title: Cost-effectiveness analysis of community active case finding and household contact investigation for tuberculosis case detection in urban Africa.
abstract: BACKGROUND
  Case detection by passive case finding (PCF) strategy alone is inadequate for detecting all tuberculosis (TB) cases in high burden settings especially Sub-Saharan Africa. Alternative case detection strategies such as community Active Case Finding (ACF) and Household Contact Investigations (HCI) are effective but empirical evidence of their cost-effectiveness is sparse. The objective of this study was to determine whether adding ACF or HCI compared with standard PCF alone represent cost-effective alternative TB case detection strategies in urban Africa.
  
  
  METHODS
  A static decision modeling framework was used to examine the costs and effectiveness of three TB case detection strategies: PCF alone, PCF+ACF, and PCF+HCI. Probability and cost estimates were obtained from National TB program data, primary studies conducted in Uganda, published literature and expert opinions. The analysis was performed from the societal and provider perspectives over a 1.5 year time-frame. The main effectiveness measure was the number of true TB cases detected and the outcome was incremental cost-effectiveness ratios (ICERs) expressed as cost in 2013 US$ per additional true TB case detected.
  
  
  RESULTS
  Compared to PCF alone, the PCF+HCI strategy was cost-effective at US$443.62 per additional TB case detected. However, PCF+ACF was not cost-effective at US$1492.95 per additional TB case detected. Sensitivity analyses showed that PCF+ACF would be cost-effective if the prevalence of chronic cough in the population screened by ACF increased 10-fold from 4% to 40% and if the program costs for ACF were reduced by 50%.
  
  
  CONCLUSIONS
  Under our baseline assumptions, the addition of HCI to an existing PCF program presented a more cost-effective strategy than the addition of ACF in the context of an African city. Therefore, implementation of household contact investigations as a part of the recommended TB control strategy should be prioritized.
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States of America; Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
authors: Juliet N
authors: JN
authors: Sekandi
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States of America.
authors: Kevin
authors: K
authors: Dobbin
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States of America.
authors: James
authors: J
authors: Oloya
authors: School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.
authors: Alphonse
authors: A
authors: Okwera
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia, United States of America.
authors: Christopher C
authors: CC
authors: Whalen
authors: Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, Georgia, United States of America.
authors: Phaedra S
authors: PS
authors: Corso
mesh_terms: D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005191:Family Characteristics; D006801:Humans; D008403:Mass Screening / Q000191:economics*; D015995:Prevalence; D012111:Residence Characteristics; D014376:Tuberculosis / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology; D014454:Uganda / Q000453:epidemiology; D014507:Urbanization