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BMC Med. 2017 May 17;15(1):104. doi: 10.1186/s12916-017-0865-x.

Revisiting annual screening for latent tuberculosis infection in healthcare workers: a cost-effectiveness analysis.

Author information

1
Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, QC, Canada.
2
Faculty of Medicine, McGill University, Montreal, QC, Canada.
3
McGill International TB Centre, McGill University, Montreal, Quebec, Canada.
4
Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, QC, Canada. kevin.schwartzman@mcgill.ca.
5
Faculty of Medicine, McGill University, Montreal, QC, Canada. kevin.schwartzman@mcgill.ca.
6
McGill International TB Centre, McGill University, Montreal, Quebec, Canada. kevin.schwartzman@mcgill.ca.
7
McGill University Health Centre, 1001 boulevard Décarie, Room D05.2511, Montreal, H4A 3J1, Quebec, Canada. kevin.schwartzman@mcgill.ca.
8
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.

Abstract

BACKGROUND:

In North America, tuberculosis incidence is now very low and risk to healthcare workers has fallen. Indeed, recent cohort data question routine annual tuberculosis screening in this context. We compared the cost-effectiveness of three potential strategies for ongoing screening of North American healthcare workers at risk of exposure. The analysis did not evaluate the cost-effectiveness of screening at hiring, and considered only workers with negative baseline tests.

METHODS:

A decision analysis model simulated a hypothetical cohort of 1000 workers following negative baseline tests, considering duties, tuberculosis exposure, testing and treatment. Two tests were modelled, the tuberculin skin test (TST) and QuantiFERON®-TB-Gold In-Tube (QFT). Three screening strategies were compared: (1) annual screening, where workers were tested yearly; (2) targeted screening, where workers with high-risk duties (e.g. respiratory therapy) were tested yearly and other workers only after recognised exposure; and (3) post exposure-only screening, where all workers were tested only after recognised exposure. Workers with high-risk duties had 1% annual risk of infection, while workers with standard patient care duties had 0.3%. In an alternate higher-risk scenario, the corresponding annual risks of infection were 3% and 1%, respectively. We projected costs, morbidity, quality-adjusted survival and mortality over 20 years after hiring. The analysis used the healthcare system perspective and a 3% annual discount rate.

RESULTS:

Over 20 years, annual screening with TST yielded an expected 2.68 active tuberculosis cases/1000 workers, versus 2.83 for targeted screening and 3.03 for post-exposure screening only. In all cases, annual screening was associated with poorer quality-adjusted survival, i.e. lost quality-adjusted life years, compared to targeted or post-exposure screening only. The annual TST screening strategy yielded an incremental cost estimate of $1,717,539 per additional case prevented versus targeted TST screening, which in turn cost an incremental $426,678 per additional case prevented versus post-exposure TST screening only. With the alternate "higher-risk" scenario, the annual TST strategy cost an estimated $426,678 per additional case prevented versus the targeted TST strategy, which cost an estimated $52,552 per additional case prevented versus post-exposure TST screening only. In all cases, QFT was more expensive than TST, with no or limited added benefit. Sensitivity analysis suggested that, even with limited exposure recognition, annual screening was poorly cost-effective.

CONCLUSIONS:

For most North American healthcare workers, annual tuberculosis screening appears poorly cost-effective. Reconsideration of screening practices is warranted.

KEYWORDS:

Cost-effectiveness; Health personnel; Latent tuberculosis; Screening

PMID:
28514962
PMCID:
PMC5436424
DOI:
10.1186/s12916-017-0865-x
[Indexed for MEDLINE]
Free PMC Article

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