• Am. J. Respir. Crit. Care Med. · Sep 2011

    Comparative Study

    Priorities for screening and treatment of latent tuberculosis infection in the United States.

    • Benjamin P Linas, Kenneth A Freedberg, and C Robert Horsburgh.
    • HIV Epidemiology and Outcomes Research Unit, Boston Medical Center, Section of Infectious Disease, Evans Biomedical Research Center, 650 Albany St. Rm 647, Boston, MA 02118, USA. benjamin.linas@bmc.org
    • Am. J. Respir. Crit. Care Med.. 2011 Sep 1;184(5):590-601.

    RationaleTo improve the effectiveness of tuberculosis (TB) control programs in the United States by identifying cost-effective priorities for screening for latent tuberculosis infection (LTBI).ObjectivesTo estimate the cost-effectiveness of LTBI screening using the tuberculin skin test (TST)and interferon-g release assays (IGRAs).MethodsA Markov model of screening for LTBI with TST and IGRA in risk-groups considered in current LTBI screening guidelines.Measurements And Main ResultsIn all risk-groups, TST and IGRA screening resulted in increased mean life expectancy, ranging from 0.03–0.24 life-months per person screened. IGRA screening resulted in greater life expectancy gains than TST. Screening always cost more than not screening, but IGRA was cost-saving compared with TST in some groups. Four patterns of cost-effectiveness emerged, related to four risk categories. (1) Individuals at highest risk of TB reactivation (close contacts and those infected with HIV): the incremental cost-effectiveness ratio (ICER) of IGRA compared with TST was less than $100,000 per quality-adjusted life year (QALY) gained. (2) The foreign-born: IGRA was cost-saving compared with TST and cost-effective compared with no screening (ICER ,$100,000 per QALY gained). (3) Vulnerable populations (e.g., homeless, drug user, or former prisoner): the ICER of TST screening was approximately $100,000–$150,000 per QALY gained, but IGRA was not cost-effective. (4) Medical comorbidities (e.g., diabetes): the ICER of screening with TST or IGRA was greater than $100,000 per QALY.ConclusionsLTBI screening guidelines could make progress toward TB elimination by prioritizing screening for close contacts, those infected with HIV, and the foreign-born regardless of time living in the United States. For these groups, IGRA screening was more cost-effective than TST screening.

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