title: A cost-benefit analysis of a proposed overseas refugee latent tuberculosis infection screening and treatment program.
abstract: BACKGROUND
  This 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.
  
  
  METHODS
  Costs 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.
  
  
  RESULTS
  For 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).
  
  
  CONCLUSIONS
  Implementing 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.
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, USA. latewing@gmail.com.
authors.forename: La'Marcus T
authors.initials: LT
authors.lastname: Wingate
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, USA. zby5@cdc.gov.
authors.forename: Margaret S
authors.initials: MS
authors.lastname: Coleman
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, USA. ije7@cdc.gov.
authors.forename: Christopher
authors.initials: C
authors.lastname: de la Motte Hurst
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, USA. msemple09@jcu.edu.
authors.forename: Marie
authors.initials: M
authors.lastname: Semple
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, USA. waz6@cdc.gov.
authors.forename: Weigong
authors.initials: W
authors.lastname: Zhou
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, USA. mzc4@cdc.gov.
authors.forename: Martin S
authors.initials: MS
authors.lastname: Cetron
authors.affiliation: Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA, USA. bzp3@cdc.gov.
authors.forename: John A
authors.initials: JA
authors.lastname: Painter
mesh_terms: D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004641:Emigration and Immigration; D005260:Female; D006801:Humans; D038622:Internationality; D055985:Latent Tuberculosis / Q000175:diagnosis / Q000191:economics / Q000453:epidemiology / Q000628:therapy; D008297:Male; D008403:Mass Screening / Q000191:economics* / Q000379:methods; D015995:Prevalence; D012036:Refugees; D014376:Tuberculosis; D014481:United States