Date and Time
February 23, 2011
1:30 PM - 3:00 PM

Availability
Open to the public
No RSVP required

Speaker
Daniel Winetsky - HSR MS & MD candidate

Please note: All research in progress seminars are off-the-record. Any information about methodology and/or results are embargoed until publication 

Abstract:

BACKGROUND: Prisons of the former Soviet Union (FSU) have some of the highest rates of multidrug-resistant tuberculosis (MDR-TB) ever observed, and are thought to drive rising TB levels in these countries' general populations.  Effective case finding strategies in prisons may interrupt the cycle of transmission, reducing treatment costs and potentially reducing TB incidence more broadly. We projected the costs and health effects of alternative case finding strategies for prisons with high prevalence of MDR-TB.

METHODS: We developed a dynamic state-transition model of TB and drug resistance, with inputs from the epidemiology of prisons in the FSU. We evaluated eight alternative case finding strategies including: self-referral, symptom screening and screening with mass miniature radiography (MMR) alone or in combination, followed by sputum smear microscopy for inmates who screen positive, either alone or in combination with sputum culture or PCR analysis. Over a ten-year time horizon, we projected costs, quality-adjusted life years (QALYs) saved, TB and MDR-TB prevalence.

RESULTS:  The strategy currently used in most FSU prisons, annual MMR screening followed by smear microscopy alone cost more and was less effective than screening with symptom questionnaires followed by smear microscopy (S1).Annual screening with both symptom questionnaires and MMR followed by smear microscopy (S2) had an incremental cost-effectiveness ratio (ICER) of $1,286/QALY compared with S1. Annual symptom and MMR screening followed by both smear microscopy and sputum PCR analysis had an ICER of $2,659/QALY compared with S2. These results compare favorably to the per-capita GDP of FSU countries ($1,900 – $18,300). In sensitivity analyses, symptom screening with smear microscopy and PCR at times replaced S2 as a cost-effective strategy. The cost-effectiveness of these strategies was consistent with their capacity to reduce MDR-TB prevalence.

CONCLUSIONS:  In prisons of the FSU, the current strategy of annual MMR screening should be modified to include symptom screening, which will both reduce costs and improve outcomes. The incorporation of sputum PCR analysis into case finding strategies could reduce the prevalence of MDR-TB in prisons over time. More sensitive but also resource-intensive case finding strategies may ultimately reduce costs and improve outcomes by interrupting transmission of TB and MDR-TB.