In-kind nutritional supplementation for household contacts of persons with tuberculosis would be cost-effective for reducing tuberculosis incidence and mortality in India: a modeling study

Abstract

Background: Undernutrition is the leading cause of tuberculosis (TB) globally, but nutritional interventions are often considered cost prohibitive. The RATIONS study demonstrated that nutritional support provided to household contacts of persons with TB can reduce TB incidence. However, the long-term cost-effectiveness of this intervention is unclear. Methods: We assessed the cost-effectiveness of a RATIONS-style intervention (daily 750 kcal dietary supplementation and multi-micronutrient tablet). Using a Markov state transition model we simulated TB incidence, treatment, and TB-attributable mortality among household contacts receiving the RATIONS intervention, as compared to no nutritional support. We calculated health outcomes (TB cases, TB deaths, and disability-adjusted life years [DALYs]) over the lifetime of intervention recipients and assessed costs from government and societal perspectives. We tested the robustness of results to parameter changes via deterministic and probabilistic sensitivity analysis. Findings: Over two years, household contacts receiving the RATIONS intervention would experience 39% (95% uncertainty interval (UI): 23, 52) fewer TB cases and 59% (95% UI: 44, 69) fewer TB deaths. The intervention was estimated to avert 13,775 (95% UI: 9036, 20,199) TB DALYs over the lifetime of the study cohort comprising 100,000 household contacts and was cost-effective from both government (incremental cost-effectiveness ratio: $229 per DALY averted [95% UI: 133, 387]) and societal perspectives ($184 per DALY averted [95% UI: 83, 344]). The results were most sensitive to the cost of the nutritional supplement. Interpretation Prompt nutritional support for household contacts of persons with TB disease would be cost-effective in reducing TB incidence and mortality in India.