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Should NICE reconsider the 2016 UK guidelines on TB contact tracing? A cost-effectiveness analysis of contact investigations in London
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  • Published on:
    Cost-effectiveness and tuberculosis elimination: a détente?
    • Sean M Cavany, Postdoctoral Scholar Biological Sciences, University of Notre Dame
    • Other Contributors:
      • Charlotte Anderson, Senior Scientist
      • Helen Maguire, Professor
      • Frank Sandmann, Research Scientist
      • H. Lucy Thomas, Consultant
      • Richard G. White, Professor
      • Tom Sumner, Assistant Professor

    We would like to thank Dr. Wingfield et al. for their thoughtful response on our cost-effectiveness analysis of tuberculosis contact tracing in London(1). The authors provide a number of insights which complement and expand upon our results and highlight the many complexities of TB interventions, both currently and as we head towards elimination.

    Wingfield et al. raise important points regarding heterogeneity on contact tracing yield, something we touched upon in the discussion of our paper. As they mention, such heterogeneity is likely to increase as countries such as the UK near elimination. We found that the yield of active cases around non-pulmonary cases needed to be very high – in our analyses, the incremental cost-effectiveness ratio (ICER) for screening such contacts was below £30,000 per quality-adjusted life year (QALY) when the yield of contacts reached about 0.1 active cases found per index case, i.e. when 4% of contacts screened are positive. However, this ignores synergistic effects caused by those infectious contacts potentially being more infectious and infectious for longer, due to their being part of a high-risk group, and so the actual threshold may be lower.

    We also agree with Wingfield et al. that careful thought must be given to the interpretation of the ICER in the context of TB elimination, as in any context. Rather than treating the willingness-to-pay threshold as a strict and universal cut-off value, the ICER should be considered alo...

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    Conflict of Interest:
    None declared.
  • Published on:
    Cost-effectiveness and tuberculosis elimination: never the twain shall meet
    • Tom Wingfield, Clinical Lecturer in Infection LIV-TB Cross Campus Collaboration, University of Liverpool and Liverpool School of Tropical Medicine, Liverpool
    • Other Contributors:
      • Peter MacPherson, Senior Lecturer
      • L Peter Ormerod, Physician and Professor
      • S Bertel Squire, Professor
      • Paul Cleary, Consultant Epidemiologist

    The National Institute for Health and Care Excellence (NICE) 2016 Tuberculosis (TB) guidelines no longer recommend screening contacts of adults with extra-pulmonary TB (ETB). However, no new evidence since the previous published guidelines was provided to support this policy change. Moreover, despite the guidance, some regional TB multidisciplinary teams and services continue to screen ETB contacts.(1)

    In their original article in Thorax, Cavany et al estimated the cost-effectiveness of screening ETB contacts in London.(2) The authors’ findings suggest that screening of such contacts is unlikely to be cost-effective at the threshold of £30,000/QALY - the “willingness to pay” threshold commonly used by NICE.(3) The authors’ findings are tempered by the data being London-specific and not generalizable to the rest of England, and the lack of robust available evidence on either transmission rates or index cases’ pre-diagnosis symptom duration. Nevertheless, the authors recognise these limitations and their sensitivity analysis suggests that, even with assumptions of higher rates of transmission or prolonged symptom duration, their principal findings would not change.

    The findings of this strong, well-designed study are important and provide much needed evidence for national debate around strategies for TB contact screening. Resources for TB services across England, especially those allocated to tracing contacts of TB patients, are becoming increasingly constrain...

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    Conflict of Interest:
    None declared.