Cost-effectiveness of post-treatment follow-up examinations and secondary prevention of tuberculosis in a high-incidence setting: a model-based analysis

Abstract

Background In settings of high tuberculosis incidence, previously treated individuals remain at high risk of recurrent tuberculosis and contribute substantially to overall disease burden. Whether tuberculosis case finding and preventive interventions among previously treated people are cost-effective has not been established. We aimed to estimate costs and health benefits of annual post-treatment follow-up examinations and secondary preventive therapy for tuberculosis in a tuberculosis-endemic setting.Methods We developed a transmission-dynamic mathematical model and calibrated it to data from two high-incidence communities of approximately 40 000 people in suburban Cape Town, South Africa. We used the model to estimate overall cost and disability-adjusted life-years (DALYs) associated with annual follow-up examinations and secondary isoniazid preventive therapy (IPT), alone and in combination, among individuals completing tuberculosis treatment. We investigated scenarios under which these interventions were restricted to the first year after treatment completion, or extended indefinitely. For each intervention scenario, we projected health system costs and DALYs averted with respect to the current status quo of tuberculosis control. All estimates represent mean values derived from 1000 epidemic trajectories simulated over a 10-year period (2019-28), with 95% uncertainty intervals (UIs) calculated as the 2•5th and 97•5th percentile values.Findings We estimated that a single follow-up examination at the end of the first year after treatment completion combined with 12 months of secondary IPT would avert 2472 DALYs (95% UI −888 to 7801) over a 10-year period and is expected to be cost-saving compared with current control efforts. Sustained annual follow-up and continuous secondary IPT beyond the first year after treatment would avert an additional 1179 DALYs (−1769 to 4377) over 10 years at an expected additional cost of US$18•2 per DALY averted. Strategies of follow-up without secondary IPT were dominated (ie, expected to result in lower health impact at higher costs) by strategies that included secondary IPT.Interpretation In this high-incidence setting, post-treatment follow-up and secondary preventive therapy can accelerate declines in tuberculosis incidence and potentially save resources for tuberculosis control. Empirical trials to assess the feasibility of these interventions in settings most severely affected by tuberculosis are needed.

Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 Explanation and Elaboration: A Report of the ISPOR CHEERS II Good Practices Task Force

“…126,128 Alternatively, if an innovative modeling approach is being used, this approach might be related to the outcomes needed for decision makers or how the chosen model structure better reflects disease natural history, current treatment practice, and efficacy and safety compared with previous models in the disease area. The use of an innovative approach might also be related to the extent Example of Item 15: Currency, price date and conversion 124 "We estimated the costs for the base-case and intervention scenarios in 2018 US dollars, adopting a South African health-care system perspective (table 1). Average costs reflect 2018 estimates for tuberculosis health-care and diagnostic services in Cape Town that were obtained through review of the published literature and the official price list of the National Health Laboratory Service, South Africa.…”

Defining Outcomes of Tuberculosis (Treatment): From the Past to the Future

“…Other evidence shows the positive impact of post-TB rehabilitation on lung health [48]. A recent study from a high incidence TB/HIV setting in South Africa demonstrated that a post-TB follow-up strategy without, or preferred with, post-TB preventative therapy could be a cost-effective approach to improve TB control [49].…”

Burden of tuberculosis and its association with socio-economic development status in 204 countries and territories, 1990–2019

“…Individuals who have received the previous treatment are still at high risk of recurrent TB. Follow-up after the treatment and secondary preventive treatment can accelerate the decline in the incidence of TB, and follow-up after the treatment is also very important (8). In addition, innovations in patient-centered strategies and advances in testing and treatment are also critical to ending the TB epidemic (9,10).…”