Division of Global Migration and Quarantine, U.S. Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
Infectious Disease Section, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN 55417, USA.
J Travel Med. 2024 Aug 3;31(6). doi: 10.1093/jtm/taad054.
The risk of developing strongyloidiasis hyperinfection syndrome appears to be elevated among individuals who initiate corticosteroid treatment. Presumptive treatment or treatment after screening for populations from Strongyloides stercoralis-endemic areas has been suggested before initiating corticosteroids. However, potential clinical and economic impacts of preventative strategies have not been evaluated.
Using a decision tree model for a hypothetical cohort of 1000 individuals from S. stercoralis-endemic areas globally initiating corticosteroid treatment, we evaluated the clinical and economic impacts of two interventions, 'Screen and Treat' (i.e. screening and ivermectin treatment after a positive test), and 'Presumptively Treat', compared to current practice (i.e. 'No Intervention'). We evaluated the cost-effectiveness (net cost per death averted) of each strategy using broad ranges of pre-intervention prevalence and hospitalization rates for chronic strongyloidiasis patients initiating corticosteroid treatment.
For the baseline parameter estimates, 'Presumptively Treat' was cost-effective (i.e. clinically superior with cost per death averted less than a threshold of $10.6 million per life) compared to 'No Intervention' ($532 000 per death averted) or 'Screen and Treat' ($39 000 per death averted). The two parameters contributing the most uncertainty to the analysis were the hospitalization rate for individuals with chronic strongyloidiasis who initiate corticosteroids (baseline 0.166%) and prevalence of chronic strongyloidiasis (baseline 17.3%) according to a series of one-way sensitivity analyses. For hospitalization rates ≥0.022%, 'Presumptively Treat' would remain cost-effective. Similarly, 'Presumptively Treat' remained preferred at prevalence rates of ≥4%; 'Screen and Treat' was preferred for prevalence between 2 and 4% and 'No Intervention' was preferred for prevalence <2%.
The findings support decision-making for interventions for populations from S. stercoralis-endemic areas before initiating corticosteroid treatment. Although some input parameters are highly uncertain and prevalence varies across endemic countries, 'Presumptively Treat' would likely be preferred across a range for many populations, given plausible parameters.
在开始皮质类固醇治疗的个体中，发展强中感染综合征的风险似乎升高。有人建议在开始皮质类固醇治疗之前，对来自 Strongyloides stercoralis 流行地区的人群进行筛查并进行治疗，或进行推定治疗。然而，预防策略的潜在临床和经济影响尚未得到评估。
我们使用决策树模型，对来自全球 Strongyloides stercoralis 流行地区的 1000 名个体进行了假设队列分析，评估了两种干预措施（即筛查和阳性检测后用伊维菌素治疗）和“推定治疗”与当前实践（即“无干预”）相比的临床和经济影响。我们使用广泛的皮质类固醇治疗慢性 Strongyloides 患者住院率和治疗前流行率，评估了每种策略的成本效益（每例死亡避免的净成本）。
对于基线参数估计，与“无干预”（每例死亡避免 532,000 美元）或“筛查和治疗”（每例死亡避免 39,000 美元）相比，“推定治疗”在成本效益方面具有优势（即临床效果更好，每例死亡避免的成本低于 1060 万美元的阈值）。对分析影响最大的两个参数是接受皮质类固醇治疗的慢性 Strongyloides 患者的住院率（基线为 0.166%）和慢性 Strongyloides 的流行率（基线为 17.3%）。根据一系列单因素敏感性分析，对于住院率≥0.022%，“推定治疗”仍具有成本效益。同样，在流行率≥4%的情况下，“推定治疗”仍然是首选；在流行率在 2%至 4%之间时，“筛查和治疗”是首选；而在流行率<2%时，“无干预”是首选。
这些发现支持针对来自 Strongyloides stercoralis 流行地区人群的皮质类固醇治疗前干预措施的决策。尽管一些输入参数高度不确定，并且流行率在流行国家之间有所不同，但在许多人群中，根据合理的参数，“推定治疗”可能是首选。
