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

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Abstract
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