{
  "abstract": "Background Undernutrition is a leading risk factor for tuberculosis (TB) mortality and poor treatment outcomes. We evaluated the cost-effectiveness of providing in-kind nutritional support to impoverished persons with TB (PWTB) in India.Methods We developed a Markov model comparing standard care with a household-level nutritional food-basket intervention. Model parameters were informed from systematic reviews and a recent cluster-randomised study. We estimated TB mortality, disability-adjusted life years (DALYs) and costs from the healthcare perspective. We calculated incremental cost-effectiveness ratios (ICERs), and parameter uncertainty was quantified through deterministic and probabilistic sensitivity analyses. We estimated uncertainty intervals (UIs) with 10 000 Monte Carlo iterations.Findings Nutritional support was projected to avert 10 470 DALYs per 10 000 PWTB (95% UI 1 775 to 33 255). When scaled to India’s 2.8 million annual TB cases, this corresponds to approximately 120 120 TB deaths averted nationwide (95% UI 60 760 to 162 960) under full coverage. The ICER was US$141 per DALY averted (95% UI US$44 to 836). The ICER was most sensitive to the mortality reduction achieved through nutritional support but remained below India’s willingness-to-pay threshold (US$550 per DALY averted) as long as the intervention achieved at least a 13% relative reduction in mortality. Nutritional support was cost-effective in 94% of simulations.Interpretation In-kind nutritional support for PWTB is highly cost-effective and could substantially reduce TB mortality and disengagement from care. Scaling up such interventions could meaningfully improve TB outcomes nationwide and accelerate progress towards the end TB strategy targets.",
  "authors": [
    {
      "affiliations": [
        "Department of Biostatistics, Boston University, Boston, Massachusetts, USA"
      ],
      "name": "Julia Gallini"
    },
    {
      "affiliations": [
        "National Tuberculosis Elimination Programme, New Delhi, India",
        "Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India"
      ],
      "name": "Urvashi B Singh"
    },
    {
      "affiliations": [
        "Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA",
        "University of Massachusetts Chan School of Medicine, Worcester, Massachusetts, USA"
      ],
      "name": "Madolyn Dauphinais"
    },
    {
      "affiliations": [
        "Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India"
      ],
      "name": "Sonali Sarkar"
    },
    {
      "affiliations": [
        "Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA"
      ],
      "name": "Madeline Carwile"
    },
    {
      "affiliations": [
        "Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India"
      ],
      "name": "Rakesh Kumar"
    },
    {
      "affiliations": [
        "National Tuberculosis Elimination Programme, New Delhi, India"
      ],
      "name": "Raghuram Rao"
    },
    {
      "affiliations": [
        "Wadhwani Institute for Artificial Intelligence, Mumbai, India"
      ],
      "name": "Aparna Chaudhary"
    },
    {
      "affiliations": [
        "Department of Infectious Disease Epidemiology and Dynamics, London School of Hygiene and Tropical Medicine, London, UK"
      ],
      "name": "C Finn McQuaid"
    },
    {
      "affiliations": [
        "Harvard Medical School, Boston, Massachusetts, USA"
      ],
      "name": "Kimberly Maloomian"
    },
    {
      "affiliations": [
        "Program in International Nutrition, Cornell University Division of Nutritional Sciences, Ithaca, New York, USA",
        "Cornell Joan Klein Jacobs Center for Precision Nutrition and Health, Cornell University, Ithaca, New York, USA"
      ],
      "name": "Srishti Sinha"
    },
    {
      "affiliations": [
        "Cornell Joan Klein Jacobs Center for Precision Nutrition and Health, Cornell University, Ithaca, New York, USA",
        "Division of Medical Informatics, St John’s Research Institute, Bengaluru, India"
      ],
      "name": "Saurabh Mehta"
    },
    {
      "affiliations": [
        "Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA"
      ],
      "name": "David W Dowdy"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA"
      ],
      "name": "Anne F Liu"
    },
    {
      "affiliations": [
        "Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA"
      ],
      "name": "Benjamin P Linas"
    },
    {
      "affiliations": [
        "Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA"
      ],
      "name": "C Robert Horsburgh, Jr."
    },
    {
      "affiliations": [
        "Department of Biostatistics, Boston University, Boston, Massachusetts, USA"
      ],
      "name": "Laura F White"
    },
    {
      "affiliations": [
        "Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA",
        "Section of Infectious Diseases, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA"
      ],
      "name": "Pranay Sinha"
    }
  ],
  "title": "Cost-effectiveness of in-kind nutritional support for impoverished persons with tuberculosis to reduce mortality and disengagement from care in India: a modelling study",
  "uid": "14678d35-916d-56f9-af82-f293fb18c156"
}