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Screening and Treatment of Latent Tuberculosis Among Healthcare Workers at Low, Moderate, and High Risk for Tuberculosis Exposure: A Cost-Effectiveness Analysis

Published online by Cambridge University Press:  02 January 2015

Shelley R. Salpeter  and
Edwin E. Salpeter
Shelley R. Salpeter*
Affiliation:
Santa Clara Valley Medical Center, San Jose, Stanford, California Stanford University School of Medicine, Stanford, California
Edwin E. Salpeter
Affiliation:
Cornell University, Ithaca, New York
*
Santa Clara Valley Medical Center, 751 S. Bascom Avenue, San Jose, CA 95128
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Abstract

Objective:

To evaluate cost-effective screening and treatment strategies for healthcare workers (HCWs) at risk for tuberculosis exposure.

Design:

A Markov model was developed to track three hypothetical cohorts of HCWs at low, moderate, and high risk for tuberculosis exposure. For those found to be tuberculin reactors at entry, the choice was for isoniazid treatment or no treatment. For those without tuberculin reactivity, the choice of screening intervals was 6 months, 1 year, 2 years, or 5 years. Outcomes measured were tuberculosis cases, death, life expectancy, and cost. Assumptions were derived from published data and analyses.

Results:

Treatment of initial reactors with isoniazid in all three risk groups was associated with a net savings of $14,800 to $15,700 for each tuberculosis case prevented. For those without evidence of infection at entry, the most cost-effective screening interval was 1 year for high-risk groups, 2 years for moderate-risk groups, and 5 years for low-risk groups, with a net savings $0.20 to $26 per HCW per year. Screening at a more frequent interval was still cost-effective.

Conclusions:

For HCWs found to be tuberculin reactors, treatment of their latent infection is to their benefit and is associated with a net cost-savings. Regular tuberculin screening of HCWs can be cost-effective or result in a net cost-savings. Each institution could use its own skin test surveillance data to create an optimum screening program for its employees. However, for most HCWs, a 1-year screening interval would be a cost-effective and safe choice.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 25 , Issue 12 , December 2004 , pp. 1056 - 1061
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2004

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References

1.Barrett-Connor, E. The epidemiology of tuberculosis in physicians. JAMA 1979;241:33–38.CrossRefGoogle ScholarPubMed
2.Sepkowitz, KA. Tuberculosis and the health care worker: a historical perspective. Ann Intern Med 1994;120:71–79.Google ScholarPubMed
3.Field, MJ, Institute of Medicine, Committee on Regulating Occupational Exposure to Tuberculosis. Tuberculosis in the Workplace. Washington, DC: National Academy Press; 2001:xiv, 340.Google Scholar
4.Sepkowitz, KA, Friedman, CR, Hafner, A, et al.Tuberculosis among urban health care workers: a study using restriction fragment length polymorphism typing. Clin Infect Dis 1995;21:1098–1101.CrossRefGoogle ScholarPubMed
5.McKenna, MT, Hutton, M, Cauthen, G, Onorato, IM. The association between occupation and tuberculosis: a population-based survey. Am J Respir Crit Care Med 1996;154:587–593.CrossRefGoogle ScholarPubMed
6.Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994. MMWR 1994;43:1–132.Google Scholar
7.Bratcher, DF, Stover, BH, Lane, NE, Paul, RI. Compliance with national recommendations for tuberculosis screening and immunization of healthcare workers in a children's hospital. Infect Control Hosp Epidemiol 2000;21:338–340.CrossRefGoogle ScholarPubMed
8.Beck, JR, Pauker, SG. The Markov process in medical prognosis. Med Decis Making 1983;3:419–458.CrossRefGoogle ScholarPubMed
9.Sonnenberg, FA, Beck, JR. Markov models in medical decision making: a practical guide. Med Decis Making 1993;13:322–338.CrossRefGoogle ScholarPubMed
10.National Center for Health Statistics. Monthly Vital Statistics Report: Annual Summary of Births, Marriages, Divorces and Deaths: United States, 2001. Washington, DC: U.S. Public Health Service; 2001.Google Scholar
11.Ferebee, SH. Controlled chemoprophylaxis trials in tuberculosis: a general review. Bibliotheca Tuberculosei 1970;26:28–106.Google ScholarPubMed
12.Comstock, GW, Ferebee, SH, Hammes, LM. A controlled trial of community-wide isoniazid prophylaxis in Alaska. Am Rev Respir Dis 1967;95:935–943.Google ScholarPubMed
13.Comstock, GW, Woolpert, SF, Livesay, VT. Tuberculosis studies in Muscogee County, Georgia: twenty-year evaluation of a community trial of BCG vaccination. Public Health Rep 1976;91:276–280.Google ScholarPubMed
14.Schneider, E, Castro, KG. Tuberculosis trends in the United States, 1992-2001. Tuberculosis (Edinb) 2003;83:21–29.CrossRefGoogle ScholarPubMed
15.Dye, C, Scheele, S, Dolin, P, Pathania, V, Raviglione, MC. Consensus statement: global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. JAMA 1999;282:677–686.CrossRefGoogle ScholarPubMed
16.Salpeter, EE, Salpeter, SR. Mathematical model for the epidemiology of tuberculosis, with estimates of the reproductive number and infection-delay function. Am J Epidemiol 1998;147:398–406.CrossRefGoogle ScholarPubMed
17.Salpeter, SR, Sanders, GD, Salpeter, EE, Owens, DK. Monitored isoniazid prophylaxis for low-risk tuberculin reactors older than 35 years of age: a risk-benefit and cost-effectiveness analysis. Ann Intern Med 1997;127:1051–1061.Google ScholarPubMed
18.Grzybowski, S, Ashley, MJ, McKinnon, NE, Pinkus, G, Philipps, R, Brown, A. In Canada: a trial of chemoprophylaxis in inactive tuberculosis. Canadian Medical Association Journal 1969;101:81–86.Google Scholar
19.Grzybowski, S, Ashley, MJ, Pinkus, G. Chemoprophylaxis in inactive tuberculosis: long-term evaluation of a Canadian trial. Canadian Medical Association Journal 1976;114:607–611.Google ScholarPubMed
20.International Union Against Tuberculosis Committee on Prophylaxis. Efficacy of various durations of isoniazid preventive therapy for tuberculosis: five years of follow-up in the IUAT trial. Bull World Health Organ 1982;60:555–564.Google Scholar
21.Stead, WW, To, T, Harrison, RW, Abraham, JH 3rdBenefit-risk considerations in preventive treatment for tuberculosis in elderly persons. Ann Intern Med 1987;107:843–845.CrossRefGoogle ScholarPubMed
22.Espinal, MA, Laszlo, A, Simonsen, L, et al.Global trends in resistance to antituberculosis drugs. N Engl J Med 2001;344:1294–1303.CrossRefGoogle ScholarPubMed
23.American Thoracic Society. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000;49:1–51.Google Scholar
24.Snider, DE JrCaras, GJ, Koplan, JP. Preventive therapy with isoniazid: cost-effectiveness of different durations of therapy. JAMA 1986;255:1579–1583.CrossRefGoogle ScholarPubMed
25.Salpeter, SR. Fatal isoniazid-induced hepatitis: its risk during chemoprophylaxis. West J Med 1993;159:560–564.Google ScholarPubMed
26.Millard, PS, Wilcosky, TC, Reade-Christopher, SJ, Weber, DJ. Isoniazid-related fatal hepatitis. West J Med 1996;164:486–491.Google ScholarPubMed
27.Mohle-Boetani, JC, Miller, B, Halpern, M, et al.School-based screening for tuberculous infection: a cost-benefit analysis. JAMA 1995;274:613–619.CrossRefGoogle ScholarPubMed
28.Fitzgerald, JM, Gafni, A. A cost-effectiveness analysis of the routine use of isoniazid prophylaxis in patients with a positive Mantoux skin test. Am Rev Respir Dis 1990;142:848–853.CrossRefGoogle ScholarPubMed
29.Brown, RE, Miller, B, Taylor, WR, et al.Health-care expenditures for tuberculosis in the United States. Arch Intern Med 1995;155:1595–1600.CrossRefGoogle ScholarPubMed
30.Bureau of Labor Statistics. Consumer Price Index. Washington, DC: Bureau of Labor Statistics; 2002.Google Scholar
31.Miller, AK, Tepper, A, Sieber, K. Historical risks of tuberculin skin test conversion among non-physician staff at a large urban hospital. Am J Ind Med 2002;42:228–235.CrossRefGoogle Scholar
32.Panlilio, AL, Burwen, DR, Curtis, AB, et al.Tuberculin skin testing surveillance of health care personnel. Clin Infect Dis 2002;35:219–227.CrossRefGoogle ScholarPubMed
33.Warren, DK, Foley, KM, Polish, LB, Seiler, SM, Fraser, VJ. Tuberculin skin testing of physicians at a midwestern teaching hospital: a 6-year prospective study. Clin Infect Dis 2001;32:1331–1337.CrossRefGoogle Scholar
34.Swinker, M. Prevalence of positive tuberculin skin reactions in a two-step testing program at a tertiary-care center in eastern North Carolina. Infect Control Hosp Epidemiol 2000;21:39–40.CrossRefGoogle Scholar
35.Behrman, AJ, Shofer, FS. Tuberculosis exposure and control in an urban emergency department. Ann Emerg Med 1998;31:370–375.CrossRefGoogle Scholar
36.Blumberg, HM, Sotir, M, Erwin, M, Bachman, R, Shulman, JA. Risk of house staff tuberculin skin test conversion in an area with a high incidence of tuberculosis. Clin Infect Dis 1998;27:826–833.CrossRefGoogle Scholar
37.Christie, CD, Constantinou, P, Marx, ML, et al.Low risk for tuberculosis in a regional pediatric hospital: nine-year study of community rates and the mandatory employee tuberculin skin-test program. Infect Control Hosp Epidemiol 1998;19:168–174.CrossRefGoogle Scholar
38.LoBue, PA, Catanzaro, A. Effectiveness of a nosocomial tuberculosis control program at an urban teaching hospital. Chest 1998;113:1184–1189.CrossRefGoogle ScholarPubMed
39.Louther, J, Rivera, P, Feldman, J, Villa, N, DeHovitz, J, Sepkowitz, KA. Risk of tuberculin conversion according to occupation among health care workers at a New York City hospital. Am J Respir Crit Care Med 1997;156:201–205.CrossRefGoogle Scholar
40.Zahnow, K, Matts, JP, Hillman, D, et al.Rates of tuberculosis infection in healthcare workers providing services to HIV-infected populations: Terry Beirn Community Programs for Clinical Research on AIDS. Infect Control Hosp Epidemiol 1998;19:829–835.CrossRefGoogle ScholarPubMed
41.Ball, R, Van Wey, M. Tuberculosis skin test conversion among health care workers at a military medical center. Mil Med 1997;162:338–343.CrossRefGoogle Scholar
42.Bangsberg, DR, Crowley, K, Moss, A, Dobkin, JF, McGregor, C, Neu, HC. Reduction in tuberculin skin-test conversions among medical house staff associated with improved tuberculosis infection control practices. Infect Control Hosp Epidemiol 1997;18:566–570.CrossRefGoogle ScholarPubMed
43.Boudreau, AY, Baron, SL, Steenland, NK, et al.Occupational risk of Mycobacterium tuberculosis infection in hospital workers. Am J Ind Med 1997;32:528–534.3.0.CO;2-4>CrossRefGoogle ScholarPubMed
44.Manusov, EG, Bradshaw, RD, Fogarty, JP. Tuberculosis screening in medical students. Fam Med 1996;28:645–649.Google ScholarPubMed
45.Sinkowitz, RL, Fridkin, SK, Manangan, L, Wenger, PN, Jarvis, WR. Status of tuberculosis infection control programs at United States hospitals, 1989 to 1992. Am J Infect Control 1996;24:226–234.CrossRefGoogle ScholarPubMed
46.Bailey, TC, Fraser, VJ, Spitznagel, EL, Dunagan, WC. Risk factors for a positive tuberculin skin test among employees of an urban, midwestern teaching hospital. Ann Intern Med 1995;122:580–585.CrossRefGoogle ScholarPubMed
47.Fraser, VJ, Kilo, CM, Bailey, TC, Medoff, G, Dunagan, WC. Screening of physicians for tuberculosis. Infect Control Hosp Epidemiol 1994;15:95–100.CrossRefGoogle ScholarPubMed
48.Trends in tuberculosis morbidity: United States, 1992-2002. MMWR 2003;52:217-220, 222.Google Scholar