Domestic returns from investment in the control of tuberculosis in other countries.
BACKGROUND
We hypothesized that investments to improve the control of tuberculosis in selected high-incidence countries would prove to be cost saving for the United States by reducing the incidence of the disease among migrants.


METHODS
Using decision analysis, we estimated tuberculosis-related morbidity, mortality, and costs among legal immigrants and refugees, undocumented migrants, and temporary visitors from Mexico after their entry into the United States. We assessed the current strategy of radiographic screening of legal immigrants plus current tuberculosis-control programs alone and with the addition of either U.S.-funded expansion of the strategy of directly observed treatment, short course (DOTS), in Mexico or tuberculin skin testing to screen legal immigrants from Mexico. We also examined tuberculosis-related outcomes among migrants from Haiti and the Dominican Republic using the same three strategies.


RESULTS
As compared with the current strategy, expanding the DOTS program in Mexico at a cost to the United States of 34.9 million dollars would result in 2591 fewer cases of tuberculosis in the United States, with 349 fewer deaths from the disease and net discounted savings of 108 million dollars over a 20-year period. Adding tuberculin skin testing to radiographic screening of legal immigrants from Mexico would result in 401 fewer cases of tuberculosis in the United States but would cost an additional 329 million dollars. Expansion of the DOTS program would remain cost saving even if the initial investment were doubled, if the United States paid for all antituberculosis drugs in Mexico, or if the decline in the incidence of tuberculosis in Mexico was less than projected. A 9.4 million dollars investment to expand the DOTS program in Haiti and the Dominican Republic would result in net U.S. savings of 20 million dollars over a 20-year period.


CONCLUSIONS
U.S.-funded efforts to expand the DOTS program in Mexico, Haiti, and the Dominican Republic could reduce tuberculosis-related morbidity and mortality among migrants to the United States, producing net cost savings for the United States.
Schwartzman
Kevin
K
Respiratory Epidemiology Unit, Montreal Chest Institute, McGill University, Montreal, QC, Canada.
Oxlade
Olivia
O
Barr
R Graham
RG
Grimard
Franque
F
Acosta
Ivelisse
I
Baez
Jeannette
J
Ferreira
Elizabeth
E
Melgen
Ricardo Elías
RE
Morose
Willy
W
Salgado
Arturo Cruz
AC
Jacquet
Vary
V
Maloney
Susan
S
Laserson
Kayla
K
Mendez
Ariel Pablos
AP
Menzies
Dick
D
D000995:Antitubercular Agents / Q000191:economics / Q000627:therapeutic use; D017046:Cost Savings; D003661:Decision Support Techniques; D023801:Directly Observed Therapy / Q000191:economics*; D004293:Dominican Republic; D004641:Emigration and Immigration; D006205:Haiti; D017048:Health Care Costs; D006801:Humans; D015994:Incidence; D007391:International Cooperation; D007449:Investments; D008168:Lung / Q000000981:diagnostic imaging*; D008390:Markov Chains; D008403:Mass Screening; D008800:Mexico / Q000453:epidemiology; D018803:Models, Economic; D013902:Radiography, Thoracic / Q000191:economics; D014374:Tuberculin Test / Q000191:economics*; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000517:prevention & control*; D014481:United States / Q000453:epidemiology
D000995:Antitubercular Agents