Cost-effectiveness of screening for active cases of tuberculosis in Flanders, Belgium

Introduction In 2014, the global incidence of tuberculosis was 133 cases per 100 000 population. (1) The World Health Organization (WHO) wishes to reduce the global incidence of tuberculosis below 10 cases per 100 000 population by 2035. (2) Although the incidence in many high-income countries is already below this target level, tuberculosis remains a public health challenge. (3) In most low-incidence countries there are low rates of tuberculosis transmission among the native population, a developing predominance of cases among the elderly--and other vulnerable and hard-to-reach risk groups--and individuals who carry latent tuberculosis infection for years before they become symptomatic. (4,5) Low burdens of tuberculosis often lead to diminishing public awareness, inadequate political commitment, limited clinical and diagnostic expertise and the underfunding of tuberculosis research. (4,6) At the same time, economic crises, growing inequity, increases in the incidence of diseases that are risk factors for tuberculosis and the dissemination of drug-resistant forms of Mycobacterium tuberculosis may all be contributing to an expansion in the burden posed by tuberculosis. (6-9) If WHO's tuberculosis goal for 2035 is to be achieved, global funding and commitment for tuberculosis care, control and prevention need to be increased (10) and the cost-effective use of the resources that are--or become--available has to be optimized. (11) WHO's framework towards tuberculosis elimination in low-incidence countries, provides further goals and a customized strategy for countries such as Belgium. (6,12,13) According to this framework, interventions and target groups must be prioritized based on an assessment--of the epidemiology of tuberculosis and health-care context in each setting--that is guided by data analysis and operational research. (6) We therefore evaluated the cost-effectiveness of the tuberculosis screening activities, in northern Belgium, that are currently organized and funded by the Flemish government. The reporting of this study conforms to the Consolidated Health Economic Evaluation Reporting Standards (available from the corresponding author). (14) Methods Study setting Flanders is the Dutch-speaking northern part of Belgium and has about 6.4 million inhabitants. (15) The Flemish governments Agency for Care and Health is responsible for the general coordination of the tuberculosis policy in Flanders. It also coordinates and partially carries out and has the final responsibility for--the investigation of contacts of individuals with infectious tuberculosis. Because of resource constraints, a management contract was established between the Flemish government and the Flemish Association for Respiratory Health and Tuberculosis Control. The association has its headquarters in Brussels and eight regional centres for respiratory health care in Flanders. On behalf of the Flemish government, the association carries out active detection through contact investigation, systematic screening of five high-risk groups and the screening of other individuals--hereafter simply called others--who, though they do not belong to any specific risk groups, have presented for a consultation at a centre for respiratory health care. The high-risk groups that are screened systematically but voluntarily by the association are: (i) all asylum seekers assigned to Flanders; (ii) all undocumented migrants i.e. individuals lacking legal status in Belgium--held in detention centres in Flanders; (iii) other immigrants who intend to stay in Flanders for more than three months and come from high-incidence countries--i.e. countries that have more than 50 active cases of tuberculosis per 100 000 population; (iv) prisoners in Flanders; and (v) the youth held in juvenile detention centres in Flanders. There is no legal obligation for screening--people are invited and strongly motivated but can refuse to participate. …