The cost-effectiveness of preventing tuberculosis in physicians using tuberculin skin testing or a hypothetical vaccine.
BACKGROUND
Tuberculin skin testing using the purified protein derivative is recommended as part of a tuberculosis control program for health care workers. However, compliance with skin testing programs has been poor and their cost-effectiveness is unknown.


METHODS
A Markov-based decision analysis was performed to determine the cost-effectiveness of tuberculin skin testing over the entire lifetimes of physicians who are now in medical school. Assumptions were deliberately chosen to present a conservative estimate of cost-effectiveness. Indirect costs were not included.


RESULTS
Annual testing cost $29,000 per life-year saved and $39,000 per case of pulmonary tuberculosis prevented. In contrast, particulate respirators have been shown to cost millions of dollars per case prevented. Skin testing every 6 months was cost-effective in a subpopulation at high risk of infection (> or = 1.8-fold). During their entire lifetimes, physicians now in medical school can expect to avert 137 cases of pulmonary tuberculosis, prevent 7 tuberculosis deaths, and save 182 life-years because of skin testing programs. Improved compliance with annual skin testing and prophylactic isoniazid could more than triple this benefit. If available, a moderately effective vaccine would be even more cost-effective than tuberculin skin testing programs.


CONCLUSIONS
Tuberculin skin testing is cost-effective and should be an integral part of any tuberculosis control program. Vaccination may one day be a feasible and cost-effective alternative to skin testing programs.
Nettleman
M D
MD
Department of Internal Medicine, Virginia Commonwealth University, Richmond, USA.
Geerdes
H
H
Roy
M C
MC
D000328:Adult; D000368:Aged; D000995:Antitubercular Agents / Q000627:therapeutic use; D001500:BCG Vaccine / Q000191:economics*; D002423:Cause of Death; D018890:Chemoprevention; D003299:Cooperative Behavior; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005240:Feasibility Studies; D006801:Humans; D007538:Isoniazid / Q000627:therapeutic use; D008390:Markov Chains; D008875:Middle Aged; D009784:Occupational Diseases / Q000517:prevention & control*; D010820:Physicians; D012134:Respiratory Protective Devices / Q000191:economics; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013997:Time Factors; D014374:Tuberculin Test / Q000191:economics*; D014397:Tuberculosis, Pulmonary / Q000517:prevention & control*; D026712:Value of Life
D000995:Antitubercular Agents; D001500:BCG Vaccine; D007538:Isoniazid