Infection Control & Hospital Epidemiology (2019), 40, 341–349 doi:10.1017/ice.2018.334
Original Article
A screening strategy for latent tuberculosis in healthcare workers: Cost-effectiveness and budget impact of universal versus targeted screening
May Ee Png PhD1, Joanne Yoong PhD2, Catherine Wei Min Ong FAMS, PhD3,4, Dale Fisher FRACP3,4 and
Natasha Bagdasarian MD, MPH3,4 1Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore, 2Center for Economic and Social Research East, University of Southern California, Washington, DC, United States, 3Division of Infectious Disease, Department of Medicine, National University Health System, Singapore, Singapore and 4Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
Abstract
Objective: To evaluate the clinical, cost-efficiency, and budgetary implications of universal versus targeted latent tuberculosis infection (LTBI) screening strategies among healthcare workers (HCWs) in an intermediate tuberculosis (TB)-burden country. Design: Pragmatic cost-effectiveness and budget impact analysis using decision-analytic modeling. Setting: A tertiary-care hospital in Singapore.
Methods: We compared 7 potentially implementable LTBI screening programs including universal and targeted strategies with different screening frequencies. Feasible targeting methods included stratification by country of origin (a proxy for risk of prior TB exposure) and by high-risk occupation. The clinical and financial consequences of each strategy were estimated relative to “no screening” (current practice) and compared to locally appropriate cost-effectiveness thresholds. All analyses were conducted from the hospital’s perspective over a 3-year time horizon, based on the typical hospital planning period. Parameter uncertainties were accounted for using sensitivity analyses.
Results: In our model, relative to current practice, screening new international hires and triennial screening of existing high-risk workers is most cost-effective (US$58 per quality adjusted life year [QALY]) and decreases active TB cases from 19 to 14. Screening all new hires com- bined with triennial universal screening, with or without annual high-risk screening or annual universal screening, reduced active TB to a range of 19 to 6 cases, but these strategies are less cost-effective and require substantially higher expenditures.
Conclusions: Targeted LTBI screening for HCWs can be highly cost-effective for hospitals in settings similar to Singapore. More inclusive screening strategies (including regular universal screening) can yield better outcomes but are less efficient and may even be unaffordable.
(Received 18 April 2018; accepted 24 November 2018)
The occupational risk of acquiring tuberculosis varies considerably in healthcare settings.1 Although nosocomial transmission of tuberculosis (TB) has been relatively uncommon in low-TB- burden countries,2 healthcare workers (HCWs) who routinely per- form high-risk procedures (eg, bronchoscopy) are at increased risk of TB exposure.3 In addition, international travel has facilitated TB outbreaks in healthcare settings. A recent report from the United Kingdom traced multidrug-resistant TB (MDR-TB) transmission between hospitalized patients in which the index patient was an HIV-positive HCW who had previously worked at a hospital in South Africa during a 2005 outbreak of MDR-TB.4 Nosocomial TB transmission is thus no longer dependent solely on the TB bur- den of a single country.
Author for correspondence: Joanne Yoong, Email:
jyoong@usc.edu Cite this article: Png ME, et al. (2019). A screening strategy for latent tuberculosis in
healthcare workers: Cost-effectiveness and budget impact of universal versus targeted screening. Infection Control & Hospital Epidemiology, 40: 341–349,
https://doi.org/ 10.1017/ice.2018.334
© 2019 by The Society for Healthcare Epidemiology of America. All rights reserved. Actively screening and treating latent TB infection (LTBI) can
reduce the risk of progression to active TB in high-risk groups. On exposure and conversion to LTBI, ∼10% of immunocompetent individuals with LTBI will develop active TB, of whom 5% will develop active disease in the first 2 years and the next 5% of whom will develop TB at some point in their lifetime.5 LTBI screening for HCWs does not routinely take place in all countries. However, screening programs that focus on testing and treating HCWs who have been identified as high risk may still be valuable. For in- stance in the United States, the TB incidence rate in non–US-born HCWs was 10-fold higher than in their US-born counterparts.6 Although universal screening for LTBI is recommended by the US Centers for Disease Control and Prevention,7 intensified screening of HCWs from high TB-burden countries has also been proposed.6 Singapore has an intermediate TB incidence of 35–45 cases per
100,000 population among Singapore residents,8 but a consider- able number of HCWs are at higher risk. For instance, almost
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