title: Flight related tuberculosis contact investigations in the United States: comparative risk and economic analysis of alternate protocols.
abstract: BACKGROUND
  In-flight transmission risk of Mycobacterium tuberculosis is not well defined, although studies suggest it is low. The impact of flight-related tuberculosis (TB) contact investigations (TBCIs) on TB prevention and control is not well established, and they compete for resources with activities with established benefits. We sought to determine the risks and cost-benefits of using more restrictive criteria in comparison to the Centers for Disease Control and Prevention (CDC) 2008 protocol for TBCIs.
  
  
  METHODS
  The risk-benefits of a modified CDC protocol were analyzed in comparison to the 2008 CDC protocol using data from flight-related TBCIs conducted in the United States from 2007 through 2009. We predicted the numbers and characteristics of case-travelers that would be identified using each protocol's criteria, and results of the associated passenger-contacts' TB screening tests. The economic analysis compared the costs of TBCIs to avoided costs of TB treatment and mortality using a Return on Investment model.
  
  
  RESULTS
  The estimated in-flight transmission risk using a modified CDC protocol was 1.4%-19% versus 1.1%-24% for the 2008 protocol. Numbers of TBCIs and immediate costs to health departments were reduced by half. Long-term cost-benefits were comparable.
  
  
  CONCLUSIONS
  CDC's modified protocol appears to be a feasible alternative that will conserve public health resources without jeopardizing the public's health.
authors.affiliation: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic, Infectious Diseases, Division of Global Migration and Quarantine, Atlanta, GA, USA. Electronic address: marienauk@yahoo.com.
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Marienau
authors.affiliation: Global Health Sector, SRA International, Atlanta, GA, USA.
authors.forename: Elaine H
authors.initials: EH
authors.lastname: Cramer
authors.affiliation: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic, Infectious Diseases, Division of Global Migration and Quarantine, Atlanta, GA, USA.
authors.forename: Margaret S
authors.initials: MS
authors.lastname: Coleman
authors.affiliation: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic, Infectious Diseases, Division of Global Migration and Quarantine, Atlanta, GA, USA.
authors.forename: Nina
authors.initials: N
authors.lastname: Marano
authors.affiliation: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic, Infectious Diseases, Division of Global Migration and Quarantine, Atlanta, GA, USA.
authors.forename: Martin S
authors.initials: MS
authors.lastname: Cetron
mesh_terms: D064870:Air Travel; D002487:Centers for Disease Control and Prevention, U.S.; D016358:Contact Tracing / Q000191:economics* / Q000379:methods*; D003362:Cost-Benefit Analysis; D006801:Humans; D018570:Risk Assessment; D057236:Travel Medicine; D014376:Tuberculosis / Q000453:epidemiology / Q000635:transmission*; D014481:United States / Q000453:epidemiology
keywords: Air travel; Contact investigation; Cost–benefit analysis; TB; Transmission risk; Tuberculosis