Screening and Rapid Molecular Diagnosis of Tuberculosis in Prisons in Russia and Eastern Europe: A Cost-Effectiveness Analysis

Background: prisons of the former soviet union (fsu) have high rates of multidrug-resistant tuberculosis (mdr-tb) and are thought to drive general population tuberculosis (tb) epidemics. effective prison case detection,though employing more expensive technologies,may reduce long-term treatment costs and slow mdr-tb transmission. methods and findings: we developed a dynamic transmission model of tb and drug resistance matched to the epidemiology and costs in fsu prisons. we evaluated eight strategies for tb screening and diagnosis involving,alone or in combination,self-referral,symptom screening,mass miniature radiography (mmr),and sputum pcr with probes for rifampin resistance (xpert mtb/rif). over a 10-y horizon,we projected costs,quality-adjusted life years (qalys),and tb and mdr-tb prevalence. using sputum pcr as an annual primary screening tool among the general prison population most effectively reduced overall tb prevalence (from 2.78% to 2.31%) and mdr-tb prevalence (from 0.74% to 0.63%),and cost us$543/qaly for additional qalys gained compared to mmr screening with sputum pcr reserved for rapid detection of mdr-tb. adding sputum pcr to the currently used strategy of annual mmr screening was cost-saving over 10 y compared to mmr screening alone,but produced only a modest reduction in mdr-tb prevalence (from 0.74% to 0.69%) and had minimal effect on overall tb prevalence (from 2.78% to 2.74%). strategies based on symptom screening alone were less effective and more expensive than mmr-based strategies. study limitations included scarce primary tb time-series data in fsu prisons and uncertainties regarding screening test characteristics. conclusions: in prisons of the fsu,annual screening of the general inmate population with sputum pcr most effectively reduces tb and mdr-tb prevalence,doing so cost-effectively. if this approach is not feasible,the current strategy of annual mmr is both more effective and less expensive than strategies using self-referral or symptom screening alone,and the addition of sputum pcr for rapid mdr-tb detection may be cost-saving over time. please see later in the article for the editors' summary. © 2012 winetsky et al.