Abstract
Prisons of the former Soviet Union (FSU) have high rates of multidrug-resistant tuberculosis (MDR-TB) and are thought to drive general population tuberculosis (TB) epidemics. Effective prison case detection, though employing more expensive technologies, may reduce long-term treatment costs and slow MDR-TB transmission. We developed a dynamic transmission model of TB and drug resistance matched to the epidemiology and costs in FSU prisons. We evaluated eight strategies for TB screening and diagnosis involving, alone or in combination, self-referral, symptom screening, mass miniature radiography (MMR), and sputum PCR with probes for rifampin resistance (Xpert MTB/RIF). Over a 10-y horizon, we projected costs, quality-adjusted life years (QALYs), and TB and MDR-TB prevalence. Using sputum PCR as an annual primary screening tool among the general prison population most effectively reduced overall TB prevalence (from 2.78% to 2.31%) and MDR-TB prevalence (from 0.74% to 0.63%), and cost US$543/QALY for additional QALYs gained compared to MMR screening with sputum PCR reserved for rapid detection of MDR-TB. Adding sputum PCR to the currently used strategy of annual MMR screening was cost-saving over 10 y compared to MMR screening alone, but produced only a modest reduction in MDR-TB prevalence (from 0.74% to 0.69%) and had minimal effect on overall TB prevalence (from 2.78% to 2.74%). Strategies based on symptom screening alone were less effective and more expensive than MMR-based strategies. Study limitations included scarce primary TB time-series data in FSU prisons and uncertainties regarding screening test characteristics. In prisons of the FSU, annual screening of the general inmate population with sputum PCR most effectively reduces TB and MDR-TB prevalence, doing so cost-effectively. If this approach is not feasible, the current strategy of annual MMR is both more effective and less expensive than strategies using self-referral or symptom screening alone, and the addition of sputum PCR for rapid MDR-TB detection may be cost-saving over time.
Highlights
Despite various control efforts, tuberculosis (TB) remains a major public health challenge in much of the developing and transitioning world, with an estimated 9.4 million new cases and nearly 2 million deaths in 2009 [1]
In prisons of the former Soviet Union (FSU), annual screening of the general inmate population with sputum PCR most effectively reduces TB and multidrug-resistant TB (MDR-TB) prevalence, doing so cost-effectively. If this approach is not feasible, the current strategy of annual mass miniature radiography (MMR) is both more effective and less expensive than strategies using self-referral or symptom screening alone, and the addition of sputum PCR for rapid MDR-TB detection may be cost-saving over time
We considered eight strategies for TB screening and diagnosis: no screening; MMR screening; symptom screening; sputum PCR screening; combined MMR and symptom screening; MMR screening with sputum PCR for rapid MDR-TB detection; symptom screening with sputum PCR for rapid MDR-TB detection; and combined MMR and symptom screening with sputum PCR for rapid MDR-TB detection
Summary
Tuberculosis (TB) remains a major public health challenge in much of the developing and transitioning world, with an estimated 9.4 million new cases and nearly 2 million deaths in 2009 [1]. The emergence of multidrug-resistant TB (MDR-TB) threatens to overwhelm recent gains in disease control and substantially increase costs, given that it requires lengthy and expensive treatment regimens [1]. In Eastern Europe and Central Asia, where the prevalence of MDR-TB is among the highest worldwide, increased rates of incarceration are associated with increased civilian rates of MDR-TB and account for up to 60% of increased TB incidence in the general population [3] Prisons of the former Soviet Union (FSU) have high rates of multidrug-resistant tuberculosis (MDR-TB) and are thought to drive general population tuberculosis (TB) epidemics. Rifampicin resistance is an indicator of multidrug-resistant TB (MDR-TB), the emergence of which is thwarting ongoing global efforts to control TB
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