In-kind Nutritional Supplementation for Persons With Drug-susceptible Tuberculosis and Their Household Contacts Would be Cost-effective for Reducing Tuberculosis Incidence and Mortality in Jharkhand, India: A Modeling Study

Background Undernutrition is the leading cause of tuberculosis (TB) globally, but nutritional interventions are often considered cost-prohibitive. The RATIONS study demonstrated that nutritional supplementation to household contacts of persons with TB can reduce TB incidence, yet economic evaluations of such strategies remain limited. Methods Using a Markov model, we assessed the cost-effectiveness of a RATIONS-style intervention (monthly food basket providing 750 kcal, 23 g of protein, and a multi-micronutrient tablet daily) for household contacts of persons with TB, as compared to no nutritional support. We calculated health outcomes (TB episodes, TB deaths, and disability-adjusted life years [DALYs]) over the lifetime of intervention recipients and assessed costs from healthcare and societal perspectives. We tested the robustness of results to parameter changes via deterministic and probabilistic sensitivity analysis. Findings Over 2 years, household contacts receiving the RATIONS intervention experienced 38% (95% uncertainty interval [UI]: 23-52) fewer TB episodes and 58% (95% UI: 44-70) fewer TB deaths. Over the lifetime of a cohort of 100 000 household contacts, the intervention was projected to avert 11 524 DALYs (95% UI: 7446-17 393) and was cost-effective from both the healthcare (incremental cost-effectiveness ratio [ICER]: $289 per DALY averted [95% UI: 156-537]) and societal perspectives ($229 per DALY averted [95% UI: 102-468]). Cost-effectiveness was most sensitive to the cost of the nutritional supplement. Conclusions Prompt nutritional support for household contacts of persons with TB disease would be cost-effective in reducing TB incidence and mortality in India.