Modelling the cost-effectiveness of strategies to prevent tuberculosis in child contacts in a high-burden setting
- Anna M Mandalakas1,2,3,
- Anneke C Hesseling3,
- Robert P Gie3,
- H S Schaaf3,
- Ben J Marais4,5,
- Edina Sinanovic6
- 1Section on Retrovirology and Global Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- 2Center for Global Health, Texas Children's Hospital, Houston, Texas, USA
- 3Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa
- 4The Children's Hospital at Westmead, Medical School, Sydney, Australia
- 5Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Tygerberg, South Africa
- 6Health Economics Unit, University of Cape Town, Cape Town, South Africa
- Correspondence to Anna M Mandalakas, MSEpi, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates Street, FC-630, Houston, TX 77030, USA;
Contributors All authors were involved in manuscript preparation. AMM conceived of the idea to undertake the cost-effectiveness analysis, developed the models, gathered data and directed discussion supporting estimation of model probabilities, participated in cost determination, completed and synthesized the analysis, and wrote the first and subsequent drafts of the manuscript. ACH was involved in model development including estimation of model probabilities, completed cost determination, and participated in data synthesis and manuscript preparation. RPG was involved in model development including estimation of model probabilities and costs, and participated in data synthesis and manuscript preparation. HSS and BJM were involved in model development including estimation of model probabilities and manuscript preparation. ES was involved in model development, including estimation of model probabilities, completed cost determination, and participated in data analysis, data synthesis and manuscript preparation.
- Received 9 August 2011
- Accepted 29 April 2012
- Published Online First 20 June 2012
Background WHO recommends isoniazid preventive therapy (IPT) for young children in close contact with an infectious tuberculosis (TB) case. No models have examined the cost effectiveness of this recommendation.
Methods A decision analysis model was developed to estimate health and economic outcomes of five TB infection screening strategies in young household contacts. In the no-testing strategy, children received IPT based on age and reported exposure. Other strategies included testing for infection with a tuberculin skin test (TST), interferon γ release assay (IGRA) or IGRA after TST. Markov modelling included age-specific disease states and probabilities while considering risk of re-infection in a high-burden country.
Results Among the 0–2-year-old cohort, the no-testing strategy was most cost effective. The discounted societal cost of care per life year saved ranged from US$237 (no-testing) to US$538 (IGRA only testing). Among the 3–5-year-old cohort, strategies employing an IGRA after a negative TST were most effective, but were associated with significant incremental cost (incremental cost-effectiveness ratio >US$233 000), depending on the rate of Mycobacterium tuberculosis infection.
Conclusion Screening for M tuberculosis infection and provision of IPT in young children is a highly cost-effective intervention. Screening without testing for M tuberculosis infection is the most cost-effective strategy in 0–2-year-old children and the preferred strategy in 3–5-year-old children. Lack of testing capacity should therefore not be a barrier to IPT delivery. These findings highlight the cost effectiveness of contact tracing and IPT delivery in young children exposed to TB in high-burden countries.
- Cost effectiveness
- isoniazid preventive therapy
- paediatric lung disease
- paediatric physician
- inhaler devices
Funding This project was supported by funding from the Thrasher Research Fund. AM received salary support from the US Department of State to serve as a Senior Fulbright Scholar to South Africa during the completion of this analysis. Funding sources played no role in project implementation, analysis or reporting.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.