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

28 Pages Posted: 8 Apr 2021

See all articles by Pranay Sinha

Pranay Sinha

Boston University - Section of Infectious Diseases

Subitha L. Lakshminaryan

JIPMER - Department of Preventive and Social Medicine

Chelsie Cintron

Boston University - Section of Infectious Diseases

Prakash Babu Narasimhan

JIPMER - Department of Preventive and Social Medicine

Lindsey M. Locks

Boston University - Department of Global Health

Nalin Kulatilaka

Boston University Questrom School of Business - Susilo Institute for Ethics in a Global Economy; Boston University - Department of Finance & Economics

Kimberley Maloomian

Miriam Hospital - Center for Bariatric Surgery

Senbagavalli Prakash Babu

JIPMER - Department of Preventive and Social Medicine

Madeline Carwile

Boston University - Section of Infectious Diseases

Anne F. Liu

Harvard University - Brigham and Women's Hospital

C. Robert Horsburgh, Jr.

Boston University - Boston University School of Public Health

Carlos Acuna-Villaorduna

Boston University - Section of Infectious Diseases

Benjamin P. Linas

Boston University - Section of Infectious Diseases

Natasha S. Hochberg

Boston University - Section of Infectious Diseases

More...

Abstract

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.

Suggested Citation

Sinha, Pranay and Lakshminaryan, Subitha L. and Cintron, Chelsie and Narasimhan, Prakash Babu and Locks, Lindsey M. and Kulatilaka, Nalin and Maloomian, Kimberley and Prakash Babu, Senbagavalli and Carwile, Madeline and Liu, Anne F. and Horsburgh, Jr., C. Robert and Acuna-Villaorduna, Carlos and Linas, Benjamin P. and Hochberg, Natasha S., Nutritional Supplementation Cost-Effectively Decreases Tuberculosis Incidence and Mortality in India: The Ration Optimization to Impede Tuberculosis (ROTI-TB) Model. Available at SSRN: https://ssrn.com/abstract=3810768 or http://dx.doi.org/10.2139/ssrn.3810768

Pranay Sinha (Contact Author)

Boston University - Section of Infectious Diseases ( email )

801 Massachusetts Ave, 2nd Floor
Boston, MA 02118
United States

Subitha L. Lakshminaryan

JIPMER - Department of Preventive and Social Medicine

Puducherry
India

Chelsie Cintron

Boston University - Section of Infectious Diseases

771 Albany St
Boston, MA

Prakash Babu Narasimhan

JIPMER - Department of Preventive and Social Medicine

Puducherry
India

Lindsey M. Locks

Boston University - Department of Global Health ( email )

715 Albany Street
Boston, MA 02118
United States

Nalin Kulatilaka

Boston University Questrom School of Business - Susilo Institute for Ethics in a Global Economy

595 Commonwealth Avenue
Boston, MA MA 02215
United States

Boston University - Department of Finance & Economics ( email )

595 Commonwealth Avenue
Boston, MA 02215
United States
617-353-4603 (Phone)
617-353-6667 (Fax)

Kimberley Maloomian

Miriam Hospital - Center for Bariatric Surgery ( email )

164 Summit Avenue
Providence, RI 02906
United States

Senbagavalli Prakash Babu

JIPMER - Department of Preventive and Social Medicine ( email )

Puducherry
India

Madeline Carwile

Boston University - Section of Infectious Diseases

771 Albany St
Boston, MA

Anne F. Liu

Harvard University - Brigham and Women's Hospital ( email )

75 Francis St.
Boston, MA 02115
United States

C. Robert Horsburgh, Jr.

Boston University - Boston University School of Public Health

Carlos Acuna-Villaorduna

Boston University - Section of Infectious Diseases

771 Albany St
Boston, MA

Benjamin P. Linas

Boston University - Section of Infectious Diseases

771 Albany St
Boston, MA

Natasha S. Hochberg

Boston University - Section of Infectious Diseases

771 Albany St
Boston, MA

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