Cost-effectiveness and health impact of screening and treatment of Mycobacterium tuberculosis infection among formerly incarcerated individuals in Brazil

Background Formerly incarcerated individuals experience high tuberculosis (TB) incidence rates but are generally not considered among risk groups eligible for TB prevention. We investigated the potential health impact and cost-effectiveness of Mycobacterium tuberculosis (Mtb) infection screening and TB preventive treatment (TPT) for formerly incarcerated individuals in Brazil. Methods Using published evidence for Brazil, we constructed a Markov state transition model simulating TB-related health outcomes and costs among formerly incarcerated individuals. The analysis compared TB infection screening and TPT to no screening, considering a combination of Mtb infection tests and TPT regimens. We quantified health effects as reductions in TB cases, TB deaths and disability-adjusted life years (DALYs). We assessed costs from a TB programme perspective. We report intervention cost-effectiveness as the incremental costs per DALY averted, and tested how results changed across subgroups of the target population. Findings All TPT interventions were cost-effective in comparison to no screening, with a strategy including a tuberculin skin test and a 3-month isoniazid and rifapentine regimen costing $242 per DALY averted. It was estimated to avert 31 (95% uncertainty interval: 14-56) lifetime TB cases and 4.1 (1.4-8.5) lifetime TB deaths per 1,000 individuals receiving the intervention. Younger age, longer incarceration, and more recent prison release were each associated with significantly greater health benefits and more favorable cost-effectiveness ratios; however, the intervention was cost-effective for all subgroups examined. Interpretation Mtb infection screening and TPT appear cost-effective for formerly incarcerated individuals. Funding NIH. Evidence before this study In many settings, incarcerated individuals have been shown to face higher risks of Mycobacterium tuberculosis (Mtb) infection than the general population. Individuals exiting prison have been found to experience elevated tuberculosis incidence rates over several years, and studies have also reported evidence of elevated tuberculosis incidence in surrounding communities. While several studies have investigated the health impact and cost-effectiveness of interventions to detect and prevent TB disease within prisons, few studies have examined the health impact and cost-effectiveness of interventions to treat Mtb infection among formerly incarcerated individuals. Added value of this study Using a Markov model, we simulated lifetime results among a cohort of formerly incarcerated individuals in Brazil offered screening and treatment for Mtb infection. To our knowledge, this is the first study to investigate the health impact and cost-effectiveness of screening and treatment among this cohort. The results contribute to the ongoing efforts to effectively reduce the TB burden and reach the WHO’s End TB goals in 2030. Implications of all the available evidence Screening and treatment of Mtb infection among formerly incarcerated individuals would produce substantial health benefits and be highly cost-effective in the setting examined in this study. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by NIH ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript