QuantiFERON-TB gold in-tube implementation for latent tuberculosis diagnosis in a public health clinic: a cost-effectiveness analysis

BMC Infectious Diseases

Susan Dorman⁴  Vincent Marsiglia³  Maria Martins-Evora³  Danielle DiPietro¹  Howard Choi⁴  Kathryn Miele⁴  Maunank Shah² 

[1] Tulane University, New Orleans, LA, USA;Johns Hopkins University, School of Medicine, Division of Infectious Disease, Center for TB Research, 1503 East Jefferson St, Room 118, Baltimore, MD, 21231, USA;Baltimore City Health Department, Baltimore, MD, USA;Johns Hopkins University School of Medicine, Baltimore, MD, USA

关键词: Implementation;    Latent tuberculosis;    Interferon-gamma release assay;    Diagnosis;    Tuberculosis;   

Others  :  1158684
DOI  :  10.1186/1471-2334-12-360

 received in 2012-08-14, accepted in 2012-12-14,  发布年份 2012

【 摘 要 】

Background

The tuberculin skin test (TST) has limitations for latent tuberculosis infection (LTBI) diagnosis in low-prevalence settings. Previously, all TST-positive individuals referred from the community to Baltimore City Health Department (BCHD) were offered LTBI treatment, after active TB was excluded. In 2010, BCHD introduced adjunctive QuantiFERON-TB Gold In-Tube (QFT-GIT) testing for TST-positive referrals. We evaluated costs and cost-effectiveness of this new diagnostic algorithm.

Methods

A decision-analysis model compared the strategy of treating all TST-positive referrals versus only those with positive results on adjunctive QFT-GIT testing. Costs were collected at BCHD, and Incremental Cost-Effectiveness Ratios (ICERs) were utilized to report on cost-effectiveness.

Results

QFT-GIT testing at BCHD cost $43.51 per test. Implementation of QFT-GIT testing was associated with an ICER of $1,202 per quality-adjusted life-year gained and was considered highly cost-effective. In sensitivity analysis, the QFT-GIT strategy became cost-saving if QFT-GIT sensitivity increased above 92% or if less than 3.5% of individuals with LTBI progress to active TB disease.

Conclusions

LTBI screening with TST in low-prevalence settings may lead to overtreatment and increased expenditures. In this public health clinic, additional QFT-GIT testing of individuals referred for a positive TST was cost-effective.

【 授权许可】

   
2012 Shah et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

【 参考文献 】

• [1]Advisory Council for the Elimination of Tuberculosis (ACET): Tuberculosis elimination revisited: obstacles, opportunities, and a renewed commitment. MMWR Recomm Rep 1999, 48(RR-9):1-13.
• [2]ATS/CDC/IDSA: Controlling tuberculosis in the United States. Am J Respir Crit Care Med 2005, 172(9):1169-1227.
• [3]ATS/CDC/IDSA: Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR Recomm Rep 2000, 49(RR-6):1-51.
• [4]Shah M, Dipietro D, Greenbaum A, Ketemepi S, Martins-Evora M, Marsiglia V, Dorman SE: Programmatic Impact of QuantiFERON-TB Gold In-Tube Implementation on Latent Tuberculosis Diagnosis and Treatment in a Public Health Clinic. PLoS One 2012, 7(5):e36551.
• [5]Ozuah PO, Burton W, Lerro KA, Rosenstock J, Mulvihill M: Assessing the validity of tuberculin skin test readings by trained professionals and patients. Chest 1999, 116(1):104-106.
• [6]Diel R, Loddenkemper R, Nienhaus A: Predictive value of interferon-gamma release assays and tuberculin skin testing for predicting progression from latent TB infection to disease state: a meta-analysis. Chest 2012, 142(1):63-75.
• [7]Pai M, Kalantri S, Dheda K: New tools and emerging technologies for the diagnosis of tuberculosis: part I. Latent tuberculosis. Expert Rev Mol Diagn 2006, 6(3):413-422.
• [8]Pai M, Zwerling A, Menzies D: Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update. Ann Intern Med 2008, 149(3):177-184.
• [9]Mazurek GH, Jereb J, Vernon A, LoBue P, Goldberg S, Castro K: Updated guidelines for using Interferon Gamma Release Assays to detect Mycobacterium tuberculosis infection - United States, 2010. MMWR Recomm Rep 2010, 59(RR-5):1-25.
• [10]Rangaka MX, Wilkinson KA, Glynn JR, Ling D, Menzies D, Mwansa-Kambafwile J, Fielding K, Wilkinson RJ, Pai M: Predictive value of interferon-gamma release assays for incident active tuberculosis: a systematic review and meta-analysis. Lancet Infect Dis 2012, 12(1):45-55.
• [11]Kunimoto D, Der E, Beckon A, Thomas L, Egedahl M, Beatch A, Williams G, Tyrrell G, Ahmed R, Brown N, et al.: Use of the QuantiFERON-TB Gold test to confirm latent tuberculosis infection in a Canadian tuberculosis clinic. Int J Tuberc Lung Dis 2009, 13(6):726-730.
• [12]Horsburgh CR Jr: Priorities for the treatment of latent tuberculosis infection in the United States. N Engl J Med 2004, 350(20):2060-2067.
• [13]Pareek M, Watson JP, Ormerod LP, Kon OM, Woltmann G, White PJ, Abubakar I, Lalvani A: Screening of immigrants in the UK for imported latent tuberculosis: a multicentre cohort study and cost-effectiveness analysis. Lancet Infect Dis 2011, 11(6):435-444.
• [14]Menzies D, Pai M, Comstock G: Meta-analysis: new tests for the diagnosis of latent tuberculosis infection: areas of uncertainty and recommendations for research. Ann Intern Med 2007, 146(5):340-354.
• [15]Page KR, Sifakis F, Montes de Oca R, Cronin WA, Doherty MC, Federline L, Bur S, Walsh T, Karney W, Milman J, et al.: Improved adherence and less toxicity with rifampin vs isoniazid for treatment of latent tuberculosis: a retrospective study. Arch Intern Med 2006, 166(17):1863-1870.
• [16]Lardizabal A, Passannante M, Kojakali F, Hayden C, Reichman LB: Enhancement of treatment completion for latent tuberculosis infection with 4 months of rifampin. Chest 2006, 130(6):1712-1717.
• [17]Pooran A, Booth H, Miller RF, Scott G, Badri M, Huggett JF, Rook G, Zumla A, Dheda K: Different screening strategies (single or dual) for the diagnosis of suspected latent tuberculosis: a cost effectiveness analysis. BMC Pulm Med 2010, 10:7. BioMed Central Full Text
• [18]Kunst H, Khan KS: Age-related risk of hepatotoxicity in the treatment of latent tuberculosis infection: a systematic review. Int J Tuberc Lung Dis 2010, 14(11):1374-1381.
• [19]Ziakas PD, Mylonakis E: 4 months of rifampin compared with 9 months of isoniazid for the management of latent tuberculosis infection: a meta-analysis and cost-effectiveness study that focuses on compliance and liver toxicity. Clin Infect Dis 2009, 49(12):1883-1889.
• [20]Holland DP, Sanders GD, Hamilton CD, Stout JE: Costs and cost-effectiveness of four treatment regimens for latent tuberculosis infection. Am J Respir Crit Care Med 2009, 179(11):1055-1060.
• [21]de Perio MA, Tsevat J, Roselle GA, Kralovic SM, Eckman MH: Cost-effectiveness of interferon gamma release assays vs tuberculin skin tests in health care workers. Arch Intern Med 2009, 169(2):179-187.
• [22]WHO: Efficacy of various durations of isoniazid preventive therapy for tuberculosis: five years of follow-up in the IUAT trial. International Union Against Tuberculosis Committee on Prophylaxis. Bull World Health Organ 1982, 60(4):555-564.
• [23]Brown RE, Miller B, Taylor WR, Palmer C, Bosco L, Nicola RM, Zelinger J, Simpson K: Health-care expenditures for tuberculosis in the United States. Arch Intern Med 1995, 155(15):1595-1600.
• [24]Maryland TB: Statistics, Department of Health and Mental Hygiene. http://ideha.dhmh.maryland.gov/CTBCP/statistics.aspx webcite
• [25]Harstad I, Winje BA, Heldal E, Oftung F, Jacobsen GW: Predictive values of QuantiFERON-TB Gold testing in screening for tuberculosis disease in asylum seekers. Int J Tuberc Lung Dis 2010, 14(9):1209-1211.
• [26]Diel R, Loddenkemper R, Niemann S, Meywald-Walter K, Nienhaus A: Negative and positive predictive value of a whole-blood interferon-gamma release assay for developing active tuberculosis: an update. Am J Respir Crit Care Med 2011, 183(1):88-95.
• [27]Diel R, Loddenkemper R, Meywald-Walter K, Niemann S, Nienhaus A: Predictive value of a whole blood IFN-gamma assay for the development of active tuberculosis disease after recent infection with Mycobacterium tuberculosis. Am J Respir Crit Care Med 2008, 177(10):1164-1170.
• [28]Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB: Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA 1996, 276(15):1253-1258.
• [29]Life Expectancy Tables. http://www.cdc.gov/nchs/fastats/lifexpec.htm webcite
• [30]Reported Tuberculosis in the United States. 2009. http://www.cdc.gov/tb/statistics/reports/2010/pdf/report2010.pdf webcite
• [31]Maryland TB Guidelines for Prevention and Treatment of Tuberculosis. http://ideha.dhmh.maryland.gov/OIDPCS/CTBCP/CTBCPDocuments/tbguidelines.pdf webcite
• [32]Owens DK: Interpretation of cost-effectiveness analyses. J Gen Intern Med 1998, 13(10):716-717.
• [33]Nienhaus A, Schablon A, Costa JT, Diel R: Systematic review of cost and cost-effectiveness of different TB-screening strategies. BMC Health Serv Res 2011, 11:247. BioMed Central Full Text
• [34]Dewan PK, Grinsdale J, Liska S, Wong E, Fallstad R, Kawamura LM: Feasibility, acceptability, and cost of tuberculosis testing by whole-blood interferon-gamma assay. BMC Infect Dis 2006, 6:47. BioMed Central Full Text