Nyashadzaishe Mafirakureva, Boris K Tchounga, Sushant Mukherjee, Boris Tchakounte Youngui, Bob Ssekyanzi, Leonie Simo, Richard F Okello, Stavia Turyahabwe, Albert Kuate Kuate, Jennifer Cohn, Anca Vasiliu, Martina Casenghi, Daniel Atwine, Maryline Bonnet, Peter J Dodd
Background: WHO recommends household contact management (HCM) including contact screening and tuberculosis-preventive treatment (TPT) for eligible children. The CONTACT trial found increased TPT initiation and completion rates when community health workers were used for HCM in Cameroon and Uganda.
Methods: We did a cost–utility analysis of the CONTACT trial using a health-system perspective to estimate the health impact, health-system costs, and cost-effectiveness of community-based versus facility-based HCM models of care. A decision-analytical modelling approach was used to evaluate the cost-effectiveness of the intervention compared with the standard of care using trial data on cascade of care, intervention effects, and resource use. Health outcomes were based on modelled progression to tuberculosis, mortality, and discounted disability-adjusted life-years (DALYs) averted. Health-care resource use, outcomes, costs (2021 US$), and cost-effectiveness are presented.
Findings: For every 1000 index patients diagnosed with tuberculosis, the intervention increased the number of TPT courses by 1110 (95% uncertainty interval 894 to 1227) in Cameroon and by 1078 (796 to 1220) in Uganda compared with the control model. The intervention prevented 15 (–3 to 49) tuberculosis deaths in Cameroon and 10 (–20 to 33) in Uganda. The incremental cost-effectiveness ratio was $620 per DALY averted in Cameroon and $970 per DALY averted in Uganda.
Interpretation: Community-based HCM approaches can substantially reduce child tuberculosis deaths and in our case would be considered cost-effective at willingness-to-pay thresholds of $1000 per DALY averted. Their impact and cost-effectiveness are likely to be greatest where baseline HCM coverage is lowest.
Added value of this study: To our knowledge, this study is the first cost–utility analysis of HCM for child tuberculosis contacts based on a randomised trial comparing a community-based (intervention) to a facility-based approach (the standard of care), and is also the first economic analysis of a TPT intervention delivered at household level by community health workers. Our estimates of costs and effects are based on results from a multicountry cluster-randomised trial.
Implications of all the available evidence: Community-based approaches to HCM are expected to avert tuberculosis disease and deaths in children. Our approach in Cameroon and Uganda would be considered cost-effective at willingness-to-pay thresholds of US$1000 per DALY averted. The impact and cost-effectiveness of such interventions would be greater in settings with higher tuberculosis disease prevalence among contacts and lower existing coverage of screening for child household contacts.
Funding: Unitaid and UK Medical Research Council.
SRF contact: Dr Atwine Daniel (Country PI):
Article link: https://pubmed.ncbi.nlm.nih.