Cost-effectiveness and budget impact of decentralising childhood TB diagnosis

d'Elbée, M., Harker, M., Mafirakureva, N., Nanfuka, M., Nguyet, M.H.T.N., Taguebue, J.V., Moh, R., Khosa, C., Mustapha, A., Mwanga-Amumpere, J. and Borand, L., 2024. Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis in six high tuberculosis incidence countries: a mathematical modelling study. EClinicalMedicine, 70, p.102528.

  • Diagnosing tuberculosis (TB) in children is challenging due to difficulties in collecting sputum samples and the paucibacillary nature of pulmonary TB in children.
  • Alternative specimen collection methods like induced sputum and gastric aspirate require specialized equipment and trained personnel, which are often unavailable at primary health centers (PHC) and sometimes even at district hospitals (DH).
  • As a result, many children with symptoms suggestive of TB do not receive appropriate diagnostic tests, even at the DH level.
  • Stool samples can be collected more easily in young children across various settings and can be used to identify Mycobacterium tuberculosis using Xpert MTB/RIF testing.
  • Nasopharyngeal aspirates (NPA) are easier to collect than gastric aspirate or induced sputum and, when combined with stool samples, offer similar sensitivity to Xpert MTB/RIF testing on gastric aspirates or induced sputum.
  • Decentralization of pediatric TB services to the DH level could be cost-effective in Cambodia and Côte d’Ivoire, but decentralization to the PHC level is unlikely to be cost-effective in any country.
  • Targeted decentralization to areas with high TB prevalence would likely be cost-effective in all countries.
  • Implementing decentralization, particularly focused on PHCs, would require significant financial investment in the early phases.
  • The PHC-focused strategy is more costly and less effective than the DH-focused strategy due to the need for diagnostic equipment across more facilities and the higher TB diagnosis rates at the DH level.
  • Higher TB diagnosis rates at DHs may be due to care-givers bringing more severely ill children there first or because children are referred from PHCs with more advanced disease.
  • All children at DHs had chest X-rays (CXR) performed, while at PHCs, only children with persisting symptoms after 7 days were referred for CXR, contributing to higher TB detection in the DH-focused strategy.

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