In-kind nutritional supplementation for household contacts of persons with tuberculosis would be cost-effective for reducing tuberculosis incidence and mortality in India: a modeling study
Authors: Sinha Pranay , Dauphinais Madolyn , Carwile Madeline E. , Horsburgh C. Robert , Menzies Nicolas A. 
Published: January 2024

ABSTRACTBackgroundUndernutrition is the leading cause of tuberculosis (TB) globally, but nutritional interventions are often considered cost prohibitive. The RATIONS study demonstrated that nutritional support provided to household contacts of persons with TB can reduce TB incidence. However, the long-term cost-effectiveness of this intervention is unclear.MethodsWe assessed the cost-effectiveness of a RATIONS-style intervention (daily 750 kcal dietary supplementation and multi-micronutrient tablet). Using a Markov state transition model we simulated TB incidence, treatment, and TB-attributable mortality among household contacts receiving the RATIONS intervention, as compared to no nutritional support. We calculated health outcomes (TB cases, TB deaths, and disability-adjusted life years [DALYs]) over the lifetime of intervention recipients and assessed costs from government and societal perspectives. We tested the robustness of results to parameter changes via deterministic and probabilistic sensitivity analysis.FindingsOver two years, household contacts receiving the RATIONS intervention would experience 39% (95% uncertainty interval (UI): 23–52) fewer TB cases and 59% (95% UI: 44–69) fewer TB deaths. The intervention was estimated to avert 13,775 (95% UI: 9036–20,199) TB DALYs over the lifetime of the study cohort comprising 100,000 household contacts and was cost-effective from both government (incremental cost-effectiveness ratio: $229 per DALY averted [95% UI: 133–387]) and societal perspectives ($184 per DALY averted [95% UI: 83–344]). The results were most sensitive to the cost of the nutritional supplement.InterpretationPrompt nutritional support for household contacts of persons with TB disease would be cost-effective in reducing TB incidence and mortality in India.SummaryUndernutrition is the leading cause of tuberculosis in India. Using a Markov state-transition model, we found that food baskets for household contacts of persons with tuberculosis would be cost-effective in reducing tuberculosis incidence and mortality in India.Research in contextEvidence before this study:Undernutrition is the leading risk factor for TB worldwide. Recently, the RATIONS study demonstrated a roughly 40% reduction in incident TB among household contacts who received in-kind macronutrient and micronutrient supplementation.Added value of this study:Although the RATIONS study demonstrated a dramatic reduction in incident TB, it is unclear if nutritional interventions to prevent TB are cost-effective. Previously, only one cost-effectiveness analysis of nutritional interventions for household contacts has been published. Due to lack of published data, that study had to make assumptions regarding the impact of nutritional interventions on TB incidence and mortality. In this study, we conducted an economic evaluation of a RATIONS-style intervention to reduce incident TB and mortality in India using observed data.Implications of all the available evidence:In-kind nutritional supplementation for household contacts of individuals with TB disease would be cost-effective in reducing incident TB and TB mortality, particularly if TB programs leverage economies of scale to bring down the cost of the nutritional intervention.