Cost effectiveness of low-complexity screening tests in community-based case-finding for tuberculosis
Lukas E Brümmer, Ryan R Thompson, Akash Malhotra, Sourya Shrestha, Emily A Kendall, Jason R Andrews, Patrick Phillips, Payam Nahid, Adithya Cattamanchi, Florian M Marx, Claudia M Denkinger, David W Dowdy- Infectious Diseases
- Microbiology (medical)
Abstract
Introduction
In high-burden settings, low-complexity screening tests for tuberculosis (TB) could expand the reach of community-based case-finding efforts. The potential costs and cost-effectiveness of approaches incorporating these tests are poorly understood.
Methods
We developed a microsimulation model assessing three approaches to community-based case-finding in hypothetical populations (India-, South Africa-, The Philippines-, Uganda-, and Vietnam-like settings) with TB prevalence four times that of national estimates: (1) screening with a point-of-care C-reactive protein (CRP) test or (2) screening with a more sensitive “Hypothetical Screening test” (95% sensitive for Xpert Ultra-positive TB, 70% specificity; equipment/labor costs similar to Xpert Ultra, but using a $2 cartridge) followed by sputum Xpert Ultra if positive, or (3) testing all individuals with sputum Xpert Ultra. Costs are expressed in 2023 US dollars and include treatment costs.
Results
Universal Xpert Ultra was estimated to cost a mean $4.0 million (95% uncertainty range: $3.5 to $4.6 million) and avert 3,200 (2,600 to 3,900) TB-related disability-adjusted life years (DALYs) per 100,000 people screened ($670 [The Philippines] to $2000 [Vietnam] per DALY averted). CRP was projected to cost $550 (The Philippines) to $1500 (Vietnam) per DALY averted, but with 44% fewer DALYs averted. The Hypothetical Screening test showed minimal benefit compared to universal Xpert Ultra, but if specificity were improved to 95% and per-test cost to $4.5 (all-inclusive), this strategy could cost $390 (The Philippines) to $940 (Vietnam) per DALY averted.
Conclusion
Screening tests can meaningfully improve the cost-effectiveness of community-based case-finding for TB, but only if they are sensitive, specific, and inexpensive.