Cost-Effectiveness of Screening and Treating Foreign-Born Students for Tuberculosis before Entering the United States

<div><p>Introduction</p><p>The Centers for Disease Control and Prevention is considering implementation of overseas medical screening of student-visa applicants to reduce the numbers of active tuberculosis cases entering the United States.</p><p>Objective</p><p>To evaluate the costs, cases averted, and cost-effectiveness of screening for, and treating, tuberculosis in United States-bound students from countries with varying tuberculosis prevalence.</p><p>Methods</p><p>Costs and benefits were evaluated from two perspectives, combined and United States only. The combined perspective totaled overseas and United States costs and benefits from a societal perspective. The United States only perspective was a domestic measure of costs and benefits. A decision tree was developed to determine the cost-effectiveness of tuberculosis screening and treatment from the combined perspective.</p><p>Results</p><p>From the United States only perspective, overseas screening programs of Chinese and Indian students would prevent the importation of 157 tuberculosis cases annually, and result in $2.7 million in savings. From the combined perspective, screening programs for Chinese students would cost more than$2.8 million annually and screening programs for Indian students nearly $440,000 annually. From the combined perspective, the incremental cost for each tuberculosis case averted by screening Chinese and Indian students was$22,187 and $15,063, respectively. Implementing screening programs for German students would prevent no cases in most years, and would result in increased costs both overseas and in the United States. The domestic costs would occur because public health departments would need to follow up on students identified overseas as having an elevated risk of tuberculosis.</p><p>Conclusions</p><p>Tuberculosis screening and treatment programs for students seeking long term visas to attend United States schools would reduce the number of tuberculosis cases imported. Implementing screening in high-incidence countries could save the United States millions of dollars annually; however there would be increased costs incurred overseas for students and their families.</p></div

Overseas Parameters in Cost-Effectiveness Model Comparing Programs for Screening and Treating TB in Foreign-Born Student Visa-Applicants.

<p>NA = Not applicable because no cases were detected in German students; TB = Tuberculosis</p><p>A-Suspected TB includes those with abnormal chest radiograph, signs and symptoms of TB, or known HIV infection, and these persons undergo three sputum smears and cultures;</p><p>B-Reflects the proportion seen in the low incidence countries of France and Canada;</p><p>C-Calculated by multiplying number in cohort times % suspected TB times % active disease among those with suspected TB;</p><p>D-Based upon data submitted by panel physicians in China;</p><p>E-Initial TB screening consists of chest radiograph and part of physical examination;</p><p>F-costs not available for German students because the modeled results indicate that no cases would be detected in German students</p><p>Overseas Parameters in Cost-Effectiveness Model Comparing Programs for Screening and Treating TB in Foreign-Born Student Visa-Applicants.</p

Cost per Case Averted from Being Imported into the U.S. when Comparing Two Programs for Treating TB in Foreign-Born Student-Visa Applicants.

<p>TB = Tuberculosis; U.S. = United States</p><p>A- Derived by dividing the additional costs with overseas screening by the cases prevented from being imported into the United States;</p><p>B-Includes costs for treating imported TB cases in the U.S. with no overseas screening;</p><p>C-Includes overseas costs incurred while screening for and treating TB overseas, screening high risk students in the U.S., and treatment of active TB cases occurring in the U.S. after implementing overseas screening and treatment</p><p>Cost per Case Averted from Being Imported into the U.S. when Comparing Two Programs for Treating TB in Foreign-Born Student-Visa Applicants.</p

Cases of TB Diagnosed among Foreign-Born Student-Visa Applicants.

<p>U.S. = United States; TB = Tuberculosis</p><p>A-Class B-1 indicates those who have an abnormal chest radiograph, signs and symptoms of TB, or known HIV infection during overseas screening;</p><p>B-All cases assumed to be imported into U.S. in absence of screening</p><p>Cases of TB Diagnosed among Foreign-Born Student-Visa Applicants.</p

Estimates of incident cases of TB and MDR-TB among newly arrived students/exchange visitors and temporary workers in the United States, 2001–2008.^*

<p>*Newly arrived students/exchange visitors and temporary workers are those who have resided in the United States for up to 1 year after their arrival.</p>†<p>See the <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032158#s2" target="_blank">Methods</a> Section for details of the estimations.</p>‡<p>Values are World Health Organization estimates for 2008.</p>§<p>Countries are listed in descending order, according to the number of estimated incident cases of TB.</p>¶<p>The values for China include those for Hong Kong, Macau, and Taiwan.</p

Estimates of incident cases of TB and MDR-TB among newly arrived immigrants and refugees in the United States, 2001–2008.^*

<p>*Newly arrived immigrants and refugees are those who have resided in the United States for up to 1 year after their arrival.</p>†<p>The number of person-years is the same as the number of admissions, since immigrants and refugees are assumed to stay in the United States for at least 1 year after their arrival.</p>‡<p>See the <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032158#s2" target="_blank">Methods</a> Section for details of the estimations.</p>§<p>Values are World Health Organization estimates for 2008.</p>¶<p>Countries are listed in descending order, according to the estimated number of TB incident cases. Country of citizenship is assumed to be the same as country of birth for immigrants and refugees.</p>#<p>The values for China include those for Hong Kong, Macau, and Taiwan.</p

Estimates of incident cases of TB and MDR-TB among newly arrived tourists and business travelers in the United States, 2001–2008.^*

<p>*Newly arrived tourist and business travelers are those who have resided in the United States for up to 1 year after their arrival.</p>†<p>See the <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032158#s2" target="_blank">Methods</a> section for details of the estimations.</p>‡<p>Values are World Health Organization estimates for 2008.</p>§<p>Countries are listed in descending order, according to the number of estimated incident cases of TB.</p>¶<p>The values for China include those for Hong Kong, Macau, and Taiwan.</p

Estimates of incident cases of TB and MDR-TB among newly arrived foreign-born persons in the United States, 2001–2008.^*

<p>*Newly arrived foreign-born persons are those who have resided in the United States for up to 1 year after their arrival.</p>†<p>See the <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032158#s2" target="_blank">Methods</a> Section for details of the estimations.</p>‡<p>The number of person-years is the same as the number of admissions, since immigrants and refugees are assumed to stay in the United States for at least 1 year after their arrival.</p

Estimated number of TB incident cases per 100,000 admissions among newly arrived foreign-born populations in the United States, 2001–2008.*

<p>* 1) Newly arrived foreign-born persons are those who have resided in the United States for up to 1 year after arrival; 2) low, medium, and high-incidence country are countries of citizenship where the 2008 WHO-estimated TB incidence rate is 0–14 cases, 15–99 cases, and ≥100 cases per 100,000 population per year, respectively; 3) Canadian and Mexican nonimmigrant visitors without an I-94 form (not shown): 0.07 cases/100,000 admissions for those from Mexico, and 0.06 cases/100,000 admissions for those from Canada.</p