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The price of certain antiparasitic drugs (e.g., albendazole and mebendazole) has dramatically increased since 2010. The effect of these rising prices on treatment costs and use of standard of care (SOC) drugs is unknown. To measure the impact of drug prices on overall outpatient cost and quality of care, we identified outpatient visits associated with ascariasis, hookworm, and trichuriasis infections from the 2010 to 2017 MarketScan Commercial Claims and Encounters and Multi-state Medicaid databases using Truven Health MarketScan Treatment Pathways. Evaluation was limited to members with continuous enrollment in non-capitated plans 30 days prior, and 90 days following, the first diagnosis. The utilization of SOC prescriptions was considered a marker for quality of care. The impact of drug price on the outpatient expenses was measured by comparing the changes in drug and nondrug outpatient payments per patient through Welch's two sample t-tests. The total outpatient payments per patient (drug and nondrug), for the three parasitic infections, increased between 2010 and 2017. The increase was driven primarily by prescription drug payments, which increased 20.6-137.0 times, as compared with nondrug outpatient payments, which increased 0.3-2.2 times. As prices of mebendazole and albendazole increased, a shift to alternative SOC and non-SOC drug utilization was observed. Using parasitic infection treatment as a model, increases in prescription drug prices can act as the primary driver of increasing outpatient care costs. Simultaneously, there was a shift to alternative SOC, but also to non-SOC drug treatment, suggesting a decrease in quality of care.

In the United States, prices of long-established, generic anthelmintic medications have markedly risen. In the past decade, albendazole and mebendazole have increased in price by > 8,000%, whereas praziquantel has increased by > 500%. To determine the effect of these price increases on the practice patterns of healthcare providers, we conducted a cross-sectional electronic survey of clinics in the United States that primarily care for immigrant and refugee patient populations. Among 32 clinics, 53.1% reported that price increases impacted how providers diagnosed and treated helminth infections. A third (34.4%) of clinics reported that price increases have left them unable to treat known helminth infections. Other ways in which price increases impacted practice patterns included prescribing anthelmintics other than albendazole, mebendazole, or praziquantel when possible (34.4%); avoiding screening asymptomatic patients for helminth infections (15.6%); advising patients to acquire medications from another country (15.6%) or the patient's home country (9.4%); reducing anthelmintic dosing regimens to fewer pills (9.4%); and advising patients to purchase medications on the Internet (6.3%). These findings suggest price increases have negatively impacted the diagnosis and treatment of helminth infections in this population, and have resulted in the inability to treat known helminth infections. These findings have significant implications for the morbidity and mortality of infected individuals, as well as for public health in the United States.

Centers for Disease Control guidelines for schistosomiasis and strongyloidiasis in Sudanese and Somali refugees are not widely implemented. Given limited prevalence data, we conducted a seroprevalence study of schistosomiasis, strongyloidiasis, and loiasis in Sudanese refugees across diverse ages. Sudanese refugees, ages 4-78, were recruited via community organizations. Half of the patients (86/172), were seropositive for schistosomiasis (46/171; 26.9%), strongyloidiasis (56/172; 33%), or both (16/171; 9.4%). No Loa loa infections were detected. Infection rates were similar in adults and children except that no schistosomiasis was detected in children < 4 years of age at the time of immigration to the United States. The high prevalence of schistosomiasis and strongyloidiasis in a community-based sample of Sudanese confirms the urgency for compliance with CDC refugee health guidelines. We detected no co-infection with Loa loa using the most sensitive serologic techniques, allowing use of ivermectin, the most effective treatment of strongyloidiasis.

The presumptive treatment of parasitosis among immigrants with albendazole has been shown to save both money and lives, primarily via a reduction in the burden of Strongyloides stercoralis. Ivermectin is more effective than albendazole, but is also more expensive. This coupled with confusion surrounding the cost-effectiveness of guiding therapy based on eosinophil counts has led to disparate practices. We used the newly arrived year 2000 immigrant population as a hypothetical cohort in a decision analysis model to examine the cost-effectiveness of various interventions to reduce parasitosis among immigrants. When the prevalence of S. stercoralis is greater than 2%, the incremental cost-effectiveness ratios of all presumptive treatment strategies were similar. Ivermectin is associated with an incremental cost-effectiveness ratio of 1700 dollars per QALY gained for treatment with 12 mg ivermectin relative to 5 days of albendazole when the prevalence is 10%. Any presumptive treatment strategy is cost-effective when compared with most common medical interventions.

Understandably, cattle are raised for profit, as beef and/or dairy. Anything that negates that equation results in a loss to the producer and to the livestock economy. Thus, parasites negatively affect the economy of the industry. Worldwide, gastrointestinal nematode parasites, especially Ostertagia ostertagi, and those of the respiratory tract (Dictyocaulus viviparus) have a potentially major impact on herd health. In the past 10-15 years, anthelmintic (AH) drug development and the strategic use of AH have positively balanced the economic equation, so that overall, parasitism in cattle is often observed or determined to be subclinical or economical. Other control measures, such as better pasture management, are also being developed to enhance herd health and the cattle economy. The determination of the economic impact of parasitism has thus become less apparent, to the extent that measures, such as performance parameters, must be used to measure differences between treated and untreated animals or herds. These include weight gain, reproduction, lactation and forage use. To determine the effectiveness of control measures, field trials are designed to measure these parameters by the demonstration of improved performance. Because these trials are conducted in a competitive mode, results are often debated by competitors and by the scientific community because of study design. Variables must then be taken into consideration in the interpretation of results. It is now well known that, with the generation of new AH and appropriately-timed administration, parasitism of well-managed herds has been reduced to subclinical levels. Thus, we are now in the process of fine-tuning the positive effect of these control measures for enhanced production. Understandably, beef and dairy producers have 'production of high quality commodities' at a cost-effective level as a common goal. Successful cattlemen calculate expenditures and income by line item including veterinary expenses and cost and labor in administration of AH. Return is based on performance. Again, nematode parasites can disturb the equation enough to make production less profitable or even unprofitable. Most USA beef cattle producers believe that worm parasites do have an effect on cattle health and production so that 77% use AH and the market impact is that AH have become integrated into cattle herd health programs. However, to be most cost-effective, programs must be strategic but flexible with scheduling tailored for the region and the cattle operation. Other technologies should eventually provide rapid identification of worm populations by species and numbers and recognition of individual animal response to parasites and inheritance of that trait by their progeny. Computerized programs for analysis of seasonality of the epidemiology of gastrointestinal parasites and of herd performance could predict appropriate timing and cost benefit for control measures. Modes of AH administration are being developed which are more reliable and convenient in terms of delivery and labor. Control measures must also include better pasture management with less impact on the environment and to justify investment in land. In addition, successful producers are better educated, more cost-conscious, consumer-oriented, sensitive to the environment and attuned to the economics of parasitism.