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Volume 25, Number 4—April 2019
Research

Cost-effectiveness of Latent Tuberculosis Infection Screening before Immigration to Low-Incidence Countries

Jonathon R. Campbell, James C. Johnston, Victoria J. Cook, Mohsen Sadatsafavi, R. Kevin Elwood, and Fawziah MarraComments to Author 
Author affiliations: University of British Columbia, Vancouver, British Columbia, Canada (J.R. Campbell, J.C. Johnston, V.J. Cook, M. Sadatsafavi, R.K. Elwood, F. Marra); British Columbia Centre for Disease Control, Vancouver (J.C. Johnston, V.J. Cook, R.K. Elwood)

Main Article

Table 2

Model parameter estimates and values used for sensitivity analyses of intervention strategies for screening and treatment of latent TB infection in immigrants*

Parameter Estimate Range evaluated in PSA PSA distribution References
Screening parameters
TST sensitivity 0.782 0.69–0.87 Beta(43,12) (19)
TST specificity, no BCG 0.974 0.963–0.982 Beta(770,21) (20,21)
TST specificity, BCG 0.602 0.561–0.642 Beta(239,158) (20,21)
IGRA sensitivity 0.889 0.688–0.993 Beta(8,1) (19)
IGRA specificity 0.957 0.946–0.968 Beta(900,40) (20,21)
IGRA indeterminate† 0.06 0.05–0.07 Beta(83,1286) (21)
Complete TST‡ 1 Fixed Fixed
Complete medical evaluation§
1
Fixed
Fixed

Population characteristics¶
LTBI prevalence
Very high incidence 0.3162 0.2686–0.3880 Varied with reactivation rate (12,1517)
High incidence 0.2016 0.1706–0.2464 Varied with reactivation rate (12,1517)
Moderate incidence 0.0902 0.0763–0.1102 Varied with reactivation rate (12,1517)
Low incidence 0.0159 0.0135–0.0195 Varied with reactivation rate (12,1517)
Abnormal chest radiograph results or previous TB
Very high incidence 0.039 Fixed Fixed (15)
High incidence 0.028 Fixed Fixed (15)
Moderate incidence 0.029 Fixed Fixed (15)
Low incidence 0.008 Fixed Fixed (15)
Adherence to postarrival follow-up#
0.684
0.646–0.721
Beta(404.50,186.87)
(22)
Treatment parameters
Initiate** 0.938 0.907–0.964 Beta(180.83,11.95) (5)
Complete, INH 0.616 0.561–0.670 Beta(131.66,82.07) (5)
Complete, RIF 0.814 0.745–0.876 Beta(76.85,17.56) (5)
Adverse event, INH 0.049 0.044–0.055 Beta(249,4789) (24,25)
Adverse event, RIF 0.021 0.018–0.025 Beta(109,4877) (24,25)
Adverse event hospitalization 0.01 0.0005–0.03 Beta(1,99) (25)
Death, INH 0.00000988 0–0.00002 Beta(2,202495) (26)
LTBI risk reduction, INH 0.90 0.78–0.95 Normal(−2.3,0.5)†† (27)
LTBI risk reduction, RIF 0.90 0.63–0.97 Normal(−2.3,0.8)†† (28,24)
Partial risk reduction, INH 0.346 0.267–0.490 Combination of normal distributions††, ‡‡ Expert opinion, (25)
Partial risk reduction, RIF 0.30 0.17–0.40 Normal(−0.35,0.1)†† Expert opinion, (24,28)
Adverse event duration
7 d
0–24
Gamma(0.7,10)
Expert opinion, (25)
TB parameters
Death from TB 0.0476 0.0391–0.0566 Beta(76,1523) (3)
Reactivation rate 0.0011 0.0009–0.0013 Beta(90.92,82545.55) (1517)
Abnormal CXR risk change 3.9 3.0–4.9 Normal(1.36,0.15)†† (29)
Extended therapy 0.124 0.029–0.264 Beta(2.366,16.713) Expert opinion, (30)
Relapse rate 0.0359 0.0197–0.0654 Normal(−3.327,0.365)†† (30)
Hospitalization duration
17 d
Fixed
Fixed
Expert opinion, (30)
Model parameters
BCG vaccination, <30 cases 0.605 0.60–0.61 Beta(45137,29502) (12,13)
BCG vaccination, ≥30 cases 0.998 0.997–0.999 Beta(185381,384) (12,13)
BCG vaccination uptake 0.837 Fixed Fixed (14)
Discount rate 0.03 Fixed Fixed (23)
Time horizon 25 y Fixed Fixed NA

*AE, adverse event; BCG, bacillus Calmette-Guérin; IGRA, interferon-gamma release assay; INH, isoniazid; LTBI, latent tuberculosis infection; NA, not available; PSA, probabilistic sensitivity analysis; RIF, rifampin; TST, tuberculin skin test; TB, tuberculosis.
†Treated as a negative result if it occurred; was equally likely to occur in those with and without LTBI.
‡Without being mandatory, this value is 63.5% (imputed from 43.4% completing screening when 68.4% adhere with a follow-up appointment) (5).
§Without being mandatory, this value is 78% (imputed from 43.7 of 56 individuals completing medical evaluation) (5).
¶Very high incidence, >200 cases/100,000; high incidence, >100 and <200 cases/100,000; moderate incidence, >30 and <100 cases/100,000; low incidence, <30 cases/100,000.
#From a meta-analysis (22); see also Appendix (https://wwwnc.cdc.gov/EID/article/25/4/17-1630-App1.pdf).
**This model assumes all who report postarrival due to a positive preimmigration LTBI diagnostic test are offered treatment. Exploratory analysis adjusts this assumption so that only the number who would complete TST screening begin treatment.
††Results from this distribution are exponentiated.
‡‡Formula: 0.33 × (Normal(−1.168,0.228)) + 0.374 × (Normal(−0.381,0.169)) + 0.293 × 1.

Main Article

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