Coffee Break I.
Interviews by Chagas Coalition.
“Chagas Screening in Latin American migrants in Europe is cost-effective”.
Javier Sancho. Global Coalition
We start a new series of regular interviews with different actors who fight against neglected diseases. Although our focus will be mainly on the work of our colleagues and members of the Chagas Coalition, we will pay attention to other experiences, initiatives, organizations and prominent actors on different diseases which might provide an additional value to our work and interest.
Our aim is to offer a closer, fresh and more casual view on the work of those who fight against the diseases from different areas, without the academic style of scientific papers. Just like when we chat in a Coffee Break. We hope to contribute with a different way of knowledge sharing among our Coalition members and to exchange the enormous human and scientific potentials contained in the Coalition.
This time, we meet with Ana Requena. She is a young doctor, born in Granada, Andalucía, and now working in the International Health Service of Hospital Clínic in Barcelona. She is a researcher of ISGlobal and collaborated in the study Cost-effectiveness of Chagas disease screening in Latin American migrants at primary health-care centers in Europe: a Markov model analysis, published by the Lancet Global Health in February this year. The conclusion: The regular screening of migrant population under risk of Chagas is not only good for the health status of the people but also cost-effective for the European health systems.
We interviewed Ana at the meeting point of ISGlobal building in Barcelona. It was her lunchtime and she answered our questions while eating a big green salad.
First, tell us about the backstage of this article published in The Lancet.
It is part of a European initiative, the COHEMI network, which aims to assess and improve the health status of migrant population from Latin America.
Was there any other previous study like this?
There was a similar one but with a target population of pregnant women. The results validated the hypothesis that the screening of Chagas disease in Latin American pregnant women and their children was cost-effective. In fact, it provided a significant contribution for the decision making of the Health Department of the Catalonian government to implement the screening program of Chagas disease for pregnant women, which was a pioneer in Europe. That happened around 2009 and 2010.
Are you suggesting the screening for every Latin American adult living in Europe?
We think that the screening to all the people from endemic areas should be done at the Primary Health units.
Well, in a first view, it is quite clear that an earlier screening is cost-effective in any disease. It doesn’t seem a great finding.
Well, it was quite evident that if we made the screening of pregnant women we could reduce dramatically the risk of congential transmission. For adult population it is considered that we must provide diagnosis and treatment. But there are not many papers or studies about the reasons why we must or the recommendations about it. Chagas disease has the additional difficulty of remaining asymptomatic in many cases for many years. We can compare it with Tuberculosis in this aspect.
Is it worth screening all the population knowing that 30-40% of the people affected by Chagas will really develop serious complications? That in addition to the lack of trusty biomarkers that allows a more precise knowledge of the progression of the treatment.
Despite the instinct among the health professionals to answer “yes, it is worthy”, the truth is that there are no precedents of systematic screening in any country for all the population under risk. That’s why we decided to do this study in order to measure the cost-effectiveness of the screening in all the Latin American people attending primary health structures for any health need. The senior researcher of our team, Elisa Sicuri, was in charge of the economic analysis.
¿Does the study demonstrate that the screening of all adults is cheaper in the long term for the health system?
The total cost of the program implementation for a target population of 100.000 patients is high: 30 million euros. But the option of not to do it represents a 6 million euros expense for the system in terms of treatments and attention costs to those who developed the disease and its complications.
If I were a political stakeholder I would be scared by those figures.
Yeah, but here come the “QALYs”. I mean the quality-adjusted life-years.
¿What do you mean?
It’s just a measure of the health conditions and life quality of a person. In the screening proposed in this study for all Latin American migrants the results in QALYs is clear. The people gain 61,820.62 QALYs versus 57.334 in case they are not screened.
That result provides an Incremental Cost-Effectiveness Ratio (what we call ICER) of 6,000 euros for each QALY. In Europe, the standard of cost-effectiveness in terms of ICER is when they are less than 40,000 or 30,000. As you can see, the results for Chagas screening are very cost-effectiveness. Let’s consider around 20% of treatment efficacy, then each quality-adjusted life year costs 6,000 euros.
That figure seems more convincing for a health system.
Yeah, but at this point is when the political will and economic plans needs to do their job. We have to take into account the cost in the short term and patients response to accept the screening, among other issues. This study is not the only tool to take a decision. But we have reaffirmed recently, in a workshop with Chagas disease’s patients, that Primary Health Centers are the most appropriate locations to put the screening in place. We can’t wait until patients attend to the tropical diseases specialists. It wouldn’t be so expensive that the physicians in Primary Centers include serological tests for Chagas.
Is there any alternative for those health systems suffering budget limitations?
The program implementation cost is not based in annual estimates. It can be implemented gradually until the whole target potential population may be reached.
Was there any surprising finding for you in this study? Anything exciting?
I have learnt so much. In fact, I am a physician without much experience in cost-effectiveness research. I have also learnt about the enormous complexity of Chagas disease and the wide range of different scenarios you need to manage along the course of the disease. We have analyzed all the steps and phases in detail. Since the infection until the development of the disease as well as the death because of severe complications or the cases in which the parasite don’t produce any damage at all. There are almost endless changes, elements and gaps to consider in the fight against this disease.
At last, Ana finished her lunch. She takes her empty dish and smiles. Just before leaving, she adds:
I also learnt a lot with Elisa Sicuri. I hope this study can be helpful in a long term for the most important: to improve the life quality of our patients and also to improve this specific area of the health system.
