A systematic review of cost-utility analyses of screening methods in latent tuberculosis infection in high-risk populations

Mahon, James; Beale, Sophie; Holmes, Hayden; Arber, Mick; Nikolayevskyy, Vladyslav; Alagna, Riccardo; Manissero, Davide; Dowdy, David W.; Migliori, Giovanni Battista; Sotgiu, Giovanni; Duarte, Raquel

doi:10.1186/s12890-022-02149-x

Cited by 13 publications

(9 citation statements)

References 39 publications

(184 reference statements)

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“…The assessment of cost-effectiveness for TBI screening among migrants is affected by the TBI prevalence found in the screened population [ 29 ]. In our study, screening was offered to all migrants who recently arrived, asylum seekers or undocumented, regardless of incidence in the country of origin, resulting in around 30% of our population coming from countries with TB incidence <150/100,000.…”

Section: Discussionmentioning

confidence: 99%

Screening for Tuberculosis Infection among Migrants: A Cost-Effectiveness Analysis in the Italian Context

et al. 2023

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Background: Screening of tuberculosis infection (TBI) among migrants from high-incidence countries is a cornerstone of tuberculosis control in low-incidence countries. However, the optimal screening strategy has not been defined yet. Methods: A quasi-experimental study involving migrants residing in the province of Brescia was carried out that aimed at assessing the completion rate, time to completion, preventive treatment initiation rate, and cost-effectiveness of two strategies for TBI screening. They underwent TBI screening with the IGRA-only strategy (arm 1) or with the sequential strategy (tuberculin skin test, TST, followed by IGRA in case of a positive result—arm 2). The two strategies were compared in terms of screening completion, time to complete the screening process, therapy initiation, and cost-effectiveness. Results: Between May 2019 and May 2022, 657 migrants were evaluated, and 599 subjects were included in the study, with 358 assigned to arm 1 and 237 to arm 2. Screening strategy was the only factor associated with screening completion in a multivariable analysis, with the subjects assigned to the IGRA-only strategy more likely to complete the screening cascade (n = 328, 91.6% vs. n = 202, 85.2%, IRR 1.08, 95% CI (1.01–1.14), p = 0.019). The time to complete the screening process was significantly longer for patients assigned to the sequential strategy arm (74 days vs. 46 days, p = 0.002). Therapy initiation did not significantly differ between the two arms, and cost-effectiveness was higher for the sequential strategy. Conclusion: Sequential strategy implementation for TBI screening among migrants may be justified by its higher cost-effectiveness in spite of the lower completion of the screening cascade.

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Section: Discussionmentioning

confidence: 99%

Screening for Tuberculosis Infection among Migrants: A Cost-Effectiveness Analysis in the Italian Context

et al. 2023

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“…A recent systematic review of cost–utility analyses of LTBI screening tests specifically focused on high-risk populations, concluding that the economic evidence is robust enough to draw conclusions only for high-income and low-TB-burden countries, with limited evidence from high-TB-burden countries [ 10 ]. This systematic review also concluded that cost effectiveness varies depending on the LTBI prevalence or population tested; among low-risk populations, as well as children without any other LTBI or TB risk factors Screening with TST or no LTBI testing at all is often the most cost effective strategy compared to screening with IGRAs [ 7 , 10 ], reinforcing that LTBI screening should be carefully considered in low-TB-burden settings and only implemented for targeted high-risk groups who have increased risk of exposure and/or increased risk of progression to TB.…”

Section: Ltbi Screeningmentioning

confidence: 99%

“…For example, the rate of progression to active TB has been shown to have an important impact on the cost effectiveness of LTBI interventions, meaning that the cost effectiveness of screening and TPT varies widely across different subpopulations with different risks of active TB progression. While implementation considerations may be more critical in ensuring the cost effectiveness of screening and TPT in the general population, economic evaluations have been highly consistent in demonstrating that screening and prevention programs for TB are highly cost effective when targeted towards contacts with recent TB exposure and PLHIV [ 4 , 8 , 9 , 10 ].…”

Section: Introductionmentioning

confidence: 99%

The Global Expansion of LTBI Screening and Treatment Programs: Exploring Gaps in the Supporting Economic Evidence

Kota¹,

Shrestha

Kashkary

et al. 2023

Pathogens

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The global burden of latent TB infection (LTBI) and the progression of LTBI to active TB disease are important drivers of ongoing TB incidence. Addressing LTBI through screening and TB preventive treatment (TPT) is critical in order to end the TB epidemic by 2035. Given the limited resources available to health ministries around the world in the fight against TB, we must consider economic evidence for LTBI screening and treatment strategies to ensure that limited resources are used to achieve the biggest health impact. In this narrative review, we explore key economic evidence around LTBI screening and TPT strategies in different populations to summarize our current understanding and highlight gaps in existing knowledge. When considering economic evidence supporting LTBI screening or evaluating different testing approaches, a disproportionate number of economic studies have been conducted in high-income countries (HICs), despite the vast majority of TB burden being borne in low- and middle-income countries (LMICs). Recent years have seen a temporal shift, with increasing data from low- and middle-income countries (LMICs), particularly with regard to targeting high-risk groups for TB prevention. While LTBI screening and prevention programs can come with extensive costs, targeting LTBI screening among high-risk populations, such as people living with HIV (PLHIV), children, household contacts (HHC) and immigrants from high-TB-burden countries, has been shown to consistently improve the cost effectiveness of screening programs. Further, the cost effectiveness of different LTBI screening algorithms and diagnostic approaches varies widely across settings, leading to different national TB screening policies. Novel shortened regimens for TPT have also consistently been shown to be cost effective across a range of settings. These economic evaluations highlight key implementation considerations such as the critical nature of ensuring high rates of adherence and completion, despite the costs associated with adherence programs not being routinely assessed and included. Digital and other adherence support approaches are now being assessed for their utility and cost effectiveness in conjunction with novel shortened TPT regimens, but more economic evidence is needed to understand the potential cost savings, particularly in settings where directly observed preventive therapy (DOPT) is routinely conducted. Despite the growth of the economic evidence base for LTBI screening and TPT recently, there are still significant gaps in the economic evidence around the scale-up and implementation of expanded LTBI screening and treatment programs, particularly among traditionally hard-to-reach populations.

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“…To our knowledge, most costing studies comparing TB diagnostics ignore the opportunity cost—the cost of opportunity forgone, or the potential benefit that would have been incurred should the alternative been chosen—in their calculations, particularly in high-burden, low-income settings 17. For example, cost analyses of TB diagnostics measure patients’ lost income due to diagnosis but do not incorporate benefit to society in the form of reduced transmission 18 19.…”

Section: Introductionmentioning

confidence: 99%

A costing framework to compare tuberculosis infection tests

Brumwell,

Tso,

Pingali

et al. 2023

BMJ Glob Health

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ObjectiveTo develop a framework to estimate the practical costs incurred from, and programmatic impact related to, tuberculosis (TB) infection testing—tuberculin skin tests (TST) versus interferon gamma release assay (IGRA)—in a densely populated high-burden TB area.MethodsWe developed a seven-step framework that can be tailored to individual TB programmes seeking to compare TB infection (TBI) diagnostics to inform decision-making. We present methodology to estimate (1) the prevalence of TBI, (2) true and false positives and negatives for each test, (3) the cost of test administration, (4) the cost of false negatives, (5) the cost of treating all that test positive, (6) the per-test cost incurred due to treatment and misdiagnosis and (7) the threshold at which laboratory infrastructure investments for IGRA are outweighed by system-wide savings incurred due to IGRA utilisation. We then applied this framework in a densely populated, peri-urban district in Lima, Peru with high rates of Bacillus Calmette–Guérin (BCG) vaccination.FindingsThe lower sensitivity of TST compared with IGRA is a major cost driver, leading to health system and societal costs due to misdiagnosis. Additionally, patient and staff productivity costs were greater for TST because it requires two patient visits compared with only one for IGRA testing. When the framework was applied to the Lima setting, we estimate that IGRA-associated benefits outweigh infrastructural costs after performing 672 tests.ConclusionsGiven global shortages of TST and concerns about costs of IGRA testing and laboratory capacity building, this costing framework can provide public health officials and TB programmes guidance for decision-making about TBI testing locally. This framework was designed to be adaptable for use in different settings with available data. Diagnostics that increase accuracy or mitigate time to treatment should be thought of as an investment instead of an expenditure.

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A systematic review of cost-utility analyses of screening methods in latent tuberculosis infection in high-risk populations

Cited by 13 publications

References 39 publications

Screening for Tuberculosis Infection among Migrants: A Cost-Effectiveness Analysis in the Italian Context

Screening for Tuberculosis Infection among Migrants: A Cost-Effectiveness Analysis in the Italian Context

The Global Expansion of LTBI Screening and Treatment Programs: Exploring Gaps in the Supporting Economic Evidence

A costing framework to compare tuberculosis infection tests

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