Cost-Effectiveness of Screening and Treating Foreign-Born Students for Tuberculosis before Entering the United States

Abstract

IntroductionThe Centers for Disease Control and Prevention is considering implementation of overseas medical screening of student-visa applicants to reduce the numbers of active tuberculosis cases entering the United States.ObjectiveTo evaluate the costs, cases averted, and cost-effectiveness of screening for, and treating, tuberculosis in United States-bound students from countries with varying tuberculosis prevalence.MethodsCosts and benefits were evaluated from two perspectives, combined and United States only. The combined perspective totaled overseas and United States costs and benefits from a societal perspective. The United States only perspective was a domestic measure of costs and benefits. A decision tree was developed to determine the cost-effectiveness of tuberculosis screening and treatment from the combined perspective.ResultsFrom the United States only perspective, overseas screening programs of Chinese and Indian students would prevent the importation of 157 tuberculosis cases annually, and result in $2.7 million in savings. From the combined perspective, screening programs for Chinese students would cost more than $2.8 million annually and screening programs for Indian students nearly $440,000 annually. From the combined perspective, the incremental cost for each tuberculosis case averted by screening Chinese and Indian students was $22,187 and $15,063, respectively. Implementing screening programs for German students would prevent no cases in most years, and would result in increased costs both overseas and in the United States. The domestic costs would occur because public health departments would need to follow up on students identified overseas as having an elevated risk of tuberculosis.ConclusionsTuberculosis screening and treatment programs for students seeking long term visas to attend United States schools would reduce the number of tuberculosis cases imported. Implementing screening in high-incidence countries could save the United States millions of dollars annually; however there would be increased costs incurred overseas for students and their families.

Prevalence of and risk factors for active tuberculosis in migrants screened before entry to the UK: a population-based cross-sectional study

“…Although their risk of tuberculosis is lower than many other groups, they remain a substantial source of cases, and our fi ndings will enable further analyses, including updated analyses of the cost-eff ectiveness of screening programmes for students. 21 Delays introduced by the requirement for culture testing of sputum sample, which can take a minimum of 6 weeks in liquid media and 8 weeks in solid media, also pose concern-eg, such delays can result in students missing the beginning of the academic year or skilled migrants being delayed in starting work. New rapid tests with high sensitivity (eg, GeneXpert MTB/RIF system) are available and could potentially reduce these delays, but these tests should be assessed in the operational setting of pre-entry screening and compared with traditional culture methods before being widely rolled out.…”

Health profile of pediatric Special Immigrant Visa holders arriving from Iraq and Afghanistan to the United States, 2009–2017: A cross-sectional analysis

“…Due to the subjectivity of TST readings, LTBI may not have been identified among children with no other signs or symptoms of tuberculosis; however, the requirement of overseas IGRA testing may improve LTBI identification in the future. Additionally, this required change overseas may reduce both the time and financial burden required for LTBI follow-up conducted by state and local health departments [10][11][12][13].…”

Effectiveness and cost-effectiveness of screening migrants for active tuberculosis and latent tuberculous infection

“…reported even higher numbers of TB cases averted in their model, 157 cases annually, through pre-entry screening among students from China and India studying in the USA (41). Most cross-sectional studies analysing on-entry screening for migrant sub-populations are relatively smallscale, focus on the target population and do not analyse the impact on incidence (table 1).…”

“…Furthermore, the generalisability of such findings may be limited. The outcome of interest is also heterogeneous -ranging from a simple cost analysis (43)to the cost per number of detected cases (41). The findings are often very context specific and cost effectiveness is estimated from a health system perspective.…”