, long-term costs and health outcomes of an out-of-pocket strategy (53% of the cohort is vaccinated on their own expenses) and a structured vaccination program (full cohort is vaccinated covered by the publicly funded health care system), were estimated using a Markov model. The Markov model predicts the costs and effects in term of Quality-adjusted Life Years (QALYs) over a lifetime horizon using a third-party healthcare payer perspective. The primary results are presented as an incremental cost effectiveness ratio (ICER) indicating the additional cost required to achieve one additional QALY with the structured vaccination program. Results: The results show that the structured vaccination program is associated with a gain in QALYs and increased costs compared with an out-of-pocket strategy. The calculated ICERs were 27 761, 99 527 and 160 827 SEK/QALY in cohorts of age 3, 40 and 50, respectively. The sensitivity analyses showed that the results are robust when varying different parameters. Conclusion: Given the setting of Stockholm county, this analysis shows a cost per QALY of a free vaccinations program, especially for children of 3 years old, below generally acceptable cost-effectiveness thresholds in Sweden.

Burden of Disease of COVID-19: Strengthening the Collaboration for National Studies.

Objectives: Quantifying the combined impact of morbidity and mortality is a key enabler to assessing the impact of COVID-19 across countries and within countries relative to other diseases, regions, or demographics. Differences in methods, data sources, and definitions of mortality due to COVID-19 may hamper comparisons. We describe efforts to support countries in estimating the national-level burden of COVID-19 using disability-adjusted life&nbsp;years. Methods: The European Burden of Disease Network developed a consensus methodology, as well as a range of capacity-building activities to support burden of COVID-19 studies. These activities have supported 11 national studies so far, with study periods between January 2020 and December&nbsp;2021. Results: National studies dealt with various data gaps and different assumptions were made to face knowledge gaps. Still, they delivered broadly comparable results that allow for interpretation of consistencies, as well as differences in the quantified direct health impact of the&nbsp;pandemic. Discussion: Harmonized efforts and methodologies have allowed for comparable estimates and communication of results. Future studies should evaluate the impact of interventions, and unravel the indirect health impact of the COVID-19&nbsp;crisis.</p