Nutritional Supplementation Cost-Effectively Decreases Tuberculosis Incidence and Mortality in India: The Ration Optimization to Impede Tuberculosis (ROTI-TB) Model

Background: Undernutrition is the leading cause of tuberculosis (TB) in India and is associated with increased TB mortality. Independent of TB, undernutrition decreases quality of life and economic productivity. Material and Methods: We assessed the cost-effectiveness of providing augmented rations to undernourished Indians through the government’s Targeted Public Distribution System (TPDS) using Markov state transition models which simulated disease progression and mortality among undernourished individuals in three groups: general population, household contacts (HHCs) of people living with TB, and persons with HIV. The models calculate costs and outcomes (TB cases, TB deaths, and quality-adjusted life years, QALYs) associated with a 2600 KCal/day diet for adults with body mass index [BMI] of 16-18.4 kg/m2 until they attain a BMI of 20kg/m2 compared to a “do nothing” scenario wherein TPDS rations are unchanged. We employed deterministic and probabilistic sensitivity analyses to test result robustness. Results: Over 5 years, augmented rations could avert 78% of TB cases and 88% of TB deaths among currently undernourished Indians. Correspondingly, this intervention could forestall 78% and 43% of TB cases among undernourished HHCs and HIV positive persons and prevent 88% and 68% of deaths, respectively. Augmented rations resulted in ten-fold higher resolution of undernutrition. Augmented rations were highly cost-effective (incremental cost effectiveness ratio (ICER): $460/QALY). ICER was lower for HHCs ($437/QALY) and the HIV population ($407/QALY). QALYs gained from improving nutritional status eclipsed those from preventing TB. Conclusions: A robust nutritional intervention would be highly cost-effective in reducing TB incidence and mortality while reducing chronic undernutrition. Funding Information: This work was supported by the National Institutes of Health (grant 5T32AI052074-13) to PS; US Civilian Research and Development Foundation (CRDF; award USB-31150-XX-13 to N. S. H. and C. R. H.); the National Science Foundation (cooperative agreement OISE-9531011 to N. S. H. and C. R. H.), with federal funds from the Government of India’s Department of Biotechnology, the Indian Council of Medical Research, the National Institutes of Health, the National Institute of Allergy and Infectious Diseases, and the Office of AIDS Research and distributed in part by CRDF Global; grant from the Warren Alpert Foundation and Boston University School of Medicine (N.S.H); the Clinical and Translational Sciences Institute (grant 1UL1TR001430 to N.S. H.); the Providence/Boston Center for AIDS Research (grant P30AI042853 to C. R. H.); funding from Boston University Foundation India (to N.S.H.); and the Boston University/Rutgers Tuberculosis Research Unit (grant U19AI111276 to C. R. H.). Declaration of Interests: We do not report any conflicts of interest.