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Background: Tularemia is a re-emerging disease in Sweden, frequently affecting working-age individuals and often resulting in prolonged recovery times. The disease-related economic impact has not previously been investigated outside bioterrorism scenarios. In this study we assess the economic burden associated with endemic tularemia in Sweden.  

Method: Data on primary care visits, hospital admissions, and sick leaves were collected from participants with serology-confirmed tularemia through questionnaires and electronic medical records in Northern Sweden from 2011 to 2021. The dataset was enhanced with national cost-of-care data for tularemia in primary and specialist care from NordDRG (Diagnosis Related Group; 2021-2023), and sickness benefit data from the Social Insurance Agency (2011-2023). Total direct and indirect costs were estimated by integrating these data sources and adjusted for inflation to 2025 levels. Average salary and labor productivity (Gross Domestic Product [GDP] per person employed) was assumed.

Results: Among participants (n=294), the mean age was 52 years; 68.1% were employed or job-seeking, with 71.3% of these reporting sick leave during illness. Healthcare costs were primarily driven by general practitioner visits (mean 1.74 visits; 5,125 SEK per participant [p.p.]) and hospital admissions (15.6% of participants; mean 4.7 days; 11,268 SEK p.p.) with relatively low complexity (mean DRG weight 0.8), while antibiotic treatment and diagnostics were less costly (figure 1). Indirect costs included sick pay (≤14 days; 70.0%; 4,106 SEK p.p.), sickness benefit (>14 days; 30.0%; 5,835 SEK p.p.), and lost GDP-based productivity, and made up 75.7% of total costs (78,503 SEK p.p.).

A mean of 394 (range 87-1,048) tularemia cases per year were reported to the Swedish Public Health Agency between 2011-2023. The estimated annual societal cost of human tularemia infection was 30.9 million SEK (range 6.8-82.3 million SEK). 

Conclusion: Tularemia imposes a significant socioeconomic burden on society primarily through morbidity and prolonged recovery. Regional outbreaks could have detrimental effects on local economy and public services. Further evaluation of the cost-effectiveness of primary and secondary preventive measures is required.