title: Tuberculosis screening of immigrants to low-prevalence countries. A cost-effectiveness analysis.
abstract: All adult immigrant applicants to Canada undergo chest radiographic screening for tuberculosis (TB). Tuberculin skin testing could reduce the number of chest X-rays, and identify more candidates for prophylaxis. We modeled the cost-effectiveness of chest radiography and tuberculin skin testing for TB prevention over a 20-yr time frame, among three simulated cohorts of 20-yr-old immigrants. Compared with no screening, radiographic screening prevented 4.3% of expected active TB cases in the highest risk cohort (50% TB-infected, 10% human immunodeficiency virus [HIV] seroprevalence), and 8.0% in the lowest risk cohort (5% TB-infected, 1% HIV seroprevalence). Tuberculin skin testing further reduced the expected incidence 8.0% and 4.0%, respectively. Compared with no screening, radiographic screening cost $3,943 Canadian per active TB case prevented in the highest risk cohort, and $236,496 per case prevented in the lowest risk group. Compared with radiographic screening, mass tuberculin skin testing cost $32,601 per additional case prevented in the highest risk group, and $68,799 per additional case prevented in the lowest risk group. Chest radiographic screening of young immigrants from countries with a high prevalence of TB is a relatively inexpensive means of TB prevention. Tuberculin skin testing is considerably less cost-effective. For immigrants from low-prevalence countries, both interventions are extremely costly with negligible impact. The cost-effectiveness of either strategy would be greatly enhanced by increased adherence to chemoprophylaxis recommendations. Radiographic screening of groups with a high prevalence of tuberculous infection will then likely save money.
authors.affiliation: Respiratory Division, McGill University Health Centre, and Respiratory Epidemiology Unit, McGill University, Montreal, Quebec, Canada. kevins@meakins.lan.mcgill.ca
authors.forename: K
authors.initials: K
authors.lastname: Schwartzman
authors.forename: D
authors.initials: D
authors.lastname: Menzies
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control; D000328:Adult; D002170:Canada; D003362:Cost-Benefit Analysis; D003430:Cross-Sectional Studies; D004641:Emigration and Immigration / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008400:Mass Chest X-Ray / Q000191:economics; D008403:Mass Screening / Q000191:economics; D014374:Tuberculin Test / Q000191:economics; D014397:Tuberculosis, Pulmonary / Q000191:economics / Q000453:epidemiology* / Q000517:prevention & control