Cost-effectiveness of the latent tuberculosis screening program for migrants in Stockholm Region.

INTRODUCTION: The majority of tuberculosis (TB) cases in Sweden occur among migrants from endemic countries through activation of latent tuberculosis infection (LTBI). Sweden has LTBI-screening policies for migrants that have not been previously evaluated. This study aimed to assess the cost-effectiveness of the current screening strategy in Stockholm. METHODS: A Markov model was developed to predict the costs and effects of the current LTBI-screening program compared to a scenario of no LTBI screening over a 50-year time horizon. Epidemiological and cost data were obtained from local sources when available. The primary outcomes were incremental cost-effectiveness ratio (ICER) in terms of societal cost per quality-adjusted life year (QALY). RESULTS: Screening migrants in the age group 13-19 years had the lowest ICER, 300,082 Swedish Kronor (SEK)/QALY, which is considered cost-effective in Sweden. In the age group 20-34, ICER was 714,527 SEK/QALY (moderately cost-effectives) and in all age groups above 34 ICERs were above 1,000,000 SEK/QALY (not cost-effective). ICER decreased with increasing TB incidence in country of origin. CONCLUSION: Screening is cost-effective for young cohorts, mainly between 13 and 19, while cost-effectiveness in age group 20-34 years could be enhanced by focusing on migrants from highest incidence countries and/or by increasing the LTBI treatment initiation rate. Screening is not cost-effective in older cohorts regardless of the country of origin.

Evaluation of the latent tuberculosis screening and treatment strategy for asylum seekers in Stockholm, Sweden 2015-2018: a record linkage study of the care cascade.

INTRODUCTION: About 90% of active tuberculosis (TB) cases in Sweden are foreign born and are mainly due to latent TB infection (LTBI) reactivation. The aim of this study was to assess the current migrant LTBI screening programme with regards to test results and completion of the care cascade. METHOD: A retrospective cohort of all 14173 individuals attending a health examination was established for the Stockholm Region 2015-2018 through record-linkage of data extracted from the Swedish Migration Authority and medical records. Screening results, referrals to specialist care and treatment initiation were ascertained through automated data extraction for the entire cohort. Detailed cascade steps, including treatment completion, were analysed through manual data extraction for a subsample of all persons referred to specialist care in the period 2016-2017. RESULTS: Of 5470 patients screened with an interferon-gamma release assay (IGRA), 1364 (25%) were positive, of whom 358 (26%) initiated LTBI treatment. An increased trend in IGRA-positivity was seen for increased age and TB-incidence in country of origin. Among the IGRA positive patients, 604 (44%) were referred to specialist care. Lower age was the main referral predictor. In the subsample of 443 patients referred to specialist care in 2016-2017, 386 (87%) were invited, of whom 366 (95%) attended. Of 251 patients (69%) recommended for LTBI treatment, 244 (97%) started such treatment and of those 221 (91%) completed it. CONCLUSION: The low attrition in patient-dependent cascade steps shows that the voluntary approach works well. Low LTBI treatment attainment is due to the current conservative local treatment policy, which means the vast majority are IGRA-tested without an intention to treat for LTBI.

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.

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

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.