Cost-effectiveness of Alternative Strategies for Tuberculosis Screening Before Kindergarten Entry

Abstract

The cost to prevent a case of tuberculosis by using either universal screening or targeted testing of kindergarteners is high. If targeted testing replaced universal tuberculin skin testing in California, then $1.27 million savings per year would be generated for more cost-effective strategies to prevent tuberculosis. Improving the positive predictive value of the risk factor tool or applying it to groups with higher prevalence of latent tuberculosis would make its use more cost-effective. Universal tuberculin skin testing should be discontinued, and targeted testing should be considered only when the prevalence of risk factor positivity and the prevalence of tuberculin skin testing positivity among risk factor-positive individuals are high enough to meet acceptable thresholds for cost-effectiveness.

Getting to Zero: Tuberculosis Elimination in California

“…Indeed, more than 80 % of the 1,726,000 individuals undergoing mandatory screening in California each year are healthcare workers who are legally mandated to undergo annual screening for TB infection and disease despite a decrease of TB transmission in hospitals today. The cost-savings and effectiveness of risk-based TB screening rather than universal screening, has been demonstrated in other low risk groups in California including school children and school teachers [ 21 ]. Re-focusing resources on screening populations at high risk for LTBI provides an opportunity to further reduce the burden of untreated LTBI in California as a whole.…”

Iron deficiency screening for children at 18 months: a cost-utility analysis

“…We selected the inputs of the decision tree model to reflect a general framework for evaluating the cost-effectiveness of screening programs. 17 With the understanding that iron deficiency during the sensitive period for neurodevelopment may lead to long-term poor functional outcomes, we chose a lifetime time horizon in our analysis. 18,19 The model included health states at 4 terminal nodes: 1) "healthy, untreated" if iron deficiency was not present and treatment unnecessary, 2) "healthy, after treatment" if iron deficiency was detected and treated successfully, 3) "poor functional outcomes, after treatment" if iron deficiency was detected and treatment was unsuccessful and 4) "poor functional outcomes, untreated" if iron deficiency was not detected and not treated.…”

Pediatric Latent Tuberculosis

“…In an analysis from Toronto, Canada, comparing pediatric contacts of contagious TB cases with children tested for other risk factors, 7/8 of the QFT positive non-contacts were from truly high TB-burden countries with incidence >100/100,000, while none of the eighteen non-contacts born in countries with TB incidence <25/100,000 were QFT + . 12 The benefit of preventing active TB by screening children requires a certain rate of LTBI to be programmatically cost-effective, which for TST has been estimated to be 10% 13 …”