Comparative impacts and cost-effectiveness of tuberculosis active case-finding strategies in prisons in Brazil, Colombia, and Peru: a mathematical modeling study

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Abstract

BackgroundIncarceration is a leading driver of tuberculosis in Latin America. Active case-finding in prisons may reduce population-wide tuberculosis burden, but optimal strategies and cost-effectiveness remain uncertain. Methods and findingsUsing dynamic transmission models calibrated to Brazil, Colombia, and Peru, we simulated annual or biannual (twice-yearly) prison-wide screening, alone or combined with entry and exit screening from 2026-2035. We evaluated four algorithms: 1) symptom screening, 2) chest X-ray with computer-aided detection (CXR-CAD), 3) symptoms and CXR-CAD (follow-up testing if either is positive) and 4) GeneXpert Ultra with pooled sputum. Individuals screening positive then received individual Xpert. We projected impacts on within-prison and population-level tuberculosis incidence in 2035, along with discounted costs (2023 USD) and disability-adjusted life years (DALYs). Model projections showed that combined entry, exit, and biannual screening with CXR-CAD was highly impactful and cost-effective across countries, reducing tuberculosis incidence by 62-87% in prisons and 18-28% population-wide. Compared to only biannual CXR-CAD (the next best strategy), the incremental cost per DALY averted of adding entry and exit screening was $2984 (Brazil), $2925 (Colombia), and $645 (Peru). Adding symptom screening to CXR-CAD marginally increased benefit and was only cost-effective in Perus higher-incidence prisons. Biannual screening alone remained cost-effective at prison incidence levels well below national averages. In settings without CXR-CAD, pooled Xpert was an impactful, cost-effective alternative. ConclusionsThese modeling results support immediate national-level adoption of prison-wide tuberculosis screening twice-yearly and at entry and exit. Screening should begin with available methods while building capacity for CXR-CAD, the most cost-effective algorithm. AUTHOR SUMMARYO_ST_ABSWhy was this study done?C_ST_ABSO_LIIn Latin America, rising incarceration has fueled the tuberculosis epidemic, with extremely high infection rates among people deprived of liberty. These effects extend beyond prison walls, driving tuberculosis spread in outside communities. C_LIO_LIInterventions targeted to prisons may have an outsized impact on reducing tuberculosis in the broader population. C_LIO_LIThe World Health Organization strongly recommends systematic screening for tuberculosis in prisons, but there is little evidence on how often to screen, which methods to use, and whether these approaches are cost-effective across different country contexts. C_LI What did the researchers do and find?O_LIWe developed mathematical models using data from Brazil, Colombia, and Peru to simulate different prison-based tuberculosis screening strategies and project their health impacts and costs. C_LIO_LIWe compared prison-wide screening once or twice a year, screening at prison entry or exit, and combinations of these approaches. We also compared different screening methods using symptoms, chest X-ray with computer-aided detection (CXR-CAD), or pooled molecular testing (GeneXpert Ultra). C_LIO_LIThe models projected that combining entry, exit, and twice-yearly prison-wide screening with CXR-CAD would be highly impactful and cost-effective in all three countries. This strategy could substantially reduce tuberculosis in prisons and in the general population. C_LIO_LITwice-yearly prison-wide screening remained cost-effective even in prisons with much lower tuberculosis rates than national averages. C_LIO_LICXR-CAD was the optimal screening method, but pooled molecular testing was also impactful and cost-effective where CXR-CAD was not available. C_LI Implications of all the available evidenceO_LISystematic screening in prisons, twice-yearly and at entry and exit, is projected to be highly impactful and cost-effective across different settings in Latin America. C_LIO_LIThese findings support urgent adoption of intensive prison-based tuberculosis screening throughout the region, starting with the best available diagnostic tools while investing in CXR-CAD. C_LI

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