Using stool antigen to screen for Helicobacter pylori in immigrants and refugees from high prevalence countries is relatively cost effective in reducing the burden of gastric cancer and peptic ulceration

Abstract

Objectives: Refugees and immigrants from developing countries settling in industrialised countries have a high prevalence of Helicobacter pylori (H. pylori). Screening these groups for H. pylori and use of eradication therapy to reduce the future burden of gastric cancer and peptic ulcer disease is not currently recommended in most countries. We investigated whether a screening and eradication approach would be cost effective in high prevalence populations.

Methods: Nine different screening and follow-up strategies for asymptomatic immigrants from high H. pylori prevalence areas were compared with the current approach of no screening. Cost effectiveness comparisons assumed population prevalence's of H. pylori of 25%, 50% or 75%. The main outcome measure was the net cost for each cancer prevented for each strategy. Total costs of each strategy and net costs including savings from reductions in ulcers and gastric cancer were also calculated.

Results: Stool antigen testing with repeat testing after treatment was the most cost effective approach relative to others, for each prevalence value. The net cost per cancer prevented with this strategy was US$111,800 (assuming 75% prevalence), $132,300 (50%) and $193,900 (25%). A test and treat strategy using stool antigen remained relatively cost effective, even when the prevalence was 25%.

Conclusions: H. pylori screening and eradication can be an effective strategy for reducing rates of gastric cancer and peptic ulcers in high prevalence populations and our data suggest that use of stool antigen testing is the most cost effective approach.

Figure 1. H. pylori management strategies included in the analysis.

Figure 2. Net cost per number of cancers prevented for different strategies for screening and treatment of H. pylori in a population with a 75% prevalence of H. pylori infection shown as an Incremental Cost Effectiveness Ratio (ICER).

Red line indicates lowest net cost per cancer prevented.

Figure 3. Net cost per number of cancers prevented for different strategies for management of H. pylori in a population with a 50% prevalence of H. pylori infection (ICER).

Red line indicates lowest net cost per cancer prevented.

Figure 4. Net cost per number of cancers prevented for different strategies for screening and treatment of H. pylori in a population with a 25% prevalence of H. pylori infection (ICER).

Red line indicates lowest net cost per cancer prevented.

Figure 5. Sensitivity analysis for the most cost effective strategy (stool antigen with retesting).

Horizontal bars represent the estimated net effect on cost per cancer prevented in US Dollars with a 1% increase in the listed parameters.