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Open Access Highly Accessed Research article

Cost-effectiveness of tuberculosis evaluation and treatment of newly-arrived immigrants

Travis C Porco12*, Bryan Lewis1, Elliot Marseille3, Jennifer Grinsdale4, Jennifer M Flood1 and Sarah E Royce1

Author Affiliations

1 California Department of Health Services, Tuberculosis Control Branch,850 Marina Bay Parkway, Building P, Second Floor, Richmond, CA 94804, USA

2 University of California, Berkeley, Center for Infectious Disease Preparedness, 1918 University Way, Berkeley, CA 94704, USA

3 Institute for Health Policy Studies, University of California, San Francisco, USA

4 San Francisco Department of Public Health, San Francisco General Hospital, Ward 94,1001 Potrero Avenue, San Francisco, CA 94110, USA

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BMC Public Health 2006, 6:157  doi:10.1186/1471-2458-6-157

Published: 19 June 2006

Abstract

Background

Immigrants to the U.S. are required to undergo overseas screening for tuberculosis (TB), but the value of evaluation and treatment following entry to the U.S. is not well understood. We determined the cost-effectiveness of domestic follow-up of immigrants identified as tuberculosis suspects through overseas screening.

Methods

Using a stochastic simulation for tuberculosis reactivation, transmission, and follow-up for a hypothetical cohort of 1000 individuals, we calculated the incremental cost-effectiveness of follow-up and evaluation interventions. We utilized published literature, California Reports of Verified Cases of Tuberculosis (RVCTs), demographic estimates from the California Department of Finance, Medicare reimbursement, and Medi-Cal reimbursement rates. Our target population was legal immigrants to the United States, our time horizon is twenty years, and our perspective was that of all domestic health-care payers. We examined the intervention to offer latent tuberculosis therapy to infected individuals, to increase the yield of domestic evaluation, and to increase the starting and completion rates of LTBI therapy with INH (isoniazid). Our outcome measures were the number of cases averted, the number of deaths averted, the incremental dollar cost (year 2004), and the number of quality-adjusted life-years saved.

Results

Domestic follow-up of B-notification patients, including LTBI treatment for latently infected individuals, is highly cost-effective, and at times, cost-saving. B-notification follow-up in California would reduce the number of new tuberculosis cases by about 6–26 per year (out of a total of approximately 3000). Sensitivity analysis revealed that domestic follow-up remains cost-effective when the hepatitis rates due to INH therapy are over fifteen times our best estimates, when at least 0.4 percent of patients have active disease and when hospitalization of cases detected through domestic follow-up is no less likely than hospitalization of passively detected cases.

Conclusion

While the current immigration screening program is unlikely to result in a large change in case rates, domestic follow-up of B-notification patients, including LTBI treatment, is highly cost-effective. If as many as three percent of screened individuals have active TB, and early detection reduces the rate of hospitalization, net savings may be expected.