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Cost-effectiveness of triage testing for facility-based systematic screening of tuberculosis among Ugandan adults
  1. Matthew Murray1,
  2. Adithya Cattamanchi2,
  3. Claudia Denkinger3,
  4. Anja van't Hoog4,
  5. Madhukar Pai5,
  6. David Dowdy1
  1. 1Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2Division of Pulmonary and Critical Care Medicine, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
  3. 3Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
  4. 4Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, The Netherlands
  5. 5Department of Epidemiology & Biostatistics, McGill International TB Centre, McGill University, Montreal, Quebec, Canada
  1. Correspondence to Dr David W Dowdy; ddowdy1{at}jhmi.edu

Abstract

Background Systematic screening is often proposed as a way to improve case finding for tuberculosis (TB), but the cost-effectiveness of specific strategies for systematic screening remains poorly studied.

Methods We constructed a Markov-based decision analytic model to analyse the cost-effectiveness of triage testing for TB in Uganda, compared against passive case detection with Xpert MTB/RIF. We assumed a triage algorithm whereby all adults presenting to healthcare centres would be screened for cough, and those with cough of at least 2 weeks would receive the triage test, with positive triage results confirmed by Xpert MTB/RIF. We adopted the perspective of the TB control sector, using a primary outcome of the cost per year of life gained (YLG) over a lifetime time horizon.

Results Systematic screening in a population with a 5% underlying prevalence of TB was estimated to cost US$610 per YLG (95% uncertainty range US$200–US$1859) with chest X-ray (CXR) (US$5 per test, specificity 0.67), or US$588 (US$221–US$1746) with C reactive protein (CRP) (US$3 per test, specificity 0.59). In addition to the cost and specificity of the triage test, cost-effectiveness was most sensitive to the underlying prevalence of TB, monthly risk of mortality in people with untreated TB and the proportion of patients with TB who would be treated in the absence of systematic screening.

Conclusions To optimise the cost-effectiveness of facility-based systematic screening of TB with a triage test, it must be carried out in a high-risk population, or use triage tests that are cheaper or more specific than CXR or CRP.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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