May 26, 1997

The Cost-effectiveness of Preventing Tuberculosis in Physicians Using Tuberculin Skin Testing or a Hypothetical Vaccine

Author Affiliations

From the Department of Internal Medicine, Virginia Commonwealth University, Richmond (Dr Nettleman), and University of Iowa College of Medicine, Iowa City (Ms Geerdes and Dr Roy).

Arch Intern Med. 1997;157(10):1121-1127. doi:10.1001/archinte.1997.00440310087009

Background:  Tuberculin skin testing using the purified protein derivative is recommended as part of a tuberculosis control program for health care workers. However, compliance with skin testing programs has been poor and their cost-effectiveness is unknown.

Methods:  A Markov-based decision analysis was performed to determine the cost-effectiveness of tuberculin skin testing over the entire lifetimes of physicians who are now in medical school. Assumptions were deliberately chosen to present a conservative estimate of cost-effectiveness. Indirect costs were not included.

Results:  Annual testing cost $29 000 per life-year saved and $39 000 per case of pulmonary tuberculosis prevented. In contrast, particulate respirators have been shown to cost millions of dollars per case prevented. Skin testing every 6 months was cost-effective in a subpopulation at high risk of infection (≥1.8-fold). During their entire lifetimes, physicians now in medical school can expect to avert 137 cases of pulmonary tuberculosis, prevent 7 tuberculosis deaths, and save 182 life-years because of skin testing programs. Improved compliance with annual skin testing and prophylactic isoniazid could more than triple this benefit. If available, a moderately effective vaccine would be even more cost-effective than tuberculin skin testing programs.

Conclusions:  Tuberculin skin testing is cost-effective and should be an integral part of any tuberculosis control program. Vaccination may one day be a feasible and cost-effective alternative to skin testing programs.Arch Intern Med. 1997;157:1121-1127