Tweet
Screening and Rapid Molecular Diagnosis of Tuberculosis in Prisons in Russia and Eastern Europe: A Cost-Effectiveness Analysis
Daniel E. Winetsky1, Diana M. Negoescu2, Emilia H. DeMarchis1, Olga Almukhamedova3, Aizhan Dooronbekova3, Dilshod Pulatov3, Natalia Vezhnina3, Douglas K. Owens4,5, Jeremy D. Goldhaber-Fiebert5*
1 Stanford University School of Medicine, Stanford, California, United States of America, 2 Department of Management Science and Engineering, Stanford University, Stanford, California, United States of America, 3 AIDS Foundation East-West, Amsterdam, The Netherlands, 4 Veterans Affairs Palo Alto Health Care System, Palo Alto, California, United States of America, 5 Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, United States of America
Abstract
Prisons of the former Soviet Union (FSU) have high rates of multidrug-resistant tuberculosis (MDR-TB) and are thought to drive general population tuberculosis (TB) epidemics. Effective prison case detection, though employing more expensive technologies, may reduce long-term treatment costs and slow MDR-TB transmission.
Methods and Findings
We developed a dynamic transmission model of TB and drug resistance matched to the epidemiology and costs in FSU prisons. We evaluated eight strategies for TB screening and diagnosis involving, alone or in combination, self-referral, symptom screening, mass miniature radiography (MMR), and sputum PCR with probes for rifampin resistance (Xpert MTB/RIF). Over a 10-y horizon, we projected costs, quality-adjusted life years (QALYs), and TB and MDR-TB prevalence. Using sputum PCR as an annual primary screening tool among the general prison population most effectively reduced overall TB prevalence (from 2.78% to 2.31%) and MDR-TB prevalence (from 0.74% to 0.63%), and cost US$543/QALY for additional QALYs gained compared to MMR screening with sputum PCR reserved for rapid detection of MDR-TB. Adding sputum PCR to the currently used strategy of annual MMR screening was cost-saving over 10 y compared to MMR screening alone, but produced only a modest reduction in MDR-TB prevalence (from 0.74% to 0.69%) and had minimal effect on overall TB prevalence (from 2.78% to 2.74%). Strategies based on symptom screening alone were less effective and more expensive than MMR-based strategies. Study limitations included scarce primary TB time-series data in FSU prisons and uncertainties regarding screening test characteristics...