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Appendix for Economic analysis of the impact of overseas and domestic treatment and screening options for intestinal helminth infection among US-bound refugees from AsiaBrian Maskery,1 PhD, MS; Margaret S. Coleman,1 PhD; Michelle Weinberg, 1 MD; Weigong Zhou,1 MD, PhD; Lisa Rotz,1 MD; Alexander Klosovsky,2 MD; Paul T. Cantey,3 MD, MPH; LeAnne M. Fox, MD, MPH, DTM&H 3; Martin S. Cetron, MD1; and William Stauffer,1,4 MD, MSPH, DTM&H1 Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, USA2 International Organization for Migration3 Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA4 Division of Infectious Diseases and International Medicine, University of MinnesotaContents TOC \o "1-3" \h \z \u Overview PAGEREF _Toc444121381 \h 21.Decision Tree and Markov models PAGEREF _Toc444121382 \h 132. Epidemiological parameter estimates PAGEREF _Toc444121383 \h prehensive exam costs for intestinal parasite screening PAGEREF _Toc444121384 \h 224.Outpatient and inpatient treatment cost estimates PAGEREF _Toc444121385 \h 285.Overseas presumptive treatment cost estimates PAGEREF _Toc444121386 \h 326.Probability distributions PAGEREF _Toc444121387 \h 337.Baseline disease burden by parasite PAGEREF _Toc444121388 \h 367.Additional sensitivity analysis PAGEREF _Toc444121389 \h 38OverviewThis Appendix provides the complete details of the methods used in “Economic analysis of the impact of overseas and domestic treatment and screening options for intestinal helminth infection among US-bound refugees from Asia.” An economic decision tree model was developed to assess the costs and health impacts of four interventions for four parasites (Ascaris lumbricoides, Trichuris trichiura, hookworm, and Strongyloides stercoralis): 1) “No Program”, 2) “Domestic Screening and Treatment”, 3) “Overseas Albendazole and Ivermectin” presumptive treatment, and 4) “Overseas Albendazole and Domestic Screening for Strongyloides”. The distributions of age and country of origin of resettled refugees were averaged from multiple years of data ADDIN EN.CITE <EndNote><Cite><Author>Martin</Author><Year>2012</Year><RecNum>23</RecNum><DisplayText>[1]</DisplayText><record><rec-number>23</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349789622">23</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Daniel C. Martin</author><author>James E. Yankay</author></authors></contributors><titles><title>Refugees and Asylees 2011</title><secondary-title>Annual Flow Report</secondary-title></titles><volume>May 2012, , accessed on October 1, 2012</volume><dates><year>2012</year></dates><publisher>DHS, Office of Immigration Statistics Policy</publisher><urls></urls></record></Cite></EndNote>[1]. Markov transition state models were used to estimate the long term effects of Strongyloides infections that may remain asymptomatic for many years or may cause severe disease, known as hyperinfection ADDIN EN.CITE <EndNote><Cite><Author>Milder</Author><Year>1981</Year><RecNum>33</RecNum><DisplayText>[2]</DisplayText><record><rec-number>33</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349991346">33</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Milder, JE</author><author>Walzer, PD</author><author>Kilgore, G</author><author>Rutherford, I</author><author>Klein, M</author></authors></contributors><titles><title>Clinical features of Strongyloides stercoralis infection in an endemic area of the United States</title><secondary-title>Gastroenterology</secondary-title></titles><periodical><full-title>Gastroenterology</full-title></periodical><pages>1481-4188</pages><volume>80</volume><dates><year>1981</year></dates><urls></urls></record></Cite></EndNote>[2]. The costs of domestic screening and outpatient treatment were estimated based on expected clinical procedures valued at a weighted average of Medicare ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>88</RecNum><DisplayText>[3]</DisplayText><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385133">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Physician Fee Schedule, . accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[3] and private insurance reimbursement rates. Presumptive treatment costs were estimated by the International Organization for Migration (IOM); currently the primary health service provider for US-bound refugees. For each uncertain parameter estimate, we provided our best estimate based on what we believe to be the most likely value as well as minimum and maximum values (Table S1). These uncertainty ranges are used in univariate and multivariate sensitivity analyses.Study populationFrom 2002-11, about 51,500 refugees relocated to the United States each year. The refugee population included an average of 27,700 from Asian countries, with most (94%) from: Myanmar (31.9%), Iraq (22.7%), Bhutan (16.7%), Iran (11.6%), Laos (5.7%), and Vietnam (5.6%). ADDIN EN.CITE <EndNote><Cite><RecNum>32</RecNum><DisplayText>[4]</DisplayText><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349982139">32</key></foreign-keys><ref-type name="Government Document">46</ref-type><contributors><authors><author>,</author></authors></contributors><titles><title>Department of Homeland Security (2012) Yearbook of Immigration Statistics , accessed on October 1, 2012</title></titles><dates></dates><pub-location>Washington, D.C.</pub-location><urls></urls></record></Cite></EndNote>[4] The median age of Asian refugees was 24 years. ADDIN EN.CITE <EndNote><Cite><RecNum>32</RecNum><DisplayText>[4]</DisplayText><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349982139">32</key></foreign-keys><ref-type name="Government Document">46</ref-type><contributors><authors><author>,</author></authors></contributors><titles><title>Department of Homeland Security (2012) Yearbook of Immigration Statistics , accessed on October 1, 2012</title></titles><dates></dates><pub-location>Washington, D.C.</pub-location><urls></urls></record></Cite></EndNote>[4] The CDC works with IOM and other partners to coordinate health care and travel logistics for US-bound refugees. At present, IOM delivers presumptive albendazole treatment to US-bound refugees for which treatment is not contraindicated (i.e. pregnant women and children less than 1 year of age). In most years, IOM provides medical examinations and treatments to 80-90% of US-bound refugees. The percentage of US-bound refugees cared for by IOM varies from country to country and year to year. Refugees traveling from countries without an IOM presence do not currently receive presumptive treatment, but CDC’s goal is to provide presumptive treatment to all refugees. Thus, 100% is used as the baseline estimate. As part of the sensitivity analysis, the coverage rate was varied between 75% and 100%.After arrival in the United States, all refugees are recommended to present for comprehensive medical evaluations. Data from the Office of Refugee Resettlement indicated that more than 90% of refugees from reporting states present for such exams; however, the tests included in the exams are not reported to CDC and vary depending on refugees’ final destinations (Curi Kim, CDC Division of Global Migration and Quarantine, liaison to Office of Refugee Resettlement, personal communication).Decision tree modelFour program options were evaluated in the decision tree model: 1) “No Program”, 2) “Domestic Screening and Treatment”, 3) “Overseas Albendazole and Ivermectin’ presumptive treatment and 4) “Overseas Albendazole and Domestic Screening for Strongyloides”. For each branch/program option, refugees were subdivided by a) no infection or being infected with: b) hookworm, c) Ascaris, d) Trichuris, or e) Strongyloides. We did not account for simultaneous infections due to lack of data on the severity of multiple versus single infections. The simplest branch is the baseline ‘No Program,’ where refugees receive no presumptive treatment overseas nor any domestic parasitic screening post resettlement. Thus, there are no program costs, and only domestic treatment costs if refugees present for treatment after arrival. The “Domestic Screening and Treatment” branch is a program in which there is no presumptive treatment overseas. Instead, refugees receive a battery of tests during their domestic comprehensive medical exams. Some refugees (10%) do not present for comprehensive exams and are as likely to develop symptomatic illness as those in the “No Program” branch. Our analysis also includes consideration of both false positive (only for Strongyloides) and false negative (for all parasites) diagnostic test results. If refugees receive false positive results, they would incur the costs associated with medication despite not being infected. If they receive false negative results, they would not receive treatment for infections. Potential treatment failures are also included in the model.The “Overseas Albendazole and Ivermectin’ presumptive treatment branch is a program where refugees are treated with both drugs immediately before their departure for the United States. Among IOM-treated refugees, some fraction may not receive presumptive treatment due to drug shortages or other logistical issues. We assumed that 90% of refugees traveling from countries with presumptive treatment programs would actually be treated and that the remaining 10% would be medically ineligible (e.g., pregnant women) or would be missed for other reasons. Drug efficacies were assumed to be the same overseas and in the United States. However, we added a correction factor in the sensitivity analysis to account for potential lower quality overseas drugs or reinfection before departing for the United States. “Overseas Albendazole and Domestic Screening for Strongyloides”’ is a hybrid program where refugees receive overseas presumptive treatment with albendazole, but not ivermectin. In this case, refugees would be screened for Strongyloides and potentially treated at their post-arrival comprehensive medical exams. A single dose of albendazole is not considered an effective treatment for Strongyloides infections.Markov processes were used to estimate the probabilities of refugees receiving outpatient or inpatient treatment in the United States. A constant annual probability of treatment was assumed over each parasite’s infection duration (Table S1). Strongyloides was assumed to remain present for the lifetime of infected persons because it is the only parasite that can reproduce in its human host. If inpatient or outpatient treatment was sought, it was assumed that all parasites would be eliminated. The Markov model included an annual probability of death from background (non-parasite) causes to account for persons who die of other causes before seeking treatment for infection. We applied the background mortality rates for all Asian Americans because Asian refugee-specific mortality data were not available ADDIN EN.CITE <EndNote><Cite><RecNum>111</RecNum><DisplayText>[5]</DisplayText><record><rec-number>111</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1404858847">111</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2010 on CDC WONDER Online Database, released 2012. Data are from the Multiple Cause of Death Files, 1999-2010, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on Jul 8, 2014 </title></titles><dates></dates><urls></urls></record></Cite></EndNote>[5]. In the baseline Markov model, a small QALY decrement (0.001) was subtracted for each year spent with untreated parasitic infection. The previous cost-effectiveness model of ivermectin presumptive treatment only applied QALY decrements to cases in which outpatient or inpatient treatment occurred. ADDIN EN.CITE <EndNote><Cite><Author>Muennig</Author><Year>2004</Year><RecNum>30</RecNum><DisplayText>[6]</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349877637">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Muennig, P</author><author>Pallin, D</author><author>Challah, C</author><author>Khan, K</author></authors></contributors><titles><title>The cost-effectiveness of ivermectin vs. albendazole in the presumptive treatment of strongyloidiasis in immigrants to the United States.</title><secondary-title>Epidemiology and Infection</secondary-title></titles><periodical><full-title>Epidemiology and Infection</full-title></periodical><pages>1055-1063</pages><volume>132</volume><number>6</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[6] However, very large decrements were estimated for both inpatient (0.201) and outpatient cases 0.081). Our assumed decrement was much smaller than the DALY weight (0.03) used for children with hookworm, Trichuris, or Ascaris infections used in the Global Burden of Disease study ADDIN EN.CITE <EndNote><Cite><Author>Salomon</Author><Year>2012</Year><RecNum>112</RecNum><DisplayText>[7]</DisplayText><record><rec-number>112</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1404862703">112</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Joshua A Salomon</author><author>Theo Vos</author><author>Daniel R Hogan</author><author>Michael Gagnon</author><author>Mohsen Naghavi</author><author>Prof Ali Mokdad</author><author>Nazma Begum</author><author>Razibuzzaman Shah</author><author>Muhammad Karyana</author><author>Soewarta Kosen</author><author>Mario Reyna Farje</author><author>Gilberto Moncada</author><author>Arup Dutta</author><author>Sunil Sazawal</author></authors></contributors><titles><title>Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010</title><secondary-title>The Lancet</secondary-title></titles><periodical><full-title>The Lancet</full-title></periodical><pages>2129-2143</pages><volume>380</volume><number>9859</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[7]. While QALYs measure quality of life and DALYs measure the disability associated with health conditions, an estimated QALY decrement should be roughly comparable to a DALY weight estimated for the updated Global Burden of Disease study. The Global Burden of Disease study does not report a DALY weight for Strongyloides or an adult-specific Ascaris, Trichuris, or hookworm for adults. Although disability from growth impairment is likely less for adults than for children with these conditions, we used a much smaller QALY decrement for our baseline analysis.Epidemiological parameter estimationThe epidemiological parameters are summarized in Table S1. Calculations and details are presented in Section 2 of this appendix.Stool ova and parasite tests are used to diagnose hookworm, Trichuris and Ascaris infections. The sensitivity of stool ova and parasite tests for diagnosis of hookworm, Trichuris and Ascaris can be improved by collecting stool samples on multiple days since parasite shedding varies day-to-day. The sensitivity and specificity of screening tests were estimated assuming that two stool ova and parasite tests and one Strongyloides serologic test would be performed at all initial comprehensive medical exams in the absence of presumptive treatment. The estimated sensitivities of these tests varied by parasite from 78% to 96% (Table S1) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lcm9sZXdpZWNraTwvQXV0aG9yPjxZZWFyPjIwMTM8L1ll
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ADDIN EN.CITE.DATA [8-13]. Sensitivities were estimated using on a meta-analysis tests for these three helminths based on the assumption that the formol-ether concentration would be used. ADDIN EN.CITE <EndNote><Cite><Author>Cartwright</Author><Year>1999</Year><RecNum>122</RecNum><DisplayText>[13, 14]</DisplayText><record><rec-number>122</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252918">122</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Charles P. Cartwright</author></authors></contributors><titles><title>Utility of Multiple-Stool-Specimen Ova and Parasite Examinations in a High-Prevalence Setting</title><secondary-title>Journal of Clinical Microbiology</secondary-title></titles><periodical><full-title>Journal of Clinical Microbiology</full-title></periodical><pages>2408-2411</pages><volume>37</volume><number>8</number><dates><year>1999</year></dates><urls></urls></record></Cite><Cite><Author>Nikolay</Author><Year>2014</Year><RecNum>121</RecNum><record><rec-number>121</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252797">121</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Birgit Nikolay</author><author>Simon J. Brooker</author><author>Rachel L. Pullan</author></authors></contributors><titles><title>Sensitivity of diagnostic tests for human soil-transmitted helminth infections: a meta-analysis in the absence of a true gold standard</title><secondary-title>International Journal for Parasitology</secondary-title></titles><periodical><full-title>International Journal for Parasitology</full-title></periodical><pages>765-774</pages><volume>44</volume><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>[13, 14] The estimated specificities were assumed to be 100%, except for Strongyloides serology (92%) ADDIN EN.CITE <EndNote><Cite><Author>Bisoffi</Author><Year>2014</Year><RecNum>109</RecNum><DisplayText>[12]</DisplayText><record><rec-number>109</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1401832109">109</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zeno Bisoffi</author><author>Dora Buonfrate</author><author>Marco Sequi</author><author>Rojelio Mejia</author><author>Ruben O. Cimino</author><author>Alejandro J. Krolewiecki</author><author>Marco Albonico</author><author>Maria Gobbo</author><author>Stefania Bonafini</author><author>Andrea Angheben</author><author>Ana Requena-Mendez</author><author>Jose? Munoz</author><author>Thomas B. Nutman</author></authors></contributors><titles><title>Diagnostic Accuracy of Five Serologic Tests for Strongyloides stercoralis Infection</title><secondary-title>PLoS Neglected Tropical Diseases</secondary-title></titles><periodical><full-title>PLoS Neglected Tropical Diseases</full-title></periodical><pages>e2640</pages><volume>8</volume><number>1</number><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>[12]. Albendazole effectiveness has been evaluated in many randomized trials in multiple endemic countries. A meta-analysis estimated that efficacy varied between 28% against Trichuris to 88% against Ascaris ADDIN EN.CITE <EndNote><Cite><Author>Keiser</Author><Year>2008</Year><RecNum>95</RecNum><DisplayText>[15]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380141974">95</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jennifer Keiser</author><author>Jurg Utzinger</author></authors></contributors><titles><title>Efficacy of Current Drugs Against Soil-Transmitted Helminth Infections Systematic Review and Meta-analysis</title><secondary-title>Journal of the American Medical Association</secondary-title></titles><periodical><full-title>Journal of the American Medical Association</full-title></periodical><pages>1937-1948</pages><volume>299</volume><number>16</number><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>[15]. Since these studies occurred in endemic areas, treated individuals may have been re-exposed after treatment and before retesting. Thus, these estimates should be conservative for U.S.-bound refugees. An upper bound efficacy estimate was based on reported rates of hookworm, Ascaris, and Trichuris infections before and after the introduction of overseas presumptive treatment with albendazole. Ivermectin is currently the drug of choice for the treatment of intestinal strongyloidiasis in the absence of dissemination or immunosuppression ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2012</Year><RecNum>76</RecNum><DisplayText>[16]</DisplayText><record><rec-number>76</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1352831607">76</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>CDC</author></authors></contributors><titles><title>Parasites - Strongyloides</title><secondary-title>Resources for Health Professionals:</secondary-title></titles><dates><year>2012</year></dates><publisher>CDC Global Health - Division of Parasitic Diseases and Malaria, accessed on November 13, 2012</publisher><urls></urls></record></Cite></EndNote>[16]. Efficacy rates have been observed between 57-100%. The lower bound was based on a study that used serologic testing to determine eradication of Strongloides ADDIN EN.CITE <EndNote><Cite><Author>Bisoffi</Author><Year>2011</Year><RecNum>94</RecNum><DisplayText>[17]</DisplayText><record><rec-number>94</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380135365">94</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zeno Bisoffi</author><author>Dora Buonfrate</author><author>Andrea Angheben</author><author>Marina Boscolo</author><author>Mariella Anselmi</author><author>Stefania Marocco</author><author>Geraldo Monteiro</author><author>Maria Gobbo</author><author>Giulia Bisoffi</author><author>Federico Gobbi</author></authors></contributors><titles><title>Randomized Clinical Trial on Ivermectin versus Thiabendazole for the Treatment of Strongyloidiasis</title><secondary-title>PLoS Neglected Tropical Diseases</secondary-title></titles><periodical><full-title>PLoS Neglected Tropical Diseases</full-title></periodical><pages>e1254</pages><volume>5</volume><number>7</number><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>[17], but for which only a single dose of ivermectin was administered. At least one study has shown that a two dose regimen is more effective. ADDIN EN.CITE <EndNote><Cite><Author>Igual-Adell</Author><Year>2004</Year><RecNum>28</RecNum><DisplayText>[18]</DisplayText><record><rec-number>28</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349874775">28</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rafael Igual-Adell</author><author>Carlos Oltra-Alcaraz</author><author>Enrique Soler-Company</author><author>Pilar Sánchez-Sánchez</author><author>Josefa Matogo-Oyana</author><author>David Rodríguez-Calabuig</author></authors></contributors><titles><title>Efficacy and safety of ivermectin and thiabendazole in the treatment of strongyloidiasis.</title><secondary-title>Expert Opinion on Pharmatherapy</secondary-title></titles><periodical><full-title>Expert Opinion on Pharmatherapy</full-title></periodical><pages>2615-2619</pages><volume>5</volume><number>12</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[18] The lowest reported efficacy for the CDC-recommended 2-day treatment regimen is 93%. 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ADDIN EN.CITE.DATA [17-19]The prevalence of hookworm, Trichuris, and Ascaris infections was estimated from a multiyear study of newly-arrived refugees conducted in the state of Minnesota ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20]. Since this study includes data from refugees that may have been treated presumptively with albendazole, it was necessary to adjust for drug effectiveness, sensitivity and specificity using the following equation: True_prevalence = ((Reported_prevalence + Specificity - 1) / (Sensitivity + Specificity – 1)) / (1 – effectiveness).The prevalence of Strongyloides infections was estimated using the median rate from a number of studies using serologic testing and conducted among relocated Asian refugees PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJ1YW5hPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48
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ADDIN EN.CITE.DATA [21-25]. The median estimate was adjusted for sensitivity and specificity, but not drug efficacy because ivermectin presumptive treatment had not been implemented when the studies were undertaken.The annual probabilities of outpatient and inpatient cases given infection were estimated from two previous studies that estimated the incidence of inpatient and outpatient strongyloidiasis among immigrant populations in New York state and Barcelona, Spain. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NdWVubmlnPC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48
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ADDIN EN.CITE.DATA [6, 26] Both studies found that strongyloidiasis cases were most commonly diagnosed as a result of unexplained eosinophilia (64% in the Barcelona study).The annual probability of outpatient and inpatient cases among refugees with Ascaris, Trichuris, and hookworm infections was assumed to be the same as for Strongyloides infections because most of these patients also present with unexplained eosinophilia and because we had no data. However, these parasites cannot replicate within the human host and the duration of infection is limited to 1 year for Ascaris, 1-2 years for Trichuris and 5-7 years for hookworm (Table S1).The risk of death from Ascaris, hookworm and/or Trichuris infections is assumed to be zero on the assumption that refugees will not be further exposed to these parasites in the United States. Therefore, parasite intensity would decrease over time even without treatment. The risk of death from inpatient strongyloidiasis was estimated to be 16.7% ADDIN EN.CITE <EndNote><Cite><Author>Muennig</Author><Year>1999</Year><RecNum>4</RecNum><DisplayText>[27]</DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1348494490">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Peter Muennig</author><author>Daniel Pallin</author><author>Randall L. Sell</author><author>Man-Seun Chan</author></authors></contributors><titles><title>The Cost Effectiveness of Strategies for the Treatment of Intestinal Parasites in Immigrants</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>773-779</pages><volume>340</volume><number>10</number><dates><year>1999</year></dates><urls></urls></record></Cite></EndNote>[27] because, by the time most patients were admitted to hospitals and diagnosed with strongyloidiasis, they were extremely ill. ADDIN EN.CITE <EndNote><Cite><Author>Newberry</Author><Year>2005</Year><RecNum>19</RecNum><DisplayText>[28]</DisplayText><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349455686">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ashley M. Newberry</author><author>David N. Williams</author><author>William M. Stauffer</author><author>David R. Boulware</author><author>Brett R. Hendel-Paterson</author><author>Patricia F. Walker</author></authors></contributors><titles><title>Strongyloides Hyperinfection Presenting as Acute Respiratory Failure and Gram-Negative Sepsis</title><secondary-title>Chest. 2005 November ; 128(5): 3681–3684</secondary-title></titles><periodical><full-title>Chest. 2005 November ; 128(5): 3681–3684</full-title></periodical><pages>3681-3684</pages><volume>128</volume><number>5</number><dates><year>2005</year></dates><urls></urls></record></Cite></EndNote>[28]We assumed that side effects of presumptive treatment would be minor and not of economic significance because there is little or no evidence that side effects require treatment. A recent study showed that none of 19,000 triple drug recipients (albendazole, ivermectin and praziquantel) in Zanzibar required a visit to a health center due to side effects. ADDIN EN.CITE <EndNote><Cite><Author>Mohammed</Author><Year>2008</Year><RecNum>35</RecNum><DisplayText>[29]</DisplayText><record><rec-number>35</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1350915218">35</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Khalfan A. Mohammed</author><author>Hamad J. Haji</author><author>Albis-Francesco Gabrielli</author><author>Likezo Mubila</author><author>Gautam Biswas,</author><author>Lester Chitsulo</author><author>Mark H. Bradley</author><author>Dirk Engels</author><author>Lorenzo Savioli</author><author>David H. Molyneux</author></authors></contributors><titles><title>Triple Co-Administration of Ivermectin, Albendazole and Praziquantel in Zanzibar: A Safety Study</title><secondary-title>PLoS Neglected Tropical Diseases</secondary-title></titles><periodical><full-title>PLoS Neglected Tropical Diseases</full-title></periodical><pages>e171</pages><volume>2</volume><number>1</number><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>[29]Cost analysisThe economic cost estimation is described in more detail in Sections 3-5 of this appendix. For “Domestic Screening and Treatment”, we assumed refugees would undergo two stool ova and parasite tests and one serologic test for Strongyloides infection. This testing would be initiated within the context of a comprehensive medical examination where intestinal parasite tests are just one set of tests. We assumed the intestinal parasite investigation would comprise 10% of the cost of the comprehensive exam and would require 0.25 hours of language translation services. Unit costs were estimated using two sets of reimbursement rates: 1) the Physician’s Fee and Coding Guide and 2) the Medicare Physician Payment and Clinical Lab Fee Schedules. ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>87</RecNum><DisplayText>[3, 30, 31]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385031">87</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Clinical Laboratory Fee Schedule, . Accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>88</RecNum><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385133">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Physician Fee Schedule, . accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite><Cite><Author>InGauge Healthcare Solutions</Author><Year>2013</Year><RecNum>104</RecNum><record><rec-number>104</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399319193">104</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>InGauge Healthcare Solutions,</author></authors></contributors><titles><title>2013 Physicians' Fee & Coding Guide</title></titles><dates><year>2013</year></dates><pub-location>Atlanta GA</pub-location><urls></urls></record></Cite></EndNote>[3, 30, 31] Language translation costs were estimated from the Bureau of Labor Statistics’ mean hourly wage for translators, $24.33 (Occupation Code: 27-3091). ADDIN EN.CITE <EndNote><Cite><RecNum>97</RecNum><DisplayText>[32]</DisplayText><record><rec-number>97</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380233063">97</key></foreign-keys><ref-type name="Report">27</ref-type><contributors></contributors><titles><title>Bureau of Labor Statistics, 2013 National Occupational Employment and Wage Estimates. Washington DC, , Accessed on May 1, 2014</title></titles><dates></dates><urls></urls></record></Cite></EndNote>[32] An additional assumed 33% was added to the hourly wage rate to cover employee benefits.Persons with positive test results were assumed to return for a follow-up visit and to receive a prescription for medicine (albendazole for hookworm, Trichuris, or Ascaris or ivermectin for Strongyloides infections). Medicine costs were estimated using the Red Book(R) database ADDIN EN.CITE <EndNote><Cite><Author>Micromedex (R)</Author><Year>2013</Year><RecNum>102</RecNum><DisplayText>[33]</DisplayText><record><rec-number>102</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1384893040">102</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>Micromedex (R),</author></authors></contributors><titles><title>Healthcare Series [Red Book]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically. Accessed on May 1, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[33], assuming average dosages of 400mg for albendazole over one day and 18 mg over two days for ivermectin.Outpatient treatment cost data were not available directly. Given the non-specific symptoms of parasitic infections, some patients may seek treatment multiple times before a diagnosis is made. We assumed that a tropical disease specialist may order a battery of tests and require two outpatient consultations to diagnose a patient. Strongyloidiasis hospitalization costs were estimated from the 2006-2011 National Inpatient Sample data (ICD code 127.2 as the primary diagnosis) ADDIN EN.CITE <EndNote><Cite><RecNum>85</RecNum><DisplayText>[34]</DisplayText><record><rec-number>85</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366297361">85</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2007-2009. Agency for Healthcare Research and Quality, Rockville, MD. hcup-us.nisoverview.jsp </title></titles><dates></dates><urls></urls></record></Cite></EndNote>[34] and adjusted to 2013 USD using the Medical Consumer Price Index . Opportunity costs were estimated based on the amount of time estimated to be required for screening (2 hrs. including two return trips with stool samples), treatment given positive test (1 hr.), outpatient treatment (1 day), and hospitalization (10 days). The value of time was estimated using US GDP per capita-hr. estimates ($5.84 per hr.) ADDIN EN.CITE <EndNote><Cite><Author>International Monetary Fund</Author><Year>2013</Year><RecNum>106</RecNum><DisplayText>[35]</DisplayText><record><rec-number>106</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399414497">106</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>International Monetary Fund,</author></authors></contributors><titles><title>2013 World Economic Outlook database. Accessed on June 3, 2013.</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[35]. For the sensitivity analysis, time was valued at the average hourly wage rate from the Bureau of Labor Statistics to estimate an upper bound (see Section 4 for details). The amount of time required for outpatient treatment and hospitalization are likely to be conservative, especially the opportunity cost of hospitalization since time required for rehabilitative therapy after hospitalization is not included. Estimates of the cost of Strongyloides-only screening for the “Overseas Albendazole and Domestic Screening for Strongyloides” program omitted the costs of stool ova and parasites diagnostics and assumed that only 5% of the comprehensive exam (rather than 10%) would be devoted to intestinal parasite screening.For ‘Overseas Ivermectin and Albendazole” or “Overseas Albendazole and Domestic Screening for Strongyloides” presumptive treatment costs were estimated by IOM and included medicine, delivery, administrative, and overhead costs based on data from three IOM sites in Thailand, Nepal, and Malaysia (see Section 5 for more details). We also assumed that some refugees would undergo stool ova and parasites testing despite overseas presumptive treatment because they may be infected with intestinal pathogens that are not susceptible to albendazole or ivermectin, or they may present with symptoms consistent with parasitic diseases that are also consistent with other types of diseases (e.g., diarrhea).Table S1. Epidemiological and economic input parametersDescriptionBase case analysisLowHighDistri-bution aRefEpidemiological parametersBaseline infection prevalence (without treatment) bHookworm0.0280.0280.11B ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20]Ascaris0.00840.00840.017B ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20]Trichuris0.00560.00560.015B ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20]Strongyloides0.200.060.34B PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJ1YW5hPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48
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ADDIN EN.CITE.DATA [17-19]Test sensitivity bStrongyloides serologic test0.910.890.92B ADDIN EN.CITE <EndNote><Cite><Author>Bisoffi</Author><Year>2014</Year><RecNum>109</RecNum><DisplayText>[12]</DisplayText><record><rec-number>109</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1401832109">109</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zeno Bisoffi</author><author>Dora Buonfrate</author><author>Marco Sequi</author><author>Rojelio Mejia</author><author>Ruben O. Cimino</author><author>Alejandro J. Krolewiecki</author><author>Marco Albonico</author><author>Maria Gobbo</author><author>Stefania Bonafini</author><author>Andrea Angheben</author><author>Ana Requena-Mendez</author><author>Jose? Munoz</author><author>Thomas B. Nutman</author></authors></contributors><titles><title>Diagnostic Accuracy of Five Serologic Tests for Strongyloides stercoralis Infection</title><secondary-title>PLoS Neglected Tropical Diseases</secondary-title></titles><periodical><full-title>PLoS Neglected Tropical Diseases</full-title></periodical><pages>e2640</pages><volume>8</volume><number>1</number><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>[12]Two stool O&P for hookworm0.780.530.88B ADDIN EN.CITE <EndNote><Cite><Author>Cartwright</Author><Year>1999</Year><RecNum>122</RecNum><DisplayText>[13, 14]</DisplayText><record><rec-number>122</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252918">122</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Charles P. Cartwright</author></authors></contributors><titles><title>Utility of Multiple-Stool-Specimen Ova and Parasite Examinations in a High-Prevalence Setting</title><secondary-title>Journal of Clinical Microbiology</secondary-title></titles><periodical><full-title>Journal of Clinical Microbiology</full-title></periodical><pages>2408-2411</pages><volume>37</volume><number>8</number><dates><year>1999</year></dates><urls></urls></record></Cite><Cite><Author>Nikolay</Author><Year>2014</Year><RecNum>121</RecNum><record><rec-number>121</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252797">121</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Birgit Nikolay</author><author>Simon J. Brooker</author><author>Rachel L. 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ADDIN EN.CITE.DATA [9, 11, 12]Two stool O&P for hookworm, Ascaris, or Trichuris111NAAssumptionDuration of infection bHookworm 657G ADDIN EN.CITE <EndNote><Cite><Author>Bethony</Author><Year>2006</Year><RecNum>110</RecNum><DisplayText>[36]</DisplayText><record><rec-number>110</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1404400790">110</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jeffrey Bethony</author><author>Simon Brooker</author><author>Marco Albonico</author><author>Stefan M Geiger</author><author>Alex Loukas</author><author>David Diemert</author><author>Peter J Hotez</author></authors></contributors><titles><title>Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm</title><secondary-title>The Lancet</secondary-title></titles><periodical><full-title>The Lancet</full-title></periodical><pages>1521-1532</pages><volume>367</volume><dates><year>2006</year></dates><urls></urls></record></Cite></EndNote>[36]Trichuris212G ADDIN EN.CITE <EndNote><Cite><Author>Bethony</Author><Year>2006</Year><RecNum>110</RecNum><DisplayText>[36]</DisplayText><record><rec-number>110</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1404400790">110</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jeffrey Bethony</author><author>Simon Brooker</author><author>Marco Albonico</author><author>Stefan M Geiger</author><author>Alex Loukas</author><author>David Diemert</author><author>Peter J Hotez</author></authors></contributors><titles><title>Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm</title><secondary-title>The Lancet</secondary-title></titles><periodical><full-title>The Lancet</full-title></periodical><pages>1521-1532</pages><volume>367</volume><dates><year>2006</year></dates><urls></urls></record></Cite></EndNote>[36]Ascaris111N/A ADDIN EN.CITE <EndNote><Cite><Author>Bethony</Author><Year>2006</Year><RecNum>110</RecNum><DisplayText>[36]</DisplayText><record><rec-number>110</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1404400790">110</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jeffrey Bethony</author><author>Simon Brooker</author><author>Marco Albonico</author><author>Stefan M Geiger</author><author>Alex Loukas</author><author>David Diemert</author><author>Peter J Hotez</author></authors></contributors><titles><title>Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm</title><secondary-title>The Lancet</secondary-title></titles><periodical><full-title>The Lancet</full-title></periodical><pages>1521-1532</pages><volume>367</volume><dates><year>2006</year></dates><urls></urls></record></Cite></EndNote>[36]Annual probability of seeking treatment given infection bOutpatient visit for hookworm/ trichuriasis/ascariasis0.0010.000120.005BPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NdWVubmlnPC9BdXRob3I+PFllYXI+MjAwNDwvWWVhcj48
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ADDIN EN.CITE.DATA [6, 26]Case fatality rate for inpatient strongyloidiasis0.1670.020.25B ADDIN EN.CITE <EndNote><Cite><Author>Muennig</Author><Year>1999</Year><RecNum>4</RecNum><DisplayText>[27]</DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1348494490">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Peter Muennig</author><author>Daniel Pallin</author><author>Randall L. Sell</author><author>Man-Seun Chan</author></authors></contributors><titles><title>The Cost Effectiveness of Strategies for the Treatment of Intestinal Parasites in Immigrants</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>773-779</pages><volume>340</volume><number>10</number><dates><year>1999</year></dates><urls></urls></record></Cite></EndNote>[27]Program parametersProportion of refugees receiving domestic comprehensive medical exam0.90.81.0UAssumptionProbability refugees arrive from countries with presumptive treatment program1.000.751.00UIOM reportProbability refugees receive presumptive treatment0.900.800.98UAssumptionProbability stool O&P will be ordered given presumptive treatment0.050.030.07UAssumptionAdjustment factor for overseas versus domestic treatment 0-110.751UAssumptionDemographicsProbability of death background rateVaries with ageN/A ADDIN EN.CITE <EndNote><Cite><RecNum>111</RecNum><DisplayText>[5]</DisplayText><record><rec-number>111</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1404858847">111</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2010 on CDC WONDER Online Database, released 2012. Data are from the Multiple Cause of Death Files, 1999-2010, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on Jul 8, 2014 </title></titles><dates></dates><urls></urls></record></Cite></EndNote>[5]Median age of refugees at arrival24 ADDIN EN.CITE <EndNote><Cite><RecNum>32</RecNum><DisplayText>[4]</DisplayText><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349982139">32</key></foreign-keys><ref-type name="Government Document">46</ref-type><contributors><authors><author>,</author></authors></contributors><titles><title>Department of Homeland Security (2012) Yearbook of Immigration Statistics , accessed on October 1, 2012</title></titles><dates></dates><pub-location>Washington, D.C.</pub-location><urls></urls></record></Cite></EndNote>[4]Economic parametersU.S. cost estimates (2013 USD)Screen for all nematodes c11678260G ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>87</RecNum><DisplayText>[3, 30, 31]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385031">87</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Clinical Laboratory Fee Schedule, . 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ADDIN EN.CITE.DATA [32, 34, 35]QALY estimatesQALY decrement for Strongyloides infections0.00100.01BAssumptionQALY decrement for hookworm, Ascaris, Trichuris infections0.00100.01BAssumptiona Distribution types: U- uniform, B- beta, G- gamma (See Section 5 of appendix for more details)b Details in Section 2 of Appendixc Details in Section 3 of Appendixd Details in Section 4 of Appendixe Details in Section 5 of Appendix1.Decision Tree and Markov modelsDecision tree modelsThe costs and health impacts of alternative programs were estimated using a decision tree model that terminated with Markov processes. A simplified schematic of the decision tree model is shown in Figure S1, the complete decision tree model is available from the corresponding author. For each of the options, refugees begin in either an infected (with one of the four parasites) or uninfected state. For ‘Domestic Screening and Treatment’, refugees may or may not present for comprehensive examinations after arrival. If they do not follow up, they do not incur screening or treatment costs. However, infected refugees would remain infected. If they do follow-up, they are tested and the results may be: True Positive (refugees are infected and treated)False Positive (refugees are not infected, but are still treated)True Negative (refuges are not infected and not treated)False Negative (patients are infected, but not treated)When patients are true positive or false positive, they will incur the cost of medications. If they are infected (true positive), the infection will be eliminated at the pathogen-specific efficacy listed in Table S1. If they are not infected (false positive), the refugees would be unnecessarily treated; however, this is unlikely to impose any costs beyond those associated with purchasing the medication. If refugees are infected, but test false negative, they will not receive medication and will remain infected.For “Overseas Albendazole and Ivermectin”, we assumed that the program would be implemented for 100% of the refugee population. In the sensitivity analysis, we allowed for the possibility that it would not be possible to implement presumptive treatment programs in all Asian countries from which refugees travel and that some fraction of refugees would need to go through the screening and treatment protocol after arriving in the United States. Refugees were again subdivided by infection status. We assumed that 90% of refugees from countries with presumptive treatment programs would receive treatment overseas and that these medications would have the same efficacy as if the drugs were administered in the United States. Refugees end in one of five conditions after completing each decision process: 1) uninfected, 2) infected with hookworm, 3) infected with Trichuris, 4) infected with Ascaris, or 5) infected with Strongyloides.For “No Program”, costs are only incurred among refugees that need to seek outpatient or inpatient treatment.Markov modelFor uninfected persons the Markov process is simple. Each year, they may die based on background mortality rates for Asian Americans reported in the CDC Wonder database ADDIN EN.CITE <EndNote><Cite><RecNum>111</RecNum><DisplayText>[5]</DisplayText><record><rec-number>111</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1404858847">111</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2010 on CDC WONDER Online Database, released 2012. Data are from the Multiple Cause of Death Files, 1999-2010, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on Jul 8, 2014 </title></titles><dates></dates><urls></urls></record></Cite></EndNote>[5]. Otherwise, they remain in an uninfected stated with QALY weight based on the average estimated for the U.S. population. ADDIN EN.CITE <EndNote><Cite><Author>Hanmer</Author><Year>2006</Year><RecNum>120</RecNum><DisplayText>[37]</DisplayText><record><rec-number>120</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1454715903">120</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Janel Hanmer</author><author>William F. Lawrence</author><author>John P. Anderson</author><author>Robert M. Kaplan</author><author>Dennis G. Fryback</author></authors></contributors><titles><title>Report of Nationally Representative Values for the Noninstitutionalized US Adult Population for 7 Health-Related Quality-of-Life Scores</title><secondary-title>Med Decis Making</secondary-title></titles><periodical><full-title>Med Decis Making</full-title></periodical><pages>391-400</pages><volume>4</volume><dates><year>2006</year></dates><urls></urls></record></Cite></EndNote>[37] For persons infected with hookworm, Trichuris, or Ascaris, Figure S2 shows that refugees start in the infected state. Each year they may: 1) die at the background rate; 2) seek outpatient treatment; 3) remain infected; or, 4) become clear of infection without treatment. There are no hospitalizations or deaths caused by these three parasites. After clearing the infection, there is zero probability of reinfection. For each year spent in the infected state, there is a small QALY decrement. In the baseline analysis, this decrement is 0.001 so the QALY weight for each year of infection is the baseline weight – 0.001. We assumed that the infection would clear without treatment after 1 year for Ascaris, 2 years for Trichuris, and 6 years for hookworm (Table S1) for the baseline scenario.A schematic of the Markov model for persons infected with Strongyloides is shown in Figure S3. Each refugee again begins in an infected state. Each year, they may 1) remain infected, 2) receive outpatient treatment, 3) receive inpatient treatment, 4) they may die from other causes at the background mortality rate for all Asian Americans. If they are treated as inpatients there is a risk of death (Table S1). Anyone that received outpatient or inpatient treatment was assumed to clear the infection unless they died (i.e. there were no treatment failures). 15430503219450-68580087630000Figure S1. Simplified schematic of decision tree modela Persons infected with one of Ascaris, Trichuris, Strongyloides, or hookwormFigure S2. Schematic of Markov model for hookworm, Trichuris, and Ascaris infections473392518992855905501813922Death (unrelated to parasitic infection)Infected (asymptomatic or subclinicalInfection clearedOutpatient caseDeath (unrelated to parasitic infection)Infected (asymptomatic or subclinicalInfection clearedOutpatient case464820021424904191002002155Figure S3. Schematic of Markov model for Strongyloides infectionsDeath (unrelated to strongyloidiasis)Infected (asymptomatic or subclinical)Infection clearedInpatient caseOutpatient caseDeath (strongyloidiasis)Death (unrelated to strongyloidiasis)Infected (asymptomatic or subclinical)Infection clearedInpatient caseOutpatient caseDeath (strongyloidiasis)2. Epidemiological parameter estimatesHookworm, Trichuris, and Ascaris Stool ova and parasite tests are used to diagnose hookworm, Trichuris and Ascaris infections. The sensitivity of these tests can be improved by collecting stool samples on multiple days since parasite shedding varies day-to-day. The sensitivity and specificity of screening tests in the United States were estimated by assuming that two stool ova and parasite tests would be performed at all initial comprehensive medical exams where Asian refugees did not receive presumptive treatment. The estimated sensitivities for each different parasite varied from 78% to 96% (Table S2) ADDIN EN.CITE <EndNote><Cite><Author>Cartwright</Author><Year>1999</Year><RecNum>122</RecNum><DisplayText>[13, 14]</DisplayText><record><rec-number>122</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252918">122</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Charles P. Cartwright</author></authors></contributors><titles><title>Utility of Multiple-Stool-Specimen Ova and Parasite Examinations in a High-Prevalence Setting</title><secondary-title>Journal of Clinical Microbiology</secondary-title></titles><periodical><full-title>Journal of Clinical Microbiology</full-title></periodical><pages>2408-2411</pages><volume>37</volume><number>8</number><dates><year>1999</year></dates><urls></urls></record></Cite><Cite><Author>Nikolay</Author><Year>2014</Year><RecNum>121</RecNum><record><rec-number>121</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252797">121</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Birgit Nikolay</author><author>Simon J. Brooker</author><author>Rachel L. Pullan</author></authors></contributors><titles><title>Sensitivity of diagnostic tests for human soil-transmitted helminth infections: a meta-analysis in the absence of a true gold standard</title><secondary-title>International Journal for Parasitology</secondary-title></titles><periodical><full-title>International Journal for Parasitology</full-title></periodical><pages>765-774</pages><volume>44</volume><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>[13, 14]. Sensitivities were estimated using a meta-analysis of testing for these three helminths based on the assumption that formol-ether concentration would be used. ADDIN EN.CITE <EndNote><Cite><Author>Cartwright</Author><Year>1999</Year><RecNum>122</RecNum><DisplayText>[13, 14]</DisplayText><record><rec-number>122</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252918">122</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Charles P. Cartwright</author></authors></contributors><titles><title>Utility of Multiple-Stool-Specimen Ova and Parasite Examinations in a High-Prevalence Setting</title><secondary-title>Journal of Clinical Microbiology</secondary-title></titles><periodical><full-title>Journal of Clinical Microbiology</full-title></periodical><pages>2408-2411</pages><volume>37</volume><number>8</number><dates><year>1999</year></dates><urls></urls></record></Cite><Cite><Author>Nikolay</Author><Year>2014</Year><RecNum>121</RecNum><record><rec-number>121</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252797">121</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Birgit Nikolay</author><author>Simon J. Brooker</author><author>Rachel L. Pullan</author></authors></contributors><titles><title>Sensitivity of diagnostic tests for human soil-transmitted helminth infections: a meta-analysis in the absence of a true gold standard</title><secondary-title>International Journal for Parasitology</secondary-title></titles><periodical><full-title>International Journal for Parasitology</full-title></periodical><pages>765-774</pages><volume>44</volume><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>[13, 14] Specificities were assumed to be 100%. Albendazole effectiveness has been evaluated in many randomized trials in multiple endemic countries. A meta-analysis produced efficacy estimates of 28% against Trichuris, 72% against hookworm, and 88% against Ascaris ADDIN EN.CITE <EndNote><Cite><Author>Keiser</Author><Year>2008</Year><RecNum>95</RecNum><DisplayText>[15]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380141974">95</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jennifer Keiser</author><author>Jurg Utzinger</author></authors></contributors><titles><title>Efficacy of Current Drugs Against Soil-Transmitted Helminth Infections Systematic Review and Meta-analysis</title><secondary-title>Journal of the American Medical Association</secondary-title></titles><periodical><full-title>Journal of the American Medical Association</full-title></periodical><pages>1937-1948</pages><volume>299</volume><number>16</number><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>[15]. Since these studies occurred in endemic areas, treated individuals would likely have been re-exposed after treatment and before retesting. A comparison of prevalence before and after the introduction of presumptive albendazole treatment in US-bound refugees demonstrated a much greater effect; prevalence ratios (treated versus untreated) varied from 0.06 for Ascaris, 0.07 for hookworm and 0.27 for Trichuris ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20]. However, since these estimates were not obtained from a randomized control trial, it is not possible to distinguish declines in refugee baseline prevalence over time (even without treatment) compared to presumptive treatment-induced reductions in prevalence. Further, the prevalence of parasitic disease among refugees may have declined over time due to albendazole campaigns undertaken among non-refugee children and/or economic development in the host countries where refugees live. We used the meta-analysis efficacy estimates for the base case analysis, which we believe is very conservative since refugees will probably not be re-exposed to parasites after they arrive in the United States in contrast with the populations evaluated in the meta-analysis where the parasites are endemic. We used the pre- and post-introduction of presumptive treatment effectiveness estimates as an upper bound.The prevalence rates of hookworm, Trichuris, and Ascaris were estimated from a multiyear study of newly-arrived refugees conducted in Minnesota ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20]. Infection prevalence can be estimated from the time period before albendazole presumptive treatment was initiated, 1999, in which case the estimate would be dated. Instead, we relied on more recent prevalence data, post-1999. To use this more recent data, we had to adjust for the effectiveness of overseas presumptive treatment. The reported prevalence rates must also be adjusted for the sensitivity and specificity of diagnostic tests, again assuming that two stool ova and parasite tests were performed. Thus, the expected prevalence before presumptive treatment may be calculated as True_prevalence = ((Reported_prevalence + Specificity - 1) / (Sensitivity + Specificity – 1)) / (1 – effectiveness).Table S2. Hookworm, Ascaris, and Trichuris prevalence estimation after adjustment for drug efficacy and test sensitivityAscarisHookwormTrichurisSourcePrevalence after treatment0.0010.0070.4 ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20]Meta analysis efficacy0.880.720.28 ADDIN EN.CITE <EndNote><Cite><Author>Keiser</Author><Year>2008</Year><RecNum>95</RecNum><DisplayText>[15]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380141974">95</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jennifer Keiser</author><author>Jurg Utzinger</author></authors></contributors><titles><title>Efficacy of Current Drugs Against Soil-Transmitted Helminth Infections Systematic Review and Meta-analysis</title><secondary-title>Journal of the American Medical Association</secondary-title></titles><periodical><full-title>Journal of the American Medical Association</full-title></periodical><pages>1937-1948</pages><volume>299</volume><number>16</number><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>[15]Adjusted pre-treatment prevalence based on meta-analysis efficacy 0.832.500.56Sensitivity adjustment (Best and Minimum prevalence estimate)a0.842.840.56 ADDIN EN.CITE <EndNote><Cite><Author>Cartwright</Author><Year>1999</Year><RecNum>122</RecNum><DisplayText>[13, 14]</DisplayText><record><rec-number>122</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252918">122</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Charles P. Cartwright</author></authors></contributors><titles><title>Utility of Multiple-Stool-Specimen Ova and Parasite Examinations in a High-Prevalence Setting</title><secondary-title>Journal of Clinical Microbiology</secondary-title></titles><periodical><full-title>Journal of Clinical Microbiology</full-title></periodical><pages>2408-2411</pages><volume>37</volume><number>8</number><dates><year>1999</year></dates><urls></urls></record></Cite><Cite><Author>Nikolay</Author><Year>2014</Year><RecNum>121</RecNum><record><rec-number>121</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1468252797">121</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Birgit Nikolay</author><author>Simon J. Brooker</author><author>Rachel L. Pullan</author></authors></contributors><titles><title>Sensitivity of diagnostic tests for human soil-transmitted helminth infections: a meta-analysis in the absence of a true gold standard</title><secondary-title>International Journal for Parasitology</secondary-title></titles><periodical><full-title>International Journal for Parasitology</full-title></periodical><pages>765-774</pages><volume>44</volume><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>[13, 14]Effectiveness based on pre and post treatment 0.940.930.73 ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20]Adjusted pre-treatment prevalence based on effectiveness study1.6710.001.48Sensitivity adjustment (Maximum prevalence estimate) a1.6811.361.48 ADDIN EN.CITE <EndNote><Cite><Author>Tarafder</Author><Year>2010</Year><RecNum>89</RecNum><DisplayText>[10]</DisplayText><record><rec-number>89</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366744861">89</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>MR Tarafder</author><author>H Carabin</author><author>L Joseph</author><author>Balolong Jr, E</author><author>R Olveda</author><author>ST McGarvey</author></authors></contributors><titles><title>Estimating the sensitivity and specificity of Kato-Katz stool examination technique for detection of hookworms, Ascaris lumbricoides and Trichuris trichiura infections in humans in the absence of a ‘gold standard’</title><secondary-title>Interanational Journal of Parasitology</secondary-title></titles><periodical><full-title>Interanational Journal of Parasitology</full-title></periodical><pages>399-404</pages><volume>40</volume><number>4</number><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>[10]a Estimated sensitivity 0.81 for Ascaris, 0.99 for Trichuris and 0.78 for hookworm based on two stool O & P tests. Ivermectin 200?g/kg is currently the drug regimen of choice for the treatment of intestinal strongyloidiasis in the absence of dissemination or immunosuppression ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2012</Year><RecNum>76</RecNum><DisplayText>[16]</DisplayText><record><rec-number>76</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1352831607">76</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>CDC</author></authors></contributors><titles><title>Parasites - Strongyloides</title><secondary-title>Resources for Health Professionals:</secondary-title></titles><dates><year>2012</year></dates><publisher>CDC Global Health - Division of Parasitic Diseases and Malaria, accessed on November 13, 2012</publisher><urls></urls></record></Cite></EndNote>[16]. A study of the treatment of chronic strongyloidiasis demonstrated a 100% (n=35) cure rate for the two-day ivermectin regimen verses a 77% (n=22) cure rate with the single ivermectin dose, and a 78% (n=25) cure rate with thiabendazole ADDIN EN.CITE <EndNote><Cite><Author>Igual-Adell</Author><Year>2004</Year><RecNum>28</RecNum><DisplayText>[18]</DisplayText><record><rec-number>28</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349874775">28</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rafael Igual-Adell</author><author>Carlos Oltra-Alcaraz</author><author>Enrique Soler-Company</author><author>Pilar Sánchez-Sánchez</author><author>Josefa Matogo-Oyana</author><author>David Rodríguez-Calabuig</author></authors></contributors><titles><title>Efficacy and safety of ivermectin and thiabendazole in the treatment of strongyloidiasis.</title><secondary-title>Expert Opinion on Pharmatherapy</secondary-title></titles><periodical><full-title>Expert Opinion on Pharmatherapy</full-title></periodical><pages>2615-2619</pages><volume>5</volume><number>12</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[18]. Effectiveness of the two-dose regimen was slightly lower (93%) in a separate trial conducted in a population with co-morbidities ADDIN EN.CITE <EndNote><Cite><Author>Suputtamongkol</Author><Year>2011</Year><RecNum>29</RecNum><DisplayText>[19]</DisplayText><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349875559">29</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Yupin Suputtamongkol</author><author>Nalinee Premasathian</author><author>Kid Bhumimuang</author><author>Duangdao Waywa</author><author>Surasak Nilganuwong</author><author>Ekkapun Karuphong</author><author>Thanomsak Anekthananon</author><author>Darawan Wanachiwanawin</author><author>Saowaluk Silpasakorn</author></authors></contributors><titles><title>Efficacy and Safety of Single and Double Doses of Ivermectin versus 7-Day High Dose Albendazole for Chronic Strongyloidiasis</title><secondary-title>PLoS Neglected Tropical Diseases</secondary-title></titles><periodical><full-title>PLoS Neglected Tropical Diseases</full-title></periodical><pages>e1044</pages><volume>5</volume><number>5</number><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>[19]. A lower efficacy rate (57-68%) was estimated when using serologic confirmation of Strongyloides elimination. However, only single-dose efficacy data was evaluated in this trial ADDIN EN.CITE <EndNote><Cite><Author>Bisoffi</Author><Year>2011</Year><RecNum>94</RecNum><DisplayText>[17]</DisplayText><record><rec-number>94</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380135365">94</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zeno Bisoffi</author><author>Dora Buonfrate</author><author>Andrea Angheben</author><author>Marina Boscolo</author><author>Mariella Anselmi</author><author>Stefania Marocco</author><author>Geraldo Monteiro</author><author>Maria Gobbo</author><author>Giulia Bisoffi</author><author>Federico Gobbi</author></authors></contributors><titles><title>Randomized Clinical Trial on Ivermectin versus Thiabendazole for the Treatment of Strongyloidiasis</title><secondary-title>PLoS Neglected Tropical Diseases</secondary-title></titles><periodical><full-title>PLoS Neglected Tropical Diseases</full-title></periodical><pages>e1254</pages><volume>5</volume><number>7</number><dates><year>2011</year></dates><urls></urls></record></Cite></EndNote>[17]. Another study showed a lower cure rate with single-dose ivermectin (17/22) than with 2-dose ivermectin (35/35). ADDIN EN.CITE <EndNote><Cite><Author>Igual-Adell</Author><Year>2004</Year><RecNum>28</RecNum><DisplayText>[18]</DisplayText><record><rec-number>28</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349874775">28</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rafael Igual-Adell</author><author>Carlos Oltra-Alcaraz</author><author>Enrique Soler-Company</author><author>Pilar Sánchez-Sánchez</author><author>Josefa Matogo-Oyana</author><author>David Rodríguez-Calabuig</author></authors></contributors><titles><title>Efficacy and safety of ivermectin and thiabendazole in the treatment of strongyloidiasis.</title><secondary-title>Expert Opinion on Pharmatherapy</secondary-title></titles><periodical><full-title>Expert Opinion on Pharmatherapy</full-title></periodical><pages>2615-2619</pages><volume>5</volume><number>12</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[18]The prevalence of Strongyloides was estimated using the median rate from a number of serologic studies of Asian refugees resettled to the United States, Canada, and Australia PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJ1YW5hPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48
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ADDIN EN.CITE.DATA [21-25]. This median estimate was adjusted for sensitivity and specificity, but not drug efficacy because ivermectin presumptive treatment had not been implemented when the studies were undertaken. The raw data from studies using Strongyloides serology is summarized in Table S3. The fraction testing positive varied from 13% - 65%. However, these results did not account for the sensitivity and specificity of Strongyloides serologic tests. Study-specific sensitivity and specificity were likely to vary with the origins of the refugee population studied and the type of serologic test used. The most recent and most comprehensive study for Strongyloides serology sensitivity and specificity showed that commercially available tests had sensitivities of 89-92% and specificities of 89-97% ADDIN EN.CITE <EndNote><Cite><Author>Bisoffi</Author><Year>2014</Year><RecNum>109</RecNum><DisplayText>[12]</DisplayText><record><rec-number>109</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1401832109">109</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zeno Bisoffi</author><author>Dora Buonfrate</author><author>Marco Sequi</author><author>Rojelio Mejia</author><author>Ruben O. Cimino</author><author>Alejandro J. Krolewiecki</author><author>Marco Albonico</author><author>Maria Gobbo</author><author>Stefania Bonafini</author><author>Andrea Angheben</author><author>Ana Requena-Mendez</author><author>Jose? Munoz</author><author>Thomas B. Nutman</author></authors></contributors><titles><title>Diagnostic Accuracy of Five Serologic Tests for Strongyloides stercoralis Infection</title><secondary-title>PLoS Neglected Tropical Diseases</secondary-title></titles><periodical><full-title>PLoS Neglected Tropical Diseases</full-title></periodical><pages>e2640</pages><volume>8</volume><number>1</number><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>[12]. After adjustment using estimates of 91% sensitivity and 92% specificity, the prevalence estimates varied from 6%-69%. A Montreal study of immigrants from 1982-83 may be considered an outlier since estimates were almost twice as high as the next highest prevalence study, and the population may not be comparable to more recent refugee populations for a number of reasons. The median prevalence estimate after adjustment is 19.5% (assuming studies with separate estimates for Middle East vs. South and Southeast Asian refugees can be considered separate results). The sample size-weighted average is 19.6%. If the Montreal study was included, the median would increase to 23% and the sample-size-weighted average would increase to 26%. Among the five studies, only two were conducted in the United States; however, we believe that prevalence rates of refugees resettled to Canada and Australia would be similar to rates among refugees resettled in the United States.Table S3. Prevalence of Strongyloides stercoralis infection in refugees in published studies using serologic detection methodsSiteSample sizeSouth and Southeast AsiaSample sizeMiddle EastRefUnadjustedAdjusted aUnadjustedAdjusted aSanta Clara County, CA 2001-106727%23%13621%16% ADDIN EN.CITE <EndNote><Cite><Author>AH</Author><Year>2013</Year><RecNum>79</RecNum><DisplayText>[22]</DisplayText><record><rec-number>79</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366239499">79</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chang, AH</author><author>Perry, S</author><author>Du, JN</author><author>Agunbiade, A</author><author>Polesky, A</author><author>Parsonnet, J</author></authors></contributors><titles><title>Decreasing intestinal parasites in recent northern California refugees</title><secondary-title>American Journal of Tropical Medicine and Hygiene</secondary-title></titles><periodical><full-title>American Journal of Tropical Medicine and Hygiene</full-title></periodical><pages>191-197</pages><volume>88</volume><number>1</number><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[22]Melbourne, Australia 2006-0997321%16%NANANA ADDIN EN.CITE <EndNote><Cite><Author>Paxton</Author><Year>2012</Year><RecNum>81</RecNum><DisplayText>[25]</DisplayText><record><rec-number>81</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366242017">81</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Paxton, GA</author><author>Sangster, KJ</author><author>Maxwell, EL</author><author>McBridge CRJ</author><author>Drewe, RH</author></authors></contributors><titles><title>Post-arrival health screening in Karen refugees in Australia</title><secondary-title>PLoS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e38194</pages><volume>7</volume><number>5</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[25]Montreal, Canada 1982-8323265%69%NANANA ADDIN EN.CITE <EndNote><Cite><Author>Gyorkos</Author><Year>1990</Year><RecNum>83</RecNum><DisplayText>[24]</DisplayText><record><rec-number>83</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366242731">83</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gyorkos, T.W.</author><author>Genta, R.M.</author><author>Viens, P.</author><author>MacLean, J.D.</author></authors></contributors><titles><title>Seroepidemiology of Strongyloides infection in the Southeast Asian refugee population in Canada</title><secondary-title>American Journal of Epidemiology</secondary-title></titles><periodical><full-title>American Journal of Epidemiology</full-title></periodical><pages>257-264</pages><volume>132</volume><number>2</number><dates><year>1990</year></dates><urls></urls></record></Cite></EndNote>[24]Syracuse, NY 2008-099631%28%2313%6% ADDIN EN.CITE <EndNote><Cite><Author>Dawson-Hahn</Author><Year>2010</Year><RecNum>37</RecNum><DisplayText>[23]</DisplayText><record><rec-number>37</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1350919646">37</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Elizabeth E. Dawson-Hahn</author><author>Sarah L.M. Greenberg</author><author>Joseph B. Domachowske</author><author>Brad G. Olson</author></authors></contributors><titles><title>Eosinophilia and the Seroprevalence of Schistosomiasis and Strongyloidiasis in Newly Arrived Pediatric Refugees: An Examination of Centers for Disease Control and Prevention Screening Guidelines </title><secondary-title>The Journal of Pediatrics</secondary-title></titles><periodical><full-title>The Journal of Pediatrics</full-title></periodical><pages>1016-1018.e1</pages><volume>156</volume><number>6</number><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>[23]Melbourne, Australia 2000-0223036%34%NANANA ADDIN EN.CITE <EndNote><Cite><Author>Caruana</Author><Year>2006</Year><RecNum>15</RecNum><DisplayText>[21]</DisplayText><record><rec-number>15</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349388177">15</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sonia R . Caruana</author><author>Heath A . Kelly </author><author>Joanne Y . Y . Ngeow</author><author>Norbert J . Ryan</author><author>Catherine M . Bennett </author><author>Ley Chea</author><author>Sophy Nuon</author><author>Narin Bak</author><author>Susan A . Skull</author><author>Beverley-Ann Biggs</author></authors></contributors><titles><title>Undiagnosed and Potentially Lethal Parasite Infections Among Immigrants and Refugees in Australia</title><secondary-title>Journal of Travel Medicine</secondary-title></titles><periodical><full-title>Journal of Travel Medicine</full-title></periodical><pages>233-239</pages><volume>13</volume><number>4</number><dates><year>2006</year></dates><urls></urls></record></Cite></EndNote>[21]a The adjustments use an estimated sensitivity of 91% and a specificity of 92% in this formula ((Reported_prevalence + Specificity - 1) / (Sensitivity + Specificity – 1)). Estimates of the incidence rates of outpatient and inpatient strongyloidiasis were available from two sources. Muennig et al. ADDIN EN.CITE <EndNote><Cite><Author>Muennig</Author><Year>2004</Year><RecNum>30</RecNum><DisplayText>[6]</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349877637">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Muennig, P</author><author>Pallin, D</author><author>Challah, C</author><author>Khan, K</author></authors></contributors><titles><title>The cost-effectiveness of ivermectin vs. albendazole in the presumptive treatment of strongyloidiasis in immigrants to the United States.</title><secondary-title>Epidemiology and Infection</secondary-title></titles><periodical><full-title>Epidemiology and Infection</full-title></periodical><pages>1055-1063</pages><volume>132</volume><number>6</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[6] estimated an annual incidence rate of 42.5 outpatient visits per 100,000 persons infected with strongyloidiasis based on Medicaid data from the 1990s and an assumed Strongyloides infection prevalence of 10% among the U.S. immigrant population in New York City. Valerio et al. ADDIN EN.CITE <EndNote><Cite><Author>Valerio</Author><Year>2013</Year><RecNum>103</RecNum><DisplayText>[26]</DisplayText><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1387577259">103</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="default" size="100%">Llu</style><style face="normal" font="default" charset="162" size="100%">?s Valerio</style></author><author><style face="normal" font="default" charset="162" size="100%">S?lvia Roure</style></author><author><style face="normal" font="default" charset="162" size="100%">Gema Fernandez-Rivas</style></author><author><style face="normal" font="default" charset="162" size="100%">Luca Basile</style></author><author><style face="normal" font="default" charset="162" size="100%">Octavio Mart?nez-Cuevasa</style></author><author><style face="normal" font="default" charset="162" size="100%">Angel-Luis Ballesteros</style></author><author><style face="normal" font="default" charset="162" size="100%">Xavier Ramos</style></author><author><style face="normal" font="default" charset="162" size="100%">Miquel Sabria</style></author><author><style face="normal" font="default" charset="162" size="100%">The North Metropolitan Working Group</style><style face="normal" font="default" size="100%"> </style><style face="normal" font="default" charset="162" size="100%">on Imported Diseases</style></author></authors></contributors><titles><title>Strongyloides stercoralis, the hidden worm. Epidemiological and clinical characteristics of 70 cases diagnosed in the North Metropolitan Area of Barcelona, Spain, 2003–2012</title><secondary-title>Transactions of the Royal Society of Tropical Medicine and Hygiene</secondary-title></titles><periodical><full-title>Transactions of the Royal Society of Tropical Medicine and Hygiene</full-title></periodical><pages>465-470</pages><volume>107</volume><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[26] estimated an annual incidence of 10 cases per 100,000 immigrants in Barcelona, Spain. This estimate was not adjusted based on estimates of the prevalence of Strongyloides infection of the originating countries of the immigrant. If we assume an infection prevalence of 10%, the resulting incidence would be 100 outpatient cases per 100,000 immigrants with Strongyloides infection. Both studies reported that the majority of immigrants in each city were from Latin America, where previous studies included in a systematic review have shown that Strongyloides prevalence can vary between 1? 75% ADDIN EN.CITE <EndNote><Cite><Author>Sch?r</Author><Year>2013</Year><RecNum>108</RecNum><DisplayText>[38]</DisplayText><record><rec-number>108</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399588313">108</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Fabian Sch?r</author><author>Ulf Trostdorf </author><author>Federica Giardina </author><author>Virak Khieu</author><author>Sinuon Muth </author><author>Hanspeter Marti </author><author>Penelope Vounatsou </author><author>Peter Odermatt</author></authors></contributors><titles><title>Strongyloides stercoralis: Global Distribution and Risk Factors </title><secondary-title>PLoS Neglected Tropical Diseases</secondary-title></titles><periodical><full-title>PLoS Neglected Tropical Diseases</full-title></periodical><pages>e2288</pages><volume>7</volume><number>7</number><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[38]. Such a large range includes differences in both endemicity and research methods. Table S4 shows estimates of the annual probability of inpatient and outpatient treatment given a range of prevalence rates between 1% ? 50% with a best estimate of 10% based on the assumptions in the Muennig study ADDIN EN.CITE <EndNote><Cite><Author>Muennig</Author><Year>2004</Year><RecNum>30</RecNum><DisplayText>[6]</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349877637">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Muennig, P</author><author>Pallin, D</author><author>Challah, C</author><author>Khan, K</author></authors></contributors><titles><title>The cost-effectiveness of ivermectin vs. albendazole in the presumptive treatment of strongyloidiasis in immigrants to the United States.</title><secondary-title>Epidemiology and Infection</secondary-title></titles><periodical><full-title>Epidemiology and Infection</full-title></periodical><pages>1055-1063</pages><volume>132</volume><number>6</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[6]. The annual probability of being treated for strongyloidiasis as an outpatient was estimated to be between 8.5 and 500 cases per 100,000 infected person-years with a best estimate of 100 per 100,000. The annual probability of hospitalization was much lower and was estimated between 0.66 – 14 hospitalizations per 100,000 infected person-years with a best estimate of 2.9 per 100,000.Table S4. Observed annual incidence of strongyloidiasis and estimated annual probability of treatment given variable infection prevalence ratesObserved incidenceAnnual probability of treatment given infection prevalenceprevalence = 2%prevalence = 10%prevalence = 35%New York inpatient ADDIN EN.CITE <EndNote><Cite><Author>Muennig</Author><Year>2004</Year><RecNum>30</RecNum><DisplayText>[6]</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349877637">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Muennig, P</author><author>Pallin, D</author><author>Challah, C</author><author>Khan, K</author></authors></contributors><titles><title>The cost-effectiveness of ivermectin vs. albendazole in the presumptive treatment of strongyloidiasis in immigrants to the United States.</title><secondary-title>Epidemiology and Infection</secondary-title></titles><periodical><full-title>Epidemiology and Infection</full-title></periodical><pages>1055-1063</pages><volume>132</volume><number>6</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[6]4.3E-052.1E-034.3E-041.2E-04New York outpatient ADDIN EN.CITE <EndNote><Cite><Author>Muennig</Author><Year>2004</Year><RecNum>30</RecNum><DisplayText>[6]</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349877637">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Muennig, P</author><author>Pallin, D</author><author>Challah, C</author><author>Khan, K</author></authors></contributors><titles><title>The cost-effectiveness of ivermectin vs. albendazole in the presumptive treatment of strongyloidiasis in immigrants to the United States.</title><secondary-title>Epidemiology and Infection</secondary-title></titles><periodical><full-title>Epidemiology and Infection</full-title></periodical><pages>1055-1063</pages><volume>132</volume><number>6</number><dates><year>2004</year></dates><urls></urls></record></Cite></EndNote>[6]2.3E-061.2E-042.3E-056.6E-06Barcelona outpatient ADDIN EN.CITE <EndNote><Cite><Author>Valerio</Author><Year>2013</Year><RecNum>103</RecNum><DisplayText>[26]</DisplayText><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1387577259">103</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="default" size="100%">Llu</style><style face="normal" font="default" charset="162" size="100%">?s Valerio</style></author><author><style face="normal" font="default" charset="162" size="100%">S?lvia Roure</style></author><author><style face="normal" font="default" charset="162" size="100%">Gema Fernandez-Rivas</style></author><author><style face="normal" font="default" charset="162" size="100%">Luca Basile</style></author><author><style face="normal" font="default" charset="162" size="100%">Octavio Mart?nez-Cuevasa</style></author><author><style face="normal" font="default" charset="162" size="100%">Angel-Luis Ballesteros</style></author><author><style face="normal" font="default" charset="162" size="100%">Xavier Ramos</style></author><author><style face="normal" font="default" charset="162" size="100%">Miquel Sabria</style></author><author><style face="normal" font="default" charset="162" size="100%">The North Metropolitan Working Group</style><style face="normal" font="default" size="100%"> </style><style face="normal" font="default" charset="162" size="100%">on Imported Diseases</style></author></authors></contributors><titles><title>Strongyloides stercoralis, the hidden worm. Epidemiological and clinical characteristics of 70 cases diagnosed in the North Metropolitan Area of Barcelona, Spain, 2003–2012</title><secondary-title>Transactions of the Royal Society of Tropical Medicine and Hygiene</secondary-title></titles><periodical><full-title>Transactions of the Royal Society of Tropical Medicine and Hygiene</full-title></periodical><pages>465-470</pages><volume>107</volume><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[26]1.0E-045.0E-031.0E-03 a2.9E-04Barcelona inpatient ADDIN EN.CITE <EndNote><Cite><Author>Valerio</Author><Year>2013</Year><RecNum>103</RecNum><DisplayText>[26]</DisplayText><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1387577259">103</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="default" size="100%">Llu</style><style face="normal" font="default" charset="162" size="100%">?s Valerio</style></author><author><style face="normal" font="default" charset="162" size="100%">S?lvia Roure</style></author><author><style face="normal" font="default" charset="162" size="100%">Gema Fernandez-Rivas</style></author><author><style face="normal" font="default" charset="162" size="100%">Luca Basile</style></author><author><style face="normal" font="default" charset="162" size="100%">Octavio Mart?nez-Cuevasa</style></author><author><style face="normal" font="default" charset="162" size="100%">Angel-Luis Ballesteros</style></author><author><style face="normal" font="default" charset="162" size="100%">Xavier Ramos</style></author><author><style face="normal" font="default" charset="162" size="100%">Miquel Sabria</style></author><author><style face="normal" font="default" charset="162" size="100%">The North Metropolitan Working Group</style><style face="normal" font="default" size="100%"> </style><style face="normal" font="default" charset="162" size="100%">on Imported Diseases</style></author></authors></contributors><titles><title>Strongyloides stercoralis, the hidden worm. Epidemiological and clinical characteristics of 70 cases diagnosed in the North Metropolitan Area of Barcelona, Spain, 2003–2012</title><secondary-title>Transactions of the Royal Society of Tropical Medicine and Hygiene</secondary-title></titles><periodical><full-title>Transactions of the Royal Society of Tropical Medicine and Hygiene</full-title></periodical><pages>465-470</pages><volume>107</volume><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[26]2.9E-061.4E-042.9E-05 a8.2E-06a This is the best estimate used in the base case analysis. The Barcelona data was chosen because it is more recent and was collected from a network of treatment facilities that provided immigrant-specific incidence data in comparison to the New York study, which relied on Medicaid data and assumptions that all infected persons were immigrants.prehensive exam costs for intestinal parasite screeningHealth department costsCDC has developed a set of 12 guidelines for the comprehensive medical exam that is recommended for refugees post-resettlement, including a guideline for intestinal parasites ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2012</Year><RecNum>24</RecNum><DisplayText>[39]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349790449">24</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>CDC</author></authors><secondary-authors><author>Division of Global Migration and Quarantine</author></secondary-authors></contributors><titles><title>Refugee Health Guidelines: Intestinal Parasites Overseas Recommendations Recommendations for Overseas Presumptive Treatment of Intestinal Parasites for Refugees Destined for the United States</title></titles><dates><year>2012</year></dates><pub-location>Atlanta, , accessed on October 1, 2012</pub-location><urls></urls></record></Cite></EndNote>[39]. Among the remaining eleven guidelines, there is 1 general overview, 1 for conducting a physical examination and for collecting medical histories and 9 with specific information on other conditions and diseases.We assumed that the cost of the comprehensive exam could be subdivided such that 10% of the activities would be devoted to intestinal parasites and 90% to other health conditions in refugees. This assumption is for the cost of screening in the absence of overseas presumptive treatment with either albendazole or ivermectin. The total health department cost would include a fraction of the comprehensive exam costs plus diagnostics (2 stool ova and parasites tests for hookworm, Trichuris, and Ascaris and 1 Strongyloides antibody test). Cost estimates were based on public and private reimbursement rates. The public reimbursement rate was estimated from the 2013 Centers for Medicare and Medicaid (CMS) Clinical Laboratory Fee Schedule and the 2013 CMS Physician Fee Schedule ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>87</RecNum><DisplayText>[3, 30]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385031">87</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Clinical Laboratory Fee Schedule, . Accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>88</RecNum><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385133">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Physician Fee Schedule, . accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[3, 30]. The private reimbursement rates were summarized from the 2013 Physician’s Fee and Coding Guide ADDIN EN.CITE <EndNote><Cite><Author>InGauge Healthcare Solutions</Author><Year>2013</Year><RecNum>104</RecNum><DisplayText>[31]</DisplayText><record><rec-number>104</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399319193">104</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>InGauge Healthcare Solutions,</author></authors></contributors><titles><title>2013 Physicians' Fee & Coding Guide</title></titles><dates><year>2013</year></dates><pub-location>Atlanta GA</pub-location><urls></urls></record></Cite></EndNote>[31]. We assumed that health department costs for performing the exam and screening would be closer to the public reimbursement rate than to the private reimbursement rates. We used a weighted average of 25% x Physician’s Fee and Coding midpoint + 75% x CMS reimbursement rate to estimate the cost of screening (Table S5). The upper bound estimate was based on the high end of the reported reimbursement rates in the Physician Fee and Coding Guide. The lower bound was based on the CMS reimbursement rates. Medicare reimbursement rates were chosen instead of Medicaid reimbursement rates because there is less state-to-state variability.We assumed that all refugees would require language translation assistance. Further, we assumed that 15 minutes of the translator’s time would be devoted to intestinal parasites. The cost of the translator was estimated using 2013 Bureau of Labor Statistics mean hourly wage data for translators, (occupation code 27-3091) $23.04 ADDIN EN.CITE <EndNote><Cite><RecNum>97</RecNum><DisplayText>[32]</DisplayText><record><rec-number>97</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380233063">97</key></foreign-keys><ref-type name="Report">27</ref-type><contributors></contributors><titles><title>Bureau of Labor Statistics, 2013 National Occupational Employment and Wage Estimates. Washington DC, , Accessed on May 1, 2014</title></titles><dates></dates><urls></urls></record></Cite></EndNote>[32]. In addition, we assumed that non-wage benefits would add 33% to hourly wages so that the total cost for 15 minutes of translator time would be 15 minutes /60 minutes per hour x $23.04 hourly wage x 1.33 adjustment for non-wage benefits = $7.66.Table S5. Health department cost for screening for intestinal parasites assuming there are no overseas presumptive treatment programs (2013 USD)SourcePhysician’s Fee and Coding Guide ADDIN EN.CITE <EndNote><Cite><Author>InGauge Healthcare Solutions</Author><Year>2013</Year><RecNum>104</RecNum><DisplayText>[31]</DisplayText><record><rec-number>104</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399319193">104</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>InGauge Healthcare Solutions,</author></authors></contributors><titles><title>2013 Physicians' Fee & Coding Guide</title></titles><dates><year>2013</year></dates><pub-location>Atlanta GA</pub-location><urls></urls></record></Cite></EndNote>[31]CMS 2013 Clinical Lab Fee Schedule or Physician Fee Schedule ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>87</RecNum><DisplayText>[3, 30]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385031">87</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Clinical Laboratory Fee Schedule, . Accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>88</RecNum><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385133">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Physician Fee Schedule, . accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[3, 30]Outpatient costsICD-9 codeNo. of tests or visitsMin (USD)Max (USD)Midpoint (USD)National Midpoint or Facility Price (USD)Total cost (weighted average)(USD)Comprehensive exam (new patient, level 4 complexity)992040.10235313274128.2716.47Stool ova and parasites x287177250665816.5353.80Strongylides (Helminth antibody)866821699079.524.1638.00Interpreter (0.25 hr)7.66Total20026123178116a Note that total costs are estimated using 25% * Physicians’ Fee and Coding Guide + 75% * CMS rate and are rounded to the nearest dollar.If albendazole was provided during overseas presumptive treatment programs, the health department would only have to screen for Strongyloides. For this branch of the decision tree, we assumed that intestinal parasite screening would only comprise 5% of the comprehensive exam cost. In addition, we assumed that stool ova and parasites testing would be unnecessary; thus, the health department would only use the Strongyloides antibody test (Table S6).Table S6. Health department cost for screening for Strongyloides assuming overseas presumptive treatment with albendazole (2013 USD)SourcePhysician’s Fee and Coding Guide ADDIN EN.CITE <EndNote><Cite><Author>InGauge Healthcare Solutions</Author><Year>2013</Year><RecNum>104</RecNum><DisplayText>[31]</DisplayText><record><rec-number>104</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399319193">104</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>InGauge Healthcare Solutions,</author></authors></contributors><titles><title>2013 Physicians' Fee & Coding Guide</title></titles><dates><year>2013</year></dates><pub-location>Atlanta GA</pub-location><urls></urls></record></Cite></EndNote>[31]CMS 2013 Clinical Lab Fee Schedule or Physician Fee Schedule ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>87</RecNum><DisplayText>[3, 30]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385031">87</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Clinical Laboratory Fee Schedule, . Accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>88</RecNum><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385133">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Physician Fee Schedule, . accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[3, 30]Outpatient costsICD-9 codeNo. of tests or visitsMin (USD)Max (USD)Mean (USD)National Midpoint or Facility Price (USD)Total cost (weighted average) (USD)Comprehensive exam (new patient, level 4 complexity)992040.052353132741288Strongylides (Helminth antibody)866821.00699079.52438.00Interpreter (0.25 hr *$24.33/hr)7.66Total a881131013854a Note that total costs are estimated using 25% * Physicians’ Fee and Coding Guide + 75% * CMS rate and are rounded to the nearest dollar.If any intestinal parasite were diagnosed, we assumed that infected refugees would return for a follow-up outpatient visit (complexity level 2) and that the refugee would receive either albendazole or ivermectin for treatment. These treatment costs are summarized in Table S7. Drug costs were taken from the Red Book database and we assumed that, on average, treatment would require 2 x 200mg albendazole for hookworm, Trichuris, or Ascaris infections or 6 x 3mg ivermectin for Strongyloides infections. ADDIN EN.CITE <EndNote><Cite><Author>Micromedex (R)</Author><Year>2013</Year><RecNum>102</RecNum><DisplayText>[33]</DisplayText><record><rec-number>102</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1384893040">102</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>Micromedex (R),</author></authors></contributors><titles><title>Healthcare Series [Red Book]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically. Accessed on May 1, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[33]Table S7. Treatment costs for refugees diagnosed with intestinal parasites during comprehensive exams in the United States after arrival (2013 USD)SourcePhysician’s Fee and Coding Guide ADDIN EN.CITE <EndNote><Cite><Author>InGauge Healthcare Solutions</Author><Year>2013</Year><RecNum>104</RecNum><DisplayText>[31]</DisplayText><record><rec-number>104</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399319193">104</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>InGauge Healthcare Solutions,</author></authors></contributors><titles><title>2013 Physicians' Fee & Coding Guide</title></titles><dates><year>2013</year></dates><pub-location>Atlanta GA</pub-location><urls></urls></record></Cite></EndNote>[31]CMS 2013 Clinical Lab Fee Schedule or Physician Fee Schedule ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>87</RecNum><DisplayText>[3, 30]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385031">87</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Clinical Laboratory Fee Schedule, . Accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>88</RecNum><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385133">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Physician Fee Schedule, . accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[3, 30]Outpatient costsICD-9 codeNo. of tests or visitsMin (USD)Max (USD)Mean (USD)National Midpoint or Facility Price (USD)Total cost (weighted average) (USD)Outpatient visit (existing patient, level 2 complexity)99212192125108.524.5045.50Interpreter (0.25 hr *$24.33/hr)7.66Albendazole (2 x 200 mg)119.40Ivermectin (6 x 3mg)33.50Total for hookworm, Ascaris, or Trichuris219252236152173Total for Strongyloides a1331661506687a Note that total costs are estimated using 25% * Physicians’ Fee and Coding Guide + 75% * CMS rate and are rounded to the nearest dollar.Patient opportunity and travel costsPatient opportunity costs were estimated based on assumed time requirements for patients to: undergo comprehensive exams, provide stool samples, and travel to and from appointments (Table S8). We estimated that it would require 2 hours for the comprehensive examination and 1 hour each to provide stool samples and/or to return for a follow-up visit and diagnosis. The time requirement for comprehensive exams was prorated as discussed above. The value of time was estimated using two sources: 1) the best and minimum cost estimates was the average GDP per capita-hour taken from International Monetary Fund data ($5.84 per hour) ADDIN EN.CITE <EndNote><Cite><Author>International Monetary Fund</Author><Year>2013</Year><RecNum>106</RecNum><DisplayText>[35]</DisplayText><record><rec-number>106</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399414497">106</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>International Monetary Fund,</author></authors></contributors><titles><title>2013 World Economic Outlook database. Accessed on June 3, 2013.</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[35] and 2) the maximum cost estimate was the average wage estimate across all occupations from the Bureau of Labor Statistics $22.33 ADDIN EN.CITE <EndNote><Cite><RecNum>97</RecNum><DisplayText>[32]</DisplayText><record><rec-number>97</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380233063">97</key></foreign-keys><ref-type name="Report">27</ref-type><contributors></contributors><titles><title>Bureau of Labor Statistics, 2013 National Occupational Employment and Wage Estimates. Washington DC, , Accessed on May 1, 2014</title></titles><dates></dates><urls></urls></record></Cite></EndNote>[32]. We believe the average GDP per capita-hour is the better estimate because many refugees may not be employed at the time of the initial comprehensive exam.Table S8. Opportunity cost estimates for refugees participating in domestic screening programs (2013 USD)Screening for hookworm, Ascaris, Trichuris, and StrongyloidesTime required (hours)Fraction of exam spent on intestinal parasitesAverage GDP per capita-hour ADDIN EN.CITE <EndNote><Cite><Author>International Monetary Fund</Author><Year>2013</Year><RecNum>106</RecNum><DisplayText>[35]</DisplayText><record><rec-number>106</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399414497">106</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>International Monetary Fund,</author></authors></contributors><titles><title>2013 World Economic Outlook database. Accessed on June 3, 2013.</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[35]Average wage per hour ADDIN EN.CITE <EndNote><Cite><RecNum>97</RecNum><DisplayText>[32]</DisplayText><record><rec-number>97</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380233063">97</key></foreign-keys><ref-type name="Report">27</ref-type><contributors></contributors><titles><title>Bureau of Labor Statistics, 2013 National Occupational Employment and Wage Estimates. Washington DC, , Accessed on May 1, 2014</title></titles><dates></dates><urls></urls></record></Cite></EndNote>[32]Min cost estimateMax cost estimateComprehensive exam20.15.8422.331.24.5Time to provide two stool samples0.525.8422.335.8422.33Total time cost7.026.8Screening for Strongyloides onlyTime required (hours)No. of visitsAverage GDP per capita-hourAverage wage per hourMin cost estimateMax cost estimateComprehensive exam20.055.8422.330.582.23Total time cost0.582.23Time required for follow visit after intestinal parasites diagnosisVisit cost115.8422.335.8422.334.Outpatient and inpatient treatment cost estimatesFor outpatient treatment, we assumed that doctors would run a battery of tests to identify the underlying illness. These tests are summarized in Table S9 below with the number of each test and cost estimates. 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ADDIN EN.CITE.DATA [2, 26]. Therefore, we assumed that outpatient visits might be coded as level 2 indicating that a low level of care outside of the diagnostic tests would be required. We assumed that two visits would be required. The first visit would include the initial testing, while the second would include diagnosis and prescription of medication. Table S9. Strongyloidiasis outpatient cost estimates (2013 USD)Data sourcePhysician’s Fee and Coding Guide ADDIN EN.CITE <EndNote><Cite><Author>InGauge Healthcare Solutions</Author><Year>2013</Year><RecNum>104</RecNum><DisplayText>[31]</DisplayText><record><rec-number>104</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399319193">104</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>InGauge Healthcare Solutions,</author></authors></contributors><titles><title>2013 Physicians' Fee & Coding Guide</title></titles><dates><year>2013</year></dates><pub-location>Atlanta GA</pub-location><urls></urls></record></Cite></EndNote>[31]CMS 2013 Clinical Lab Fee Schedule or Physician Fee Schedule ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>87</RecNum><DisplayText>[3, 30]</DisplayText><record><rec-number>87</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385031">87</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Clinical Laboratory Fee Schedule, . Accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>88</RecNum><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385133">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Physician Fee Schedule, . accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[3, 30]Outpatient costsICD-9 codeNo. of visits/ testsMinMaxMidpointNational Midpoint or Facility PriceTotal cost (weighted average)Level 2 outpatient visit x2992122.0092.00125.00108.5024.5091.00Stool ova and parasites x3871773.0050.0066.0058.0016.5380.69Strongyloides and Schistosomiasis (Helminth antibody) x2866822.0069.0090.0079.5024.1675.99CBC w differential850251.0038.0051.0044.5014.4521.96Urinalysis810011.0029.0041.0035.004.0311.77Hepatic function panel800761.0050.0067.0058.5015.1726.00Giardia antibody873291.0059.0077.0068.0022.2833.71Cryptosporidium antibody872721.0059.0078.0068.5022.2833.84Total a683.00909.00796.00225.12374.97Albendazole cost (hookworm, trichuriasis or ascariasis diagnosis)119.40Ivermectin cost (strongyloidiasis diagnosis)33.50Total + Albendazole a802.401,028.40915.40344.52494.37Total + Ivermectin a716.50942.50829.50258.62408.46a Note that total costs are estimated using 25% * Physicians’ Fee and Coding Guide + 75% * CMS rate and are rounded to the nearest dollar.Strongyloidiasis hospitalizationCases requiring hospitalization are more expensive than those treated on an outpatient basis. As summarized in Table S10, data from the National Inpatient Survey collected by the Agency for Healthcare Research and Quality were used to estimate the cost of hospitalization ADDIN EN.CITE <EndNote><Cite><RecNum>85</RecNum><DisplayText>[34]</DisplayText><record><rec-number>85</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366297361">85</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2007-2009. Agency for Healthcare Research and Quality, Rockville, MD. hcup-us.nisoverview.jsp </title></titles><dates></dates><urls></urls></record></Cite></EndNote>[34]. Annual data for 2005-2011 were extracted and updated to 2013 USD by using the medical consumer price index from the Bureau of Labor Statistics ADDIN EN.CITE <EndNote><Cite><Author>Bureau of Labor Statistics</Author><Year>2013</Year><RecNum>98</RecNum><DisplayText>[40]</DisplayText><record><rec-number>98</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380233064">98</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>Bureau of Labor Statistics,</author></authors></contributors><titles><title>Consumer Price Index, Average Annual Indexes 2006-12, , accessed on May 1, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[40]. Table S10. Average duration of stay, costs, and charges for hospitalized tuberculosis cases in the United States ADDIN EN.CITE <EndNote><Cite><RecNum>85</RecNum><DisplayText>[34]</DisplayText><record><rec-number>85</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366297361">85</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2007-2009. Agency for Healthcare Research and Quality, Rockville, MD. hcup-us.nisoverview.jsp </title></titles><dates></dates><urls></urls></record></Cite></EndNote>[34]YearNo. of dischargesMean length of stayCharges in 2013 USDaCosts in 2013 USDa20119410.797,93724,1072010998.852,07215,06620099813.0N/A24,0232008787.764,90120,429200784N/AN/AN/A2006103N/AN/AN/A2005737.7N/AN/ACase-weighted average b9.757,71419,776N/A: Data not availablea Costs and charged were adjusted to 2013 USD by using the U.S. Medical Consumer Price Index ADDIN EN.CITE <EndNote><Cite><Author>Bureau of Labor Statistics</Author><Year>2013</Year><RecNum>98</RecNum><DisplayText>[40]</DisplayText><record><rec-number>98</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380233064">98</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>Bureau of Labor Statistics,</author></authors></contributors><titles><title>Consumer Price Index, Average Annual Indexes 2006-12, , accessed on May 1, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[40]b The case-weighted average was calculated by multiplying the annual means by the number of observations for a given year and then dividing by the total number of observations across all years.Patient opportunity costs in the United StatesPatient opportunity costs were estimated using: 1) the average GDP per capita-hour ($5.84 per hour for 24 hours per day) ADDIN EN.CITE <EndNote><Cite><Author>International Monetary Fund</Author><Year>2013</Year><RecNum>106</RecNum><DisplayText>[35]</DisplayText><record><rec-number>106</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399414497">106</key></foreign-keys><ref-type name="Online Database">45</ref-type><contributors><authors><author>International Monetary Fund,</author></authors></contributors><titles><title>2013 World Economic Outlook database. Accessed on June 3, 2013.</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[35] for the minimum and best cost estimate and 2) the maximum cost estimate was based on the average wage estimate across all occupations $22.33 ADDIN EN.CITE <EndNote><Cite><RecNum>97</RecNum><DisplayText>[32]</DisplayText><record><rec-number>97</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380233063">97</key></foreign-keys><ref-type name="Report">27</ref-type><contributors></contributors><titles><title>Bureau of Labor Statistics, 2013 National Occupational Employment and Wage Estimates. Washington DC, , Accessed on May 1, 2014</title></titles><dates></dates><urls></urls></record></Cite></EndNote>[32] for 8-hour work days). We assumed that outpatient treatment would be associated with the loss of one full day for any of the intestinal parasites. We assumed that the opportunity cost for hospitalization could be estimated from the average duration of inpatient treatment for strongyloidiasis patients (rounded to 10 days) based on data from the National Inpatient Survey (Table S6). These estimates are summarized in Table S11.Table S11. Estimated opportunity costs for outpatient and inpatient tuberculosis casesOpportunity costsBaseMinMaxOutpatient opportunity cost (days)1Outpatient opportunity cost (USD)140140176Inpatient opportunity cost (days)10Inpatient opportunity cost (USD)1,4001,4001,7605.Overseas presumptive treatment cost estimatesIOM provided 2013 data on costs from three sites in Asia: Thailand, Malaysia, and Nepal. The estimates from Thailand and Nepal were camp-based while those from Malaysia were for urban-based refugees. The cost estimates included 1) staff time (nurses, lab technicians, data entry, and support staff), 2) drug costs (albendazole 400mg, and ivermectin (18 mg), 3) pregnancy tests, 4) transportation costs, and 5) IOM overhead costs.The costs by site are summarized in Table S12. The average cost per refugee is estimated by dividing total costs across all three sites by the total number of refugees treated across the three sites. Table S12. Summary of cost data provided by IOM, 2013 USDBudget Line Thailand Nepal Malaysia Total Caseload 5,500 10,000 9,000 24,500Staff & Office Cost $ 33,629 $ 51,385 $ 22,282 $ 107,296 Operational Cost $ 52,632 $ 59,902 $ 33,480 $ 146,014 Total $ 90,574 $ 116,851 $ 58,550 $ 269,975 Total cost per person (albendazole and ivermectin) $ 16.47 $ 11.69 $ 6.51 $ 10.86 Cost per drug, overseas treatmentRefugee-weighted meanLower boundUpper boundAlbenazole$ 3.2$ 2.7$ 3.7Ivermectin$ 7.6$ 3.8$ 13.36.Probability distributionsWe used three types of probability distributions: beta, gamma, and uniform. The beta distribution was commonly used for probabilities that should be restricted to values between 0 and 1 (e.g., sensitivity, specificity, efficacy). The gamma distribution was used for positive real numbers (e.g., screening/treatment costs, outpatient/inpatient costs). The uniform distribution was used for parameters that were mostly based on expert opinion (e.g., QALY weights). For the beta and gamma distributions, parameters were estimated using the following formulas: Mean = (Min + 4*Best + Max)/6, Standard Deviation = (Max – Min)/6. For these estimates, Best is our best estimate, Max is our maximum or upper bound estimate and Min is our minimum or lower bound estimate. We used Treeage software to fit distributions using the mean and standard deviations as reported in the Table S13.Table S13. Estimated means and standard deviations for each uncertain parameter included in the analysisDescriptionBase case analysisLower boundUpper boundDistri-butionaMeanStandard DeviationEpidemiological parametersBaseline infection prevalence (without treatment)Hookworm0.0280.0280.11B0.06900.0006Ascaris0.00840.00840.017B0.01270.0000Trichuris0.00560.00560.015B0.01030.0000Strongyloides0.20.060.34B0.20000.0467Drug efficacyAlbendazole against hookworm0.720.720.93B0.75500.0350Albendazole against Trichuris0.280.280.73B0.35500.0750Albendazole against Ascaris0.880.880.94B0.89000.0100Ivermectin against Strongyloides0.90.570.99B0.86000.0700Test sensitivitySensitivity of Strongyloides serologic test0.910.890.92B0.90830.0050Sensitivity of two stool O&P for hookworm0.780.530.88B0.89500.0150Sensitivity of two stool O&P for Ascaris0.810.570.95B0.95830.0083Sensitivity of two stool O&P for Trichuris0.960.810.99B0.99170.0017Test specificityStrongyloides serologic test0.920.890.97B0.92330.0133Two stool O&P for hookworm, Ascaris, and Trichuris111NA??Duration of risk of infection for outpatient illnesshookworm657G6.00000.3333Trichuris212G1.83330.1667Ascaris111N/A??Annual probability of seeking treatment given infectionOutpatient visit for hookworm/ trichuriasis/ascariasis0.0010.000120.005B0.00150.0008Outpatient visit for strongyloidiasis 0.0010.000120.005B0.00150.0008Inpatient strongyloidiasis 2.90E-056.60E-061.20E-04B0.00000.0000Case fatality rate for inpatient strongyloidiasis0.1670.020.25B0.15630.0383Program parametersProportion of refugees that present for comprehensive exam in United States0.90.81U0.90000.0033Probability that refugees will arrive from IOM facilities10.751U0.85000.0033Probability that refugee will receive presumptive treatment0.90.80.98U0.89000.0027Probability that stool O&P will be ordered given presumptive treatment0.050.030.07U0.05000.0001Adjustment factor for overseas versus domestic treatment 0-110.751U0.95830.0417U.S. cost estimates (2013 USD)Screen for all nematodes11678260G133.730.3Screen for strongyloides, assuming albendazole presumptive treatment 5438112G61.012.3Screen, assuming albendazole + ivermectin presumptive treatment7857171G90.019.0Albendazole treatment 400mg173152252G182.716.7Ivermectin treatment 18mg8766166G96.716.7Outpatient treatment for intestinal parasites (screening + albendazole cost)4943451030G553.8114.2Outpatient treatment for intestinal parasites (screening + ivermectin cost)408259940G467.3113.3Inpatient treatment for strongyloides20,00015,00024,000G19833.31500.0Overseas cost estimates (2013 USD) of presumptive treatment in AsiaAlbendazole 3.22.73.7G3.950.45Ivermectin 7.63.813.3G8.851.58Opportunity cost estimates (2013 USD)Screening (all parasites)7722G9.52.5Screening (Strongyloides only)112.2G1.20.2Treatment after screening6622G8.672.67Outpatient cases 140140176G1466Inpatient strongyloides1,4001,4001,760G146060QALY estimatesQALY decrement for Strongyloides infections0.00100.01B0.00230.0017QALY decrement for hookworm, Ascaris, Trichuris infections0.00100.01B0.00230.0017a Distribution types: U- uniform, B- beta, G- gamma 7.Baseline disease burden by parasiteThe baseline disease burden by parasite was estimated using the model. For each outcome measure (cases, hospitalizations, deaths, life years, and QALYs), we calculate the total number of each measure for by setting prevalence rates for three parasites to zero to isolate the burden for the remaining parasite. Then, we calculated the number of each outcome measure. The results are summarized in Table S14.TableS14. Breakdown of cases, hospitalizations, deaths, life years and QALYs by causative parasite (60-year time horizon for a one-year cohort of 27,700 Asian refugees) a?Hookworm, Trichuris, and AscarisStrongyloidesCases6.0138Hospitalizations04.0QALYs5.5148LY013deaths00.67a Results are rounded8.Additional sensitivity analysisIn addition to the sensitivity analysis presented in the main article, we performed additional sensitivity analysis using data from the Monte Carlo Simulation analysis (10,000 iterations). Table S15 shows the range of estimates for the incremental cost per QALY for three pairs of alternatives: 1) ‘Domestic Screening and Treatment’ compared to “No Program”, 2) ‘Domestic Screening and Treatment’ compared to “Overseas Albendazole and Ivermectin”, and 3) “Overseas Albendazole and Ivermectin” compared to “No Program”. Relative to “No Program”, the “Overseas Albendazole and Ivermectin” program has an almost 90% probability of costing less than $14,000 per QALY gained and a greater than 99% probability of costing less than $50,000 per QALY gained. In comparison, “Domestic Screening and Treatment” is much more costly per QALY gained relative to “No Program”. There is a 16% probability that the cost per QALY gained will be greater than $50,000 and a 75% probability it would cost more than $13,000. Comparing “Domestic Screening and Treatment” to “Overseas Albendazole and Ivermectin”, there is a 65% probability that the overseas treatment program would be both more effective and less costly than domestic screening. Even when domestic screening is more effective, there is only about a 1% probability that that the cost per QALY would be less than $50,000 compared to overseas presumptive treatment. Table S15. Percentile estimates of the cost per QALY gained, 10,000 iterations in 2013 USD“Domestic Screening and Treatment” vs. “No Program”“Domestic Screening and Treatment” vs. “Overseas Albendazole and Ivermectin”“Overseas Albendazole and Ivermectin” vs. “No Program”1 percentile 4,815 1 percentile (12,075,242)1 percentile 458 2.5 percentile 6,029 2.5 percentile (5,196,397)2.5 percentile 600 5 percentile 7,421 5 percentile (2,628,153)5 percentile 772 10 percentile 8,732 10 percentile (1,221,610)10 percentile 1,070 25 percentile 13,156 25 percentile (401,321)25 percentile 1,912 50 percentile 21,870 50 percentile (145,656)50 percentile 3,446 75 percentile 39,852 75 percentile 128,081 75 percentile 7,024 90 percentile 77,041 90 percentile 877,380 90 percentile 13,847 95 percentile 114,246 95 percentile 1,850,790 95 percentile 20,580 97.5 percentile 168,451 97.5 percentile 4,130,060 97.5 percentile 29,510 99 percentile 268,034 99 percentile 8,882,370 99 percentile 50,210 Scatter plots of the incremental cost and incremental effectiveness per person are shown in Figure S4a-c for the first 1000 iterations of the Monte Carlo Simulation analysis. Each graph also shows three lines for which the cost per QALY gained is 1) $10,000, 2) $25,000, and 3) $50,000. As effectiveness increases, the cost of the program increases along the line to maintain a threshold value (e.g., an incremental effectiveness of 0.001 QALYs and increment cost of $10 has the same cost per QALY ratio as that for an incremental effectiveness of 0.002 QALYs and an incremental cost of $20). Each point located to the right of the lines would have a cost per QALY gained less than the thresholds. Points to the left of the lines have a cost per QALY gained greater than the thresholds. Figure S4a shows that the incremental cost per person of “Domestic Screening and Treatment” compared to “No Program” is usually in the range of $100-$200 and that the incremental effectiveness per person is usually between 0 and 0.02 QALYs per person. The majority of points are to the left of the $50,000 per QALY threshold and to the right of the $10,000 per QALY threshold. Figure S4b shows that the incremental cost per person of “Domestic Screening and Treatment” compared to “Overseas Albendazole and Ivermectin” is usually in the range of $70-$200 and that the incremental effectiveness per person is usually between -0.02 and 0.02 QALYs per person. The majority of points are to the left of the $10,000 per QALY threshold and that effectiveness is more commonly better for “Overseas Albendazole and Ivermectin”. Figure S4c shows that the incremental cost per person of “Overseas Albendazole and Ivermectin” compared to “No Program” is usually in the range of $10-$40 and that the incremental effectiveness per person is usually between 0 and 0.02 QALYs per person. The majority of points are to the left of the $10,000 per QALY threshold and that “Overseas Albendazole and Ivermectin” is never cost saving.Figure S4a. Scatter plot of incremental cost and incremental effectiveness, “Domestic Screening and Treatment” vs. “No Program” Figure S4b. Scatter plot of incremental cost and incremental effectiveness, “Domestic Screening and Treatment” vs. “Overseas Albendazole and Ivermectin” Figure S4c. Scatter plot of incremental cost and incremental effectiveness, “Overseas Albendazole and Ivermectin” vs. “No Program” 8.Two Additional Alternatives: Domestic Albendazole + Ivermectin and Domestic Albendazole and Screening for StrongyloidesThis section provides analyses for two additional alternatives: “Domestic Albendazole and Ivermectin” and “Domestic Albendazole and Screening for Strongyloides”. These alternatives are recommended in CDC guidelines ADDIN EN.CITE <EndNote><Cite><Author>CDC</Author><Year>2014</Year><RecNum>105</RecNum><DisplayText>[41]</DisplayText><record><rec-number>105</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399324861">105</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>CDC</author></authors></contributors><titles><title>Guidelines for the U.S. Domestic Medical Examination for Newly Arriving Refugees , Accessed on May 5, 2014.</title></titles><dates><year>2014</year></dates><urls></urls></record></Cite></EndNote>[41] for refugees arriving from countries without presumptive treatment programs. These programs are very similar to the options presented in the article: “Overseas Albendazole and Ivermectin” and “Overseas Albendazole and Domestic Screening for Strongyloides”. The only difference is that presumptive treatment is provided after arrival in the United States rather than prior to departure for the United States. These alternatives were not included in the article because drug prices are much higher in the United States and because we do not anticipate any major differences in health outcomes. The cost for “Domestic Albendazole and Ivermectin” is about $165 per refugee as summarized in Table S16. This is much greater than the estimated cost overseas ($10.80). Because of the big difference in costs between domestic and overseas presumptive treatment, this alternative is only included in the appendix.The cost of domestic presumptive treatment with albendazole only is included in Table S17. This cost can be added to the cost of domestic screening for Strongyloides infection (Table S6) to estimate the total program cost for “Domestic Albendazole and Screening for Strongyloides”. The total cost will also include follow-up treatment with ivermectin for individuals who test positive (Table S7).Table S16. Cost estimates for “Domestic Albendazole and Ivermectin” in 2013 USDSource??Physician’s Fee and Coding Guide ADDIN EN.CITE <EndNote><Cite><Author>InGauge Healthcare Solutions</Author><Year>2013</Year><RecNum>104</RecNum><DisplayText>[31]</DisplayText><record><rec-number>104</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399319193">104</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>InGauge Healthcare Solutions,</author></authors></contributors><titles><title>2013 Physicians' Fee & Coding Guide</title></titles><dates><year>2013</year></dates><pub-location>Atlanta GA</pub-location><urls></urls></record></Cite></EndNote>[31]CMS 2013 Clinical Physician Fee Schedule ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>88</RecNum><DisplayText>[3]</DisplayText><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385133">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Physician Fee Schedule, . accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[3] ?Outpatient costsICD-9 codeNo. of tests or visitsMin (USD)Max (USD)Midpoint (USD)National Midpoint or Facility Price (USD)Total cost (weighted average)(USD)Comprehensive exam (new patient, level 4 complexity)99204$0.05$235$313$274$128.27 $8.24 Albendazole drug costNANANANANANA $119.40 IvermectinNANANANANANA $33.50 Interpreter (0.125 hr)3.83Total??$168.48 $172.38 $170.43 $163.14 $164.96 a Note that total costs are estimated using 25% * Physicians’ Fee and Coding Guide + 75% * CMS rate and are rounded to the nearest dollar.Table S17. Cost estimates for domestic presumptive treatment with albendazole only, 2013 USDSource??Physician’s Fee and Coding Guide ADDIN EN.CITE <EndNote><Cite><Author>InGauge Healthcare Solutions</Author><Year>2013</Year><RecNum>104</RecNum><DisplayText>[31]</DisplayText><record><rec-number>104</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1399319193">104</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>InGauge Healthcare Solutions,</author></authors></contributors><titles><title>2013 Physicians' Fee & Coding Guide</title></titles><dates><year>2013</year></dates><pub-location>Atlanta GA</pub-location><urls></urls></record></Cite></EndNote>[31]CMS 2013 Clinical Lab Fee Schedule or Physician Fee Schedule ADDIN EN.CITE <EndNote><Cite><Author>Centers for Medicare and Medicaid Services</Author><Year>2013</Year><RecNum>88</RecNum><DisplayText>[3]</DisplayText><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366385133">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Centers for Medicare and Medicaid Services,</author></authors></contributors><titles><title>Physician Fee Schedule, . accessed on March 20, 2013</title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[3]?Outpatient costsICD-9 codeNo. of tests or visitsMin (USD)Max (USD)Midpoint (USD)National Midpoint or Facility Price (USD)Total cost (weighted average)(USD)Comprehensive exam (new patient, level 4 complexity)992040.05$235$313$274$128.27 $ 8.24 Albendazole drug costNANANANANANA $ 119.40 IvermectinNANANANANANA0Interpreter (0.125 hr)3.83Total????? $ 131.47 a Note that total costs are estimated using 25% * Physicians’ Fee and Coding Guide + 75% * CMS rate and are rounded to the nearest dollar.The estimated costs and health outcomes of ‘Domestic Albendazole + Ivermectin” and’ Domestic Albendazole and Screening for Strongyloides’ compared to other alternatives is shown in Table S18. The cost is much higher relative to overseas presumptive treatment programs and expected health outcomes are the same. Thus, these alternatives are not preferred because it costs approximately 10 times more to provide presumptive treatment in the United States compared to providing the same treatment regimen overseas prior to departure.Table S18. Estimates costs and health outcomes of Domestic Albendazole and Ivermectin and Domestic Albendazole and Screening for Strongyloides compared to other alternatives?No program'“Overseas Albendazole and Ivermectin”“Domestic Screening and Treatment'“Overseas Albendazole and Domestic Screening for Strongyloides”“Domestic Albendazole and Iverrmectin”“Domestic Albendazole and Screening for Strongyloides”Costs, 2013 USD??????Total costs$165,923 $418,824 $3,832,572 $2,182,483 $4,146,136 $5,227,821 Health outcomes (discounted)?????Outpatient cases1452940392928Hospitalizations4.00.81.11.10.81.1Deaths0.670.130.180.180.130.18Life years 700,526 700,536 700,535 700,535 700,536 700,535 QALYs 605,253 605,377 605,366 605,366 605,377 605,377 Economic outcomes relative to “No Program”, 2013 USD????Net cost per case averted $2,146 $34,907 $ 18,483 $34,213 $43,257 Net cost per hospitalization averted $76,606 $1,238,977 $ 680,735 $1,251,602 $1,224,141 Net cost per death averted $458,718 $7,419,026 $4,076,259 $7,330,188 $10,246,183 Net cost per life year gained $24,036 $388,754 $ 213,594 $392,708 $384,092 Net cost per QALY gained $2,219 $32,706 $18,167 $2,750 $24,872 9.Additional analyses for U.S.-bound refugees from AfricaAn estimated 13,800 African refugees settle in the United States each year. ADDIN EN.CITE <EndNote><Cite><RecNum>32</RecNum><DisplayText>[4]</DisplayText><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349982139">32</key></foreign-keys><ref-type name="Government Document">46</ref-type><contributors><authors><author>,</author></authors></contributors><titles><title>Department of Homeland Security (2012) Yearbook of Immigration Statistics , accessed on October 1, 2012</title></titles><dates></dates><pub-location>Washington, D.C.</pub-location><urls></urls></record></Cite></EndNote>[4] The prevalence of hookworm, Ascaris, and Trichuris infections among African refugees is estimated using the results from Swanson et al. ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20] using the same approach as was used for these infections among refugees from Asia (see Appendix section 2). The resulting prevalence rates vary from 0.011 for hookworm to 0.069 for Trichuris (Table S19). Table S19. Estimated prevalence rates for hookworm, Ascaris, and Trichuris infections among African refugees after adjustment for presumptive treatment efficacy?AscarisHookwormTrichurisPrevalence after treatment ADDIN EN.CITE <EndNote><Cite><Author>Swanson</Author><Year>2012</Year><RecNum>22</RecNum><DisplayText>[20]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349461757">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephen J. Swanson</author><author>Christina R. Phares</author><author>Blain Mamo</author><author>Kirk E. Smith</author><author>Martin S. Cetron</author><author>William M. Stauffer</author></authors></contributors><titles><title>Albendazole therapy and enteric parasites in United States-bound refugees.</title><secondary-title>New England Journal of Medicine</secondary-title></titles><periodical><full-title>New England Journal of Medicine</full-title></periodical><pages>1498-1507</pages><volume>366</volume><number>16</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>[20]0.0030.0030.05????Meta analysis efficacy ADDIN EN.CITE <EndNote><Cite><Author>Keiser</Author><Year>2008</Year><RecNum>95</RecNum><DisplayText>[15]</DisplayText><record><rec-number>95</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1380141974">95</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jennifer Keiser</author><author>Jurg Utzinger</author></authors></contributors><titles><title>Efficacy of Current Drugs Against Soil-Transmitted Helminth Infections Systematic Review and Meta-analysis</title><secondary-title>Journal of the American Medical Association</secondary-title></titles><periodical><full-title>Journal of the American Medical Association</full-title></periodical><pages>1937-1948</pages><volume>299</volume><number>16</number><dates><year>2008</year></dates><urls></urls></record></Cite></EndNote>[15]0.880.720.28Adjusted pre-treatment prevalence based on meta-analysis efficacy0.0250.0110.069Strongyloides prevalence was estimated using data from four refugee-specific studies that used serologic testing in the United States and Africa. Among the four studies, three studies reported prevalence rates between 31% and 42%. The fourth study showed a much lower prevalence rate (2%). The estimated prevalence was adjusted using sensitivity and specificity for Strongyloides serologic tests (Table S1) as described in Section 2 of this appendix. Overall, the prevalence was estimated to be 33% based on the sample-size weighted average prevalence from the four studies after adjusting for test sensitivity and specificity.Table S20. Estimated prevalence rates for Strongyloides infections among African refugees after adjustment for test sensitivity and specificitySiteSample sizeAfricaCountry of Origin or Last Residence in AfricaReferenceUnadjustedprevalenceAdjustedpervalenceSan Diego, CA 2006-0717233%30% Sudan Brodine et al. ADDIN EN.CITE <EndNote><Cite><Author>Brodine</Author><Year>2009</Year><RecNum>26</RecNum><DisplayText>[42]</DisplayText><record><rec-number>26</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349794121">26</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Stephanie K. Brodine</author><author>Anne Thomas</author><author>Robert Huang</author><author>Judith Harbertson</author><author>Sanjay Mehta</author><author>John Leake</author><author>Thomas Nutman</author><author>Kathleen Moser</author><author>Jamie Wolf</author><author>Roshan Ramanathan</author><author>Peter Burbelo</author><author>John Nou</author><author>Patricia Wilkins</author><author>Sharon L. Reed</author></authors></contributors><titles><title>Community Based Parasitic Screening and Treatment of Sudanese Refugees: Application and Assessment of Centers for Disease Control Guidelines</title><secondary-title>American Journal of Tropical Medicine and Hygiene</secondary-title></titles><periodical><full-title>American Journal of Tropical Medicine and Hygiene</full-title></periodical><pages>425-430</pages><volume>80</volume><number>3</number><dates><year>2009</year></dates><urls></urls></record></Cite></EndNote>[42]Santa Clara, CA 2008-102931%28%?Chang et al. ADDIN EN.CITE <EndNote><Cite><Author>Chang</Author><Year>2013</Year><RecNum>79</RecNum><DisplayText>[22]</DisplayText><record><rec-number>79</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1366239499">79</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chang, AH</author><author>Perry, S</author><author>Du, JN</author><author>Agunbiade, A</author><author>Polesky, A</author><author>Parsonnet, J</author></authors></contributors><titles><title>Decreasing intestinal parasites in recent northern California refugees</title><secondary-title>American Journal of Tropical Medicine and Hygiene</secondary-title></titles><periodical><full-title>American Journal of Tropical Medicine and Hygiene</full-title></periodical><pages>191-197</pages><volume>88</volume><number>1</number><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>[22]2000-02 Melbourne Australia1242%0%East AfricaCaruana et al. ADDIN EN.CITE <EndNote><Cite><Author>Caruana</Author><Year>2006</Year><RecNum>15</RecNum><DisplayText>[21]</DisplayText><record><rec-number>15</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349388177">15</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Sonia R . Caruana</author><author>Heath A . Kelly </author><author>Joanne Y . Y . Ngeow</author><author>Norbert J . Ryan</author><author>Catherine M . Bennett </author><author>Ley Chea</author><author>Sophy Nuon</author><author>Narin Bak</author><author>Susan A . Skull</author><author>Beverley-Ann Biggs</author></authors></contributors><titles><title>Undiagnosed and Potentially Lethal Parasite Infections Among Immigrants and Refugees in Australia</title><secondary-title>Journal of Travel Medicine</secondary-title></titles><periodical><full-title>Journal of Travel Medicine</full-title></periodical><pages>233-239</pages><volume>13</volume><number>4</number><dates><year>2006</year></dates><urls></urls></record></Cite></EndNote>[21]United States 200456242%41% Somalia and Sudan Posey et al. ADDIN EN.CITE <EndNote><Cite><Author>Posey</Author><Year>2007</Year><RecNum>14</RecNum><DisplayText>[43]</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="dess9daf9s95ajet2t0vafvidsztdv9sswfd" timestamp="1349385671">14</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Drew L. Posey</author><author>Brian G. Blackburn</author><author>Michelle Weinberg</author><author>Elaine W. Flagg</author><author>Luis Ortega</author><author>Marianna Wilson</author><author>W. Evan Secor</author><author>Kolby Sanders-Lewis</author><author>Kimberly Won</author><author>James H. Maguire</author></authors></contributors><titles><title>High Prevalence and Presumptive Treatment of Schistosomiasis and Strongyloidiasis among African Refugees</title><secondary-title>Clinical Infectious Diseases</secondary-title></titles><periodical><full-title>Clinical Infectious Diseases</full-title></periodical><pages>1310-1315</pages><volume>45</volume><dates><year>2007</year></dates><urls></urls></record></Cite></EndNote>[43]Total88734%33%??To be conservative the cost of overseas presumptive treatment was assumed to be 25% higher for African refugees compared to Asian refugees. IOM has provided 2013 data for the cost of overseas presumptive treatment for African refugees. Since the program in Africa also includes praziquantel for schistosomiasis and coartem for malaria, the per-refugee cost is higher in Africa ($33.6 vs. $10.8). However, the coartem regimen requires 6 doses over 3 days compared to 3 doses total over two days for both albendazole and ivermectin. The albendazole and ivermectin drug costs are similar in Africa and Asia. However, we decided to multiply the Asian costs ($3.20 for albendazole and $10.80 for albendazole and ivermectin) by 1.25 to be conservative. Besides prevalence rates and overseas presumptive treatment costs, all other parameters were carried over from the analysis of Asian refugees (Table S1). The results for African refugees are similar to those for Asian refugees. The cost per QALY gained ($1,338) is lowest for “Overseas Albendazole and Ivermectin”. This is also the most effective option; other options are limited by the sensitivity of tests to determine helminth infection. Table S21. Estimates costs and health outcomes of helminth screening and treatment alternatives for African refugees (n=13,800)?“No program”“Overseas Albendazole and Ivermectin”“Domestic Screening and Treatment”“Presumptive Albendazole + Domestic Screening for Strongyloides”“Domestic Albendazole + Ivermectin”“Domestic Albendazole and Screening for Strongyloides”Costs, 2013 USD??????Total costs$273,676 $509,403 $4,382,971 $2,077,176 $2,736,264 $5,581,550 Health outcomes (discounted)?????Outpatient cases2395065666665Hospitalizations6.61.31.71.71.71.7Deaths1.110.210.290.2900Life years 700,518 700,535 700,533 700,533 700,533 700,533 QALYs 605,154 605,356 605,338 605,339 605,339 605,338 Economic outcomes relative to “No Program”, 2013 USD????Net cost per case averted $1,264 $23,593 $12,410 $23,224 $31,111 Net cost per hospitalization averted $76,606 $44,667 $843,390 $453,454 $798,728 Net cost per death averted $267,470 $5,050,242 $2,715,294 $4,782,802 $4,782,802 Net cost per life year gained $24,036 $14,016 $264,647 $142,289 $250,633 Net cost per QALY gained $1,338 $22,541 $12,099 $21,283 $28,644 References ADDIN EN.REFLIST 1.Martin DC, Yankay JE. 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