Public Health Impact and Cost-Effectiveness of Screening for Active Tuberculosis Disease or Infection Among Children in South Africa

Joseph Brough; Leonardo Martinez; Mark Hatherill; Heather J Zar; Nathan C Lo; Jason R Andrews

doi:10.1093/cid/ciad449

Public Health Impact and Cost-Effectiveness of Screening for Active Tuberculosis Disease or Infection Among Children in South Africa

Clin Infect Dis. 2023 Nov 30;77(11):1544-1551. doi: 10.1093/cid/ciad449.

Authors

Joseph Brough¹, Leonardo Martinez², Mark Hatherill³, Heather J Zar⁴, Nathan C Lo⁵, Jason R Andrews⁵

Affiliations

¹ National Capital Consortium, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
² Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA.
³ South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, and Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa.
⁴ Department of Pediatrics and Child Health, Red Cross War Memorial Children's Hospital and SA-MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa.
⁵ Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA.

Abstract

Background: Although tuberculosis disease is a leading cause of global childhood mortality, there remain major gaps in diagnosis, treatment, and prevention in children because tuberculosis control programs rely predominantly on presentation of symptomatic children or contact tracing. We assessed the public health impact and cost-effectiveness of age-based routine screening and contact tracing in children in South Africa.

Methods: We used a deterministic mathematical model to evaluate age-based routine screening in 1-year increments from ages 0 to 5 years, with and without contact tracing and preventive treatment. Screening incorporated symptom history and tuberculin skin testing, with chest x-ray and GeneXpert Ultra for confirmatory testing. We projected tuberculosis cases, deaths, disability-adjusted life years (DALYs), and costs (in 2021 U.S. dollars) and evaluated the incremental cost-effectiveness ratios comparing each intervention.

Results: Routine screening at age 2 years with contact tracing and preventive treatment averted 11 900 tuberculosis cases (95% confidence interval [CI]: 6160-15 730), 1360 deaths (95% CI: 260-3800), and 40 000 DALYs (95% CI: 13 000-100 000) in the South Africa pediatric population over 1 year compared with the status quo. This combined strategy was cost-effective (incremental cost-effectiveness ratio $9050 per DALY; 95% CI: 2890-22 920) and remained cost-effective above an annual risk of infection of 1.6%. For annual risk of infection between 0.8% and 1.6%, routine screening at age 2 years was the dominant strategy.

Conclusions: Routine screening for tuberculosis among young children combined with contact tracing and preventive treatment would have a large public health impact and be cost-effective in preventing pediatric tuberculosis deaths in high-incidence settings such as South Africa.

Keywords: contact investigations; modeling; pediatrics; preventive treatment; tuberculosis.

Publication types

Research Support, N.I.H., Extramural

MeSH terms

Child
Child, Preschool
Cost-Benefit Analysis
Humans
Infant
Models, Theoretical
Public Health*
South Africa / epidemiology
Tuberculosis* / diagnosis
Tuberculosis* / epidemiology
Tuberculosis* / prevention & control

Abstract

Publication types

MeSH terms

Grants and funding