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Cost Effectiveness of Preventive Treatment for Tuberculosis in Special High-Risk Populations

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Abstract

Objective

In view of the goal of eliminating tuberculosis (TB) by 2050, economic evaluations of interventions against the development of TB are increasingly requested. Little research has been published on the incremental cost effectiveness of preventative therapy (PT) in groups at high risk for progression from latent TB infection (LTBI) with Mycobacterium TB (MTB) to active disease. A systematic review of studies with a primary focus on model-driving inputs and methodological differences was conducted.

Methods

A search of MEDLINE, the Cochrane Library and EMBASE to July 2014 was undertaken, and reference lists of eligible articles and relevant reviews were examined.

Results

A total of 876 citations were retrieved, with a total of 24 studies being eligible for inclusion, addressing six high-risk groups other than contact persons. Results varied considerably between studies and countries, and also over time. Although the selected studies generally demonstrated cost effectiveness for PT in HIV-infected subjects and healthcare workers (HCWs), the outcome of these analyses can be questioned in light of recent epidemiologic data. For immigrants from high TB-burden countries, patients with end-stage renal disease, and the immunosuppressed, now defined as further vulnerable groups, no consistent recommendation can be taken from the literature with respect to cost effectiveness of screening and treating LTBI. When the concept of a fixed willingness-to-pay (WTP) threshold as a prerequisite for final categorization was used, the sums ranged between ‘no specification’ and US$100,000 per quality-adjusted life-year.

Conclusions

To date, incremental cost-effectiveness analyses on PT in groups at high risk for TB progression, other than contacts, are surprisingly scarce. The variation found between studies likely reflects variations in the major epidemiologic factors, particularly in the estimates on the accuracy of the tuberculin skin test (TST) and interferon-gamma release assays (IGRA) as screening methods used before considering PT. Further research, including explicit evaluation of local epidemiological conditions, test accuracy, and methodology of WTP thresholds, is needed.

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Acknowledgments and Funding Disclosures

The authors declare no support from any organization for the submitted work.

In the previous 5 years, Roland Diel has received a fee and/or travel reimbursement for speaking at symposia supported by Cellestis Ltd, Oxford Immunotec, Inc., and Pharmore Ltd.

Niklas Lampenius and Albert Nienhaus declare no financial relationship with any organization that could have an interest in the submitted work.

Roland Diel planned and managed the work, analyzed and interpreted the data, and produced the first draft of the manuscript. Niklas Lampenius and Albert Nienhaus reviewed and revised the manuscript, including essential amendments. Roland Diel finalized the paper, and Niklas Lampenius and Albert Nienhaus approved the final submitted version. Roland Diel acts as the overall guarantor of the manuscript content.

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Authors and Affiliations

  1. Institute for Epidemiology, University Medical Hospital Schleswig-Holstein (Member of the German Center for Lung Research [ARCN]), Niemannsweg 11, 24015, Kiel, Germany

    Roland Diel

  2. Department of Accounting and Finance, University of Hohenheim, Stuttgart, Germany

    Niklas Lampenius

  3. Institute for Health Service Research in Dermatology and Nursing, University Medical Center Hamburg–Eppendorf, Hamburg, Germany

    Albert Nienhaus

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  1. Roland Diel
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Correspondence to Roland Diel.

Appendix: Full electronic search strategies

Appendix: Full electronic search strategies

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(cost effectiveness OR cost-effectiveness)

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NHS EED (National Health Service Economic Evaluation Database)

(’tuberculosis’ OR ‘TB’ OR ‘TB disease’)

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(‘cost-effectiveness’ OR ‘cost effectiveness’)

[TI FROM 1960 TO 2014]

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Diel, R., Lampenius, N. & Nienhaus, A. Cost Effectiveness of Preventive Treatment for Tuberculosis in Special High-Risk Populations. PharmacoEconomics 33, 783–809 (2015). https://doi.org/10.1007/s40273-015-0267-x

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