NEW YORK (Reuters Health) – Testing and treatment for latent tuberculosis infection (LTBI) in U.S. residents born outside the country is cost-effective, according to simulation modeling.
“Testing and treatment for LTBI works,” Abriana Tasillo from Boston Medical Center, in Massachusetts, told Reuters Health by email. “Even if we aren’t able to see an immediate benefit at the patient level, across the population it has the potential to make a substantial reduction in the number of cases of reactivation tuberculosis. And for those who are protected from reactivation, the health benefits of reduced morbidity and mortality can make a meaningful difference in both quality and length of life.”
Most tuberculosis cases in the United States arise among residents born outside the country, and previous studies have suggested that testing and treating such individuals is cost-effective.
Tasillo and colleagues used a decision analytic tree and Markov cohort simulation model to estimate health outcomes, costs, and cost-effectiveness of LTBI testing and treatment among non-US-born residents with or without medical comorbidities.
They investigated five testing strategies: no testing; tuberculin skin test (TST); interferon gamma release assay (IGRA); confirm-positive (positive TST gets IGRA, with both positive yielding LTBI diagnosis); and confirm-negative (negative IGRA gets TST, with either positive yielding LTBI diagnosis).
According to the model, patients diagnosed with LTBI would be treated with 3 months of self-administered rifapentine and isoniazid without toxic effects or adverse changes in quality of life.
The confirm-negative strategy delivered the best health outcomes, whereas no testing resulted in the worst health outcomes, according to the October 16 JAMA Internal Medicine online report.
Confirm-positive yielded better health outcomes than no testing and was the next-least costly strategy. IGRA provided greater health outcomes than confirm-positive.
Among patients with no comorbidities, IGRA prevented 50% of lifetime TB reactivations (0.30%, vs. 0.60% in the total cohort), had a number needed to treat (NNT) of 332, and was associated with an incremental cost-effectiveness ratio (ICER) of $83,000 per quality-adjusted life-year (QALY). Confirm-negative prevented 13% more TB reactivations than IGRA, with a lower NNT (294) and a higher ICER ($147,000/QALY).
For people with diabetes, confirm-positive prevented 28% of lifetime reactivations with an NNT of 749 and an ICER of $53,000/QALY; IGRA prevented 50% of reactivations with an NNT of 409 and an ICER of $120,000/QALY. Confirm-negative prevented 56% of reactivations with an NNT of 362 and an ICER of $230,000/QALY.
For HIV-infected people, confirm-negative prevented 55% of lifetime TB reactivations, with an NNT of 114 and an ICER of $63,000/QALY.
Testing for LTBI improved QALYs among patients with end-stage renal disease (ESRD), but ICERs for all strategies exceeded $2 million per QALY gained.
In probabilistic sensitivity analyses, IGRA was the most-preferred simulated strategy among patients with no comorbidities; confirm-positive was preferred among patients with diabetes; and confirm-negative was preferred among HIV-infected patients. The preferred strategy among ESRD patients was no testing.
“These findings demonstrate the potential impact of current recommendations for testing and treatment of tuberculosis, as well as provide support from a cost-effectiveness perspective,” Tasillo said. “We hope that this paper will provide clarity to practitioners who are following the current guidelines but also looking for more direction on the appropriate testing and treatment combination for their patients, especially those with HIV, diabetes mellitus, and ESRD.”
“Practitioners should not be afraid to test and treat their patients,” she concluded. “Even though the likelihood of a particular individual of unknown LTBI status developing reactivation TB is quite low, the benefits of testing and treatment for those who would otherwise get sick is substantial enough to support general testing and treatment in persons born outside the U.S. We hope this paper can be useful in allowing providers and policy makers to see the bigger picture.”
“We believe that the results of the study support implementation of a simple testing strategy of IGRA alone for most non-US-born residents of the United States,” write Dr. Jennifer Flood and Dr. Pennan M. Barry from the California Department of Public Health, Richmond, in a related editorial.
“By modeling self-administered treatment, the authors provide additional support for this more practical and less costly approach,” they note. “We anticipate that this approach will become routine practice and national guidance will follow shortly.”
“The findings of this study call for LTBI screening and treatment for all non-US-born persons as a routine preventive health activity,” the editorialists write. “For busy clinicians, TB prevention must be supported by health systems and tools that allow clinicians and health departments to easily track patients through the cascade of care from risk assessment to testing and through treatment completion. Both clinicians and patients must be engaged in the effort.”
The editorial concludes, “With full adoption of TB prevention in primary care using currently available modern tools, we can progress from TB control to TB elimination, making this airborne pathogen that moves easily across communities a specter of the past.”
SOURCES: http://bit.ly/2gJIYFo and http://bit.ly/2gL4REx
JAMA Intern Med 2017.
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