背景:在高负担设置中,低复杂性结核病(TB)筛查测试可以扩大基于社区的病例发现工作的范围.纳入这些测试的方法的潜在成本和成本效益知之甚少。
方法:我们开发了一个微观模拟模型,评估了在假设人群中基于社区的病例发现的三种方法(印度-,南非-,菲律宾-,乌干达-,和越南一样的设置),结核病患病率是国家估计值的四倍:(1)使用即时C反应蛋白(CRP)测试进行筛查或(2)使用更敏感的“假设筛查测试”进行筛查(对Xpert超阳性结核病的敏感性为95%,70%的特殊性;设备/劳动力成本类似于XpertUltra,但使用2美元的墨盒),然后是痰XpertUltra,如果呈阳性,或(3)用痰液XpertUltra测试所有个体。费用以2023美元表示,包括治疗费用。
结果:UniversalXpertUltra估计平均成本为400万美元(95%的不确定性范围:3.5至460万美元),每100,000人减少3,200(2,600至3,900)与结核病相关的残疾调整寿命年(DALYs)(每DALY筛查670美元[菲律宾]至2000美元[越南])。CRP预计每个DALY的成本为550美元(菲律宾)至1500美元(越南),但避免了44%的DALY。与通用XpertUltra相比,假设筛选测试显示出最小的益处,但如果特异性提高到95%,每次测试成本提高到4.5美元(全包),这一战略可能会花费390美元(菲律宾)到940美元(越南)每DALY避免。
结论:筛查测试可以有意义地提高结核病社区病例发现的成本效益,但只有当他们敏感时,具体,而且便宜。
In high-burden settings, low-complexity screening tests for tuberculosis (TB) could expand the reach of community-based
case-finding efforts. The potential costs and cost-effectiveness of approaches incorporating these tests are poorly understood.
We developed a microsimulation model assessing 3 approaches to community-based
case-finding in hypothetical populations (India-, South Africa-, The Philippines-, Uganda-, and Vietnam-like settings) with TB prevalence 4 times that of national estimates: (1) screening with a point-of-care C-reactive protein (CRP) test, (2) screening with a more sensitive \"Hypothetical Screening test\" (95% sensitive for Xpert Ultra-positive TB, 70% specificity; equipment/labor costs similar to Xpert Ultra, but using a $2 cartridge) followed by sputum Xpert Ultra if positive, or (3) testing all individuals with sputum Xpert Ultra. Costs are expressed in 2023 US dollars and include treatment costs.
Universal Xpert Ultra was estimated to cost a mean $4.0 million (95% uncertainty range: $3.5 to $4.6 million) and avert 3200 (2600 to 3900) TB-related disability-adjusted life years (DALYs) per 100 000 people screened ($670 [The Philippines] to $2000 [Vietnam] per DALY averted). CRP was projected to cost $550 (The Philippines) to $1500 (Vietnam) per DALY averted but with 44% fewer DALYs averted. The Hypothetical Screening test showed minimal benefit compared to universal Xpert Ultra, but if specificity were improved to 95% and per-test cost to $4.5 (all-inclusive), this strategy could cost $390 (The Philippines) to $940 (Vietnam) per DALY averted.
Screening tests can meaningfully improve the cost-effectiveness of community-based
case-finding for TB but only if they are sensitive, specific, and inexpensive.