Optimizing Latent Tuberculosis Treatment Strategies Among Immigrants From High-Burden Settings
Discuss this preprint
Start a discussion What are Sciety discussions?Listed in
This article is not in any list yet, why not save it to one of your lists.Abstract
Importance
Tuberculosis preventive therapy is central to reducing tuberculosis, and foreign-born individuals account for most US tuberculosis cases. Current US Preventive Services Task Force guidance recommends testing and treating all foreign-born individuals regardless of age or time since immigration, yet the risks of disease progression and of treatment-related harm are not uniform across these groups.
Objective
To evaluate the cost-effectiveness and health outcomes of tuberculosis infection treatment strategies among immigrants from high-burden settings, stratified by age and time since immigration.
Design
Decision analytical model using individual-level microsimulation (Markov model) over a 30-year horizon, with deterministic and probabilistic (second-order Monte Carlo) sensitivity analyses. Costs and outcomes were discounted at 3%.
Setting
US federally funded tuberculosis clinic care (healthcare-sector perspective), using observed data from the Boston Medical Center/Boston Public Health Commission tuberculosis clinic and published literature.
Participants
A simulated cohort of 10 000 IGRA-positive, foreign-born adults from high tuberculosis incidence settings (excluding immunosuppressed individuals), modeled as recent or remote (immigrated 25 years earlier) immigrants at ages 35 and 65 years.
Interventions
Rifampin daily for 4 months, isoniazid daily for 9 months, or no preventive therapy.
Main Outcomes and Measures
Costs, disability-adjusted life-years (DALYs), incident tuberculosis cases and deaths, treatment completion, and incremental cost-effectiveness ratios (ICERs), with the proportion of simulations in which each strategy was optimal at a willingness-to-pay threshold of $50 000 per DALY averted.
Results
Among recent immigrants, rifampin was the dominant strategy at ages 35 and 65 years (optimal in 88.5% and 93.9% of simulations), yielding the fewest tuberculosis cases (119.44 and 82.31 per 10 000) and the highest treatment completion (71.4% and 67.7%). Among remote immigrants, rifampin remained the dominant strategy (optimal in 53.41% of simulations), followed by no treatment. In older remote immigrants, no treatment was optimal in 94.7% of simulations. ICERs for treatment vs no treatment were unfavorable ($193 600 and $412 857 per DALY averted for rifampin and isoniazid, respectively, at age 65).
Conclusions and Relevance
In this decision analytical model, rifampin was cost-effective for recent immigrants, whereas no treatment was optimal for older remote immigrants. Age and time since immigration may help risk-stratify tuberculosis infection treatment and reduce unnecessary treatment in lower-risk populations.
Key Points
Question
Among immigrants from high–tuberculosis-burden settings with a positive interferon-gamma release assay (IGRA), how do rifampin, isoniazid, and no preventive therapy compare in cost effectiveness across age and time since immigration?
Findings
In this decision analytical model of 10 000 simulated immigrants, rifampin was the optimal strategy for recent immigrants at ages 35 and 65 years (optimal in 88.5% and 93.4% of simulations), whereas no treatment was optimal for older immigrants who had immigrated 25 years earlier (94.7% at age 65).
Meaning
Age and time since immigration may inform tuberculosis infection treatment decisions and reduce unnecessary treatment in lower-risk immigrants.
