Abstract
BackgroundThis study explored the effect of screening and treatment of refugees for latent tuberculosis infection (LTBI) before entrance to the United States as a strategy for reducing active tuberculosis (TB). The purpose of this study was to estimate the costs and benefits of LTBI screening and treatment in United States bound refugees prior to arrival.MethodsCosts were included for foreign and domestic LTBI screening and treatment and the domestic treatment of active TB. A decision tree with multiple Markov nodes was developed to determine the total costs and number of active TB cases that occurred in refugee populations that tested 55, 35, and 20 % tuberculin skin test positive under two models: no overseas LTBI screening and overseas LTBI screening and treatment. For this analysis, refugees that tested 55, 35, and 20 % tuberculin skin test positive were divided into high, moderate, and low LTBI prevalence categories to denote their prevalence of LTBI relative to other refugee populations.ResultsFor a hypothetical 1-year cohort of 100,000 refugees arriving in the United States from regions with high, moderate, and low LTBI prevalence, implementation of overseas screening would be expected to prevent 440, 220, and 57 active TB cases in the United States during the first 20 years after arrival. The cost savings associated with treatment of these averted cases would offset the cost of LTBI screening and treatment for refugees from countries with high (net cost-saving: $4.9 million) and moderate (net cost-saving: $1.6 million) LTBI prevalence. For low LTBI prevalence populations, LTBI screening and treatment exceed expected future TB treatment cost savings (net cost of $780,000).ConclusionsImplementing LTBI screening and treatment for United States bound refugees from countries with high or moderate LTBI prevalence would potentially save millions of dollars and contribute to United States TB elimination goals. These estimates are conservative since secondary transmission from tuberculosis cases in the United States was not considered in the model.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-2530-7) contains supplementary material, which is available to authorized users.
Highlights
This study explored the effect of screening and treatment of refugees for latent tuberculosis infection (LTBI) before entrance to the United States as a strategy for reducing active tuberculosis (TB)
The total number of refugees resettling in the United States fluctuates annually, but these results indicate that overseas LTBI screening and treatment programs have the potential to prevent thousands of TB cases and would be cost-saving if used among refugees from high and moderate LTBI prevalence regions
We focused on the 12-dose weekly isoniazid-rifapentine regimen for three reasons: 1) It is most likely to be completed in the short time span between the medical screenings and departure; 2) The 12-dose weekly isoniazid-rifapentine regimen has the highest completion rates so it is most likely to have the greatest public health impact in terms of future TB cases prevented [11]; and 3) The 12-dose weekly regimen would be logistically easier to administrate overseas in refugee camps than once daily rifampin
Summary
This study explored the effect of screening and treatment of refugees for latent tuberculosis infection (LTBI) before entrance to the United States as a strategy for reducing active tuberculosis (TB). In the United States, most active tuberculosis (TB) cases occur in foreign-born residents [1], and over 80 % of these cases occur in persons thought to have acquired latent tuberculosis infection (LTBI) overseas [2]. This epidemiologic pattern has strongly influenced CDC’s determination that identifying and treating LTBI is an important public health intervention to reduce the prevalence of active pulmonary TB cases [3]. Panel physicians work in the immigrants’ and refugees’ country of origin in most instances and are extended permission from the consular sections of United States embassies to administer medical exams that meet CDC standards (Technical Instructions) [5].
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