Economic analysis of the impact of overseas and domestic treatment and screening alternatives for parasitic infections among U.S.-bound refugees from Sub-Saharan Africa, 2013-2022

U.S.-bound refugees from sub-Saharan Africa arrive from countries where parasitic infections are highly endemic (including hookworm, ascariasis, trichuriasis, strongyloidiasis, schistosomiasis, and malaria). These infections are rare in the United States and may be underdiagnosed or misdiagnosed. This evaluation examined costs and health outcomes of four alternatives: 1) 'Overseas Presumptive Treatment', 2) Domestic Screening and Treatment', 3) 'Domestic Presumptive Treatment', and 4) 'No Program' using decision trees terminating in Markov transition state models. The current program, 'Overseas Presumptive Treatment', is the least expensive and most effective alternative with baseline parameter estimates. Relative to 'No Program', the net cost per QALY gained for 'Overseas Presumptive Treatment' has 95% uncertainty interval (UI) from cost-saving to $52,000, 'Domestic Screening and Treatment': 95% UI: $6,700-$580,000, and 'Domestic Presumptive Treatment': 95% UI $12,000-$1.29 million. Even using conservative parameter assumptions, overseas presumptive treatment is cost-effective and reduces the burden of parasitic infections among sub-Saharan refugees.