title: Screening and rapid molecular diagnosis of tuberculosis in prisons in Russia and Eastern Europe: a cost-effectiveness analysis.
abstract: 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.
  
  
  RESULTS
  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.
authors.affiliation: Stanford University School of Medicine, California, United States of America.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Winetsky
authors.forename: Diana M
authors.initials: DM
authors.lastname: Negoescu
authors.forename: Emilia H
authors.initials: EH
authors.lastname: DeMarchis
authors.forename: Olga
authors.initials: O
authors.lastname: Almukhamedova
authors.forename: Aizhan
authors.initials: A
authors.lastname: Dooronbekova
authors.forename: Dilshod
authors.initials: D
authors.lastname: Pulatov
authors.forename: Natalia
authors.initials: N
authors.lastname: Vezhnina
authors.forename: Douglas K
authors.initials: DK
authors.lastname: Owens
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Goldhaber-Fiebert
mesh_terms: D000904:Antibiotics, Antitubercular / Q000627:therapeutic use; D001454:Baltic States / Q000453:epidemiology; D019411:Clinical Laboratory Techniques / Q000191:economics / Q000379:methods*; D017517:Commonwealth of Independent States / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D024881:Drug Resistance, Bacterial; D058872:Epidemics; D006801:Humans; D007844:Latvia / Q000453:epidemiology; D008403:Mass Screening / Q000191:economics / Q000379:methods*; D008962:Models, Theoretical; D009169:Mycobacterium tuberculosis / Q000187:drug effects / Q000235:genetics / Q000302:isolation & purification*; D015995:Prevalence; D011330:Prisons; D019057:Quality-Adjusted Life Years; D060888:Real-Time Polymerase Chain Reaction / Q000191:economics / Q000379:methods*; D012293:Rifampin / Q000494:pharmacology; D012426:Russia / Q000453:epidemiology; D013620:Tajikistan / Q000453:epidemiology; D013997:Time Factors; D014376:Tuberculosis / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis / Q000191:economics / Q000453:epidemiology
chemical_list: D000904:Antibiotics, Antitubercular; D012293:Rifampin