Stanford University School of Medicine, California, United States of America.
PLoS Med. 2012;9(11):e1001348. doi: 10.1371/journal.pmed.1001348. Epub 2012 Nov 27.
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.
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.
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.
前苏联（FSU）的监狱中有很高比例的耐多药结核病（MDR-TB），被认为是导致普通人群结核病（TB）流行的原因。虽然采用更昂贵的技术进行有效的监狱病例检测可能会降低长期治疗成本并减缓 MDR-TB 的传播，但这种方法并不常见。
我们开发了一种与 FSU 监狱的流行病学和成本相匹配的结核病和耐药性动态传播模型。我们评估了八种 TB 筛查和诊断策略，这些策略单独或联合使用，包括自我转诊、症状筛查、微型放射成像（MMR）和痰液 PCR 检测利福平耐药性（Xpert MTB/RIF）。在 10 年的时间里，我们预测了成本、质量调整生命年（QALYs）以及 TB 和 MDR-TB 的流行率。使用痰液 PCR 作为一般监狱人群的年度初级筛查工具，可以最有效地降低总体 TB 流行率（从 2.78%降至 2.31%）和 MDR-TB 流行率（从 0.74%降至 0.63%），与保留用于快速检测 MDR-TB 的 MMR 筛查相比，每获得一个额外的 QALY 需花费 543 美元。与单独使用 MMR 筛查相比，在当前使用的年度 MMR 筛查策略的基础上添加痰液 PCR 在 10 年内是节省成本的，但 MDR-TB 流行率仅略有降低（从 0.74%降至 0.69%），对总体 TB 流行率的影响也很小（从 2.78%降至 2.74%）。仅基于症状筛查的策略不如基于 MMR 的策略有效且昂贵。研究局限性包括 FSU 监狱中缺乏原发性 TB 的时间序列数据以及筛查测试特征的不确定性。
在前苏联的监狱中，对一般囚犯进行年度痰液 PCR 筛查最有效地降低了 TB 和 MDR-TB 的流行率，且具有成本效益。如果这种方法不可行，那么目前的年度 MMR 策略比单独使用自我转诊或症状筛查更有效且成本更低，而添加痰液 PCR 进行快速 MDR-TB 检测可能会随着时间的推移而节省成本。
