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Abstract
Health care personnel (HCP) are at increased risk for tuberculosis (TB) due to occupational exposure. To prevent the transmission of Mycobacterium tuberculosis in health care settings, the United States (US) Centers for Disease Control and Prevention (CDC) recommends that occupational health programs conduct post-offer and pre-placement (i.e., baseline) TB screening for new HCP, where personnel with a positive initial result receiving a confirmatory test. However, the economic value of baseline screening based on the CDC recommendations, along with the use of a confirmatory testing strategy, has not been evaluated in US HCP. This study aims to identify the most optimal post-offer and pre-placement (POPP) TB screening scenario for US HCP. We conducted two studies to achieve our study aim. First, we systematically reviewed the published literature on LTBI prevalence, conversion, and reversion for US HCP compared with HCP from other high-income, low TB-incidence countries. Second, we conducted a cost-effectiveness analysis to compare health outcomes, costs, effectiveness, and the incremental cost-effectiveness ratios for five POPP screening and treatment scenarios: no screening, two-step tuberculin skin test (TST) + 9-month isoniazid (9H); two-step TST + 3-month isoniazid-rifapentine (3HP); QuantiFERON-TB Gold In-tube (QFT) + 3HP; and confirm positive QFT with QFT + 3HP (QFT/QFT + 3HP).
The pooled random-effects estimate from the systematic review indicate that 3.8% (95% CI: 2.4, 5.8) of US HCP have LTBI compared to 24% (95% CI: 16.3, 33.9) of HCP in other high-income, low TB-incidence countries. Additionally, 50.3% (95% CI: 38.6, 62.0) of US HCP received a false-positive (i.e., reversion) result during serial screening, with 2.1% (95% CI: 1.1, 3.9) converting from a negative to a positive result. The cost-effectiveness analysis showed that QFT + 3HP yielded the lowest cost to avert a TB case or death. Moreover, QFT + 3HP is the most cost-effective scenario for US-born and non–US-born HCP, at an incremental cost-effectiveness ratio of $14,559 and $14,822 per quality-adjusted life year gained, respectively.
Based on these findings, US occupational health programs should consider implementing QFT + 3HP as the standard baseline screening scenario for all HCP.