Abstract
In settings of high tuberculosis incidence, previously treated individuals remain at high risk of recurrent tuberculosis and contribute substantially to overall disease burden. Whether tuberculosis case finding and preventive interventions among previously treated people are cost-effective has not been established. We aimed to estimate costs and health benefits of annual post-treatment follow-up examinations and secondary preventive therapy for tuberculosis in a tuberculosis-endemic setting. We developed a transmission-dynamic mathematical model and calibrated it to data from two high-incidence communities of approximately 40 000 people in suburban Cape Town, South Africa. We used the model to estimate overall cost and disability-adjusted life-years (DALYs) associated with annual follow-up examinations and secondary isoniazid preventive therapy (IPT), alone and in combination, among individuals completing tuberculosis treatment. We investigated scenarios under which these interventions were restricted to the first year after treatment completion, or extended indefinitely. For each intervention scenario, we projected health system costs and DALYs averted with respect to the current status quo of tuberculosis control. All estimates represent mean values derived from 1000 epidemic trajectories simulated over a 10-year period (2019-28), with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values. We estimated that a single follow-up examination at the end of the first year after treatment completion combined with 12 months of secondary IPT would avert 2472 DALYs (95% UI -888 to 7801) over a 10-year period and is expected to be cost-saving compared with current control efforts. Sustained annual follow-up and continuous secondary IPT beyond the first year after treatment would avert an additional 1179 DALYs (-1769 to 4377) over 10 years at an expected additional cost of US$18·2 per DALY averted. Strategies of follow-up without secondary IPT were dominated (ie, expected to result in lower health impact at higher costs) by strategies that included secondary IPT. In this high-incidence setting, post-treatment follow-up and secondary preventive therapy can accelerate declines in tuberculosis incidence and potentially save resources for tuberculosis control. Empirical trials to assess the feasibility of these interventions in settings most severely affected by tuberculosis are needed. National Institutes of Health, Günther Labes Foundation, Oskar Helene Heim Foundation.
Highlights
Considerable effort will be required to accelerate declines in tuberculosis incidence and mortality worldwide and ensure progress towards the global tuberculosis elimi nation targets.[1]
We found that a strategy combining targeted follow-up examinations and secondary isoniazid preventive therapy (IPT) for 1 year after treatment completion would both improve health and reduce tuberculosis control costs
Our results suggest that posttreatment follow-up and secondary preventive therapy offered to people who have completed tuberculosis treatment would be cost-effective and potentially cost-saving for tuberculosis control
Summary
Considerable effort will be required to accelerate declines in tuberculosis incidence and mortality worldwide and ensure progress towards the global tuberculosis elimi nation targets.[1] estimates of tuberculosis incidence and mortality indicate declining trends in many high-burden countries over the past few years,[2] progress remains slow in settings with the highest incidence. Additional interventions to interrupt transmission and prevent disease progression might be necessary to effectively reduce tuberculosis in these settings. While population-level interventions such as intensified case finding and preventive treatment are costly and have not yielded anticipated benefits,[3,4] novel approaches that focus on groups at the highest risk of tuberculosis could be attractive alternatives. Whether targeting tuberculosis control interventions towards high-risk groups will be effective at the population level will depend on whether these groups are identifiable and accessible, and on the extent to which these groups contribute to transmission of Mycobacterium tuberculosis and overall tuberculosis burden. In settings with a high force of infection, persistently high rates of recurrent tuberculosis after the first year,[6,7,8] commonly due to exogenous reinfection, have been observed, which suggests that previously treated people might be Lancet Glob Health 2020; 8: e1223–33
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