October 16, 2017
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Latent TB testing, treatment cost-effective for non-US born residents in most cases

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Testing and treatment for latent tuberculosis infection are cost-effective among U.S. residents born outside the country except for those with end-stage renal disease, according to findings published in JAMA Internal Medicine.

“The treatment regimen of [Privtin (rifapentine, Sanofi-Aventis)] and isoniazid administered weekly for 3 months by directly observed therapy and self-administration was found to be safe, effective and cost-effective among [latent TB infection (LTBI)] patients in the United States,” Abriana Tasillo, BA, from the epidemiology and outcomes unit at Boston Medical Center, and colleagues wrote. “The economic value of LTBI testing and 3 months of treatment with self-administered rifapentine and isoniazid in non-U.S. born patients with medical comorbidities is not clear.”

Comorbidities like diabetes, end-stage renal disease (ESRD) and HIV infection increase the risk for TB reactivation and carry competing risks for death that can limit the health benefits of testing and treatment, researchers said. Tasillo and colleagues assessed non-U.S. born residents with no comorbidities, with diabetes, with ESRD or with HIV to determine health outcomes, costs and the cost-effectiveness of LTBI testing and treatment. They compared testing strategies, then added those strategies to treatment with 3 months of self-administered rifapentine and isoniazid.

In 10,000 probabilistic simulations, some form of testing was almost always cost-effective for patients born outside the U.S. with no comorbidities, with diabetes and with HIV. Costs increased when health outcomes improved, and the type of test depended on a payer’s willingness to cover the expense. Ranked by ascending costs and benefits, the strategies included:

  • no testing;
  • confirm positive (initial tuberculin skin test [TST], interferon gamma release assay [IGRA] only for TST-positive results; both tests positive indicates LTBI);
  • TST;
  • IGRA; and
  • confirm negative (initial IGRA, then TST for IGRA-negative results; any test positive indicates LTBI).

Incremental cost-effectiveness ratios, or ICERs, varied among non-U.S. born residents, the researchers found, but for patients with ESRD, no testing was cost-effective. For patients with no comorbidities, IGRA was cost-effective at $83,000 per quality-adjusted life-year (QALY). For those with diabetes, both confirm positive ($53,000/QALY) and IGRA ($120,000/QALY) were cost-effective, and for patients with HIV, confirm negative was preferred ($63,000/QALY). Excluding patients with ESRD, all populations preferred strategies that included IGRA in more than 60% of simulations.

In a related editorial, Jennifer Flood, MD, MPH, and Pennan M. Barry, MD, MPH, from the Tuberculosis Control Branch at the California Department of Public Health, wrote that despite having effective tools that now show cost-effectiveness, tests that can better predict disease progression and shorter, well-tolerated treatments are needed in populations at risk for TB. In the meantime, the available LTBI testing and treatment tools can benefit non-U.S. born patients, they wrote.

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“For busy clinicians, TB prevention must be supported by health systems and tools that allow clinicians and health departments to easily track patients through the cascade of care from risk assessment to testing and through treatment completion,” Flood and Barry said. “With full adoption of TB prevention in primary care using currently available modern tools, we can progress from TB control to TB elimination, making this airborne pathogen that moves easily across communities a specter of the past.” – by Savannah Demko

Disclosures: The authors, Flood and Barry report no relevant financial disclosures.