A cost-benefit analysis of a proposed overseas refugee latent tuberculosis infection screening and treatment program

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.

Preventive therapy for latent tuberculosis infection—the promise and the challenges

“…A recent modelling study showed that screening high-risk migrants entering the USA was likely cost-saving for those originating from high and medium prevalence settings. 94 While routine migrant screening for LTBI may be too costly for implementation in all countries, this strategy may provide a pathway to further reducing TB in settings where prevalence is already low.…”

Implementing tuberculosis entry screening for asylum seekers: the Groningen experience

“…The effectiveness and cost-effectiveness of asylum seeker entry screening strategies are subject to debate [12][13][14], although targeting LTBI screening at asylum seekers at the highest risk of developing TB disease (e.g. those from high-incidence countries) might improve cost-effectiveness [5,15], but further studies should be performed in the EU as well.…”

Cost analysis of measles in refugees arriving at Los Angeles International Airport from Malaysia

“…The costs of the state HDs were financed to a great extent by federal grants and other funding mechanisms. Newly arrived refugee health care was paid for by the federal government because the refugees had not been in the United States long enough to be eligible for private insurance 7,12 . The adult infected in the United States was a federal government employee with job-based insurance, 8 and the persons immunized by state HDs received vaccines purchased with government funds.…”

“…Unlike immigrants, refugees are not required to have vaccinations before immigrating, slightly increasing the risk of vaccine-preventable disease import 6 . The costs of refugee medical care both overseas and for approximately the first year in the United States are paid for by the US government 7 . The US government provides funding to the International Organization for Migration (IOM) to provide health services for US-bound refugees including panel physician activities in several countries that send a large number of refugees to the United States.…”