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Previous Volume 347:1850-1859 December 5, 2002 Number 23 Next

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ABSTRACT

Background In the United States, an increasingly disproportionate burden of tuberculosis among the foreign-born population has led to calls for improvements in the detection and treatment of latent infection in new immigrants. Current treatment guidelines do not take into account global differences in drug-resistance patterns or their implications for the treatment of immigrants. The use of multinational surveillance systems to guide the management of latent infection according to region-specific drug-resistance profiles could improve the efficiency of efforts to reduce the burden of tuberculosis in immigrants to the United States.

Methods We constructed a decision-analysis model by using a hypothetical cohort of all documented immigrants entering the United States from developing nations. Region-specific drug-resistance profiles were derived from data on 30,388 cases of infection. The model examined the effectiveness and cost effectiveness of four strategies: no intervention or tuberculin skin testing followed by treatment with isoniazid, treatment with rifampin, or treatment with rifampin plus pyrazinamide for those with a positive test result.

Results A strategy of detecting and treating latent tuberculosis infection was cost-saving among immigrants from Mexico, Haiti, sub-Saharan Africa, South Asia, and developing nations in East Asia and the Pacific. This strategy was highly cost effective among immigrants from other developing nations. Rifampin plus pyrazinamide was the preferred strategy for treating latent infection in immigrants from Vietnam, Haiti, and the Philippines.

Conclusions For new immigrants to the United States from developing nations, a strategy of detecting and treating latent tuberculosis infection would lead to substantial health and economic benefits. Because of the high prevalence of resistance to isoniazid, treatment with a rifampin-containing regimen should be strongly considered for immigrants from Vietnam, Haiti, and the Philippines.

Source Information

From the Department of Public Health (K.K.), the Department of Medicine, Division of International Medicine and Infectious Diseases (K.K.), and the Department of Pharmacy (M.B.), New York Presbyterian Hospital and Weill Medical College of Cornell University, New York; the Program in General Public Health (K.K.) and the Department of Health Policy and Management (J.G.Z.), Joseph L. Mailman School of Public Health, and the International Center for Health Outcomes and Innovation Research (J.G.Z.), Columbia University, New York; and the Sophie Davis School of Biomedical Education, City University of New York, New York (P.M.).

Address reprint requests to Dr. Khan at the Inner City Health Research Unit, St. Michael's Hospital, University of Toronto, 30 Bond St., Toronto, ON M5B 1W8, Canada, or at km.khan{at}utoronto.ca.

Full Text of this Article

Related Letters:

Management of Latent Tuberculosis Infection in Immigrants
Marks S. M., Ijaz K., Iademarco M. F., Sterling T., Munsiff S. S., Frieden T. R., Menzies D., Schwartzman K., Jenny-Avital E. R., Khan K., Muennig P., Zivin J. G.
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N Engl J Med 2003; 348:1289-1292, Mar 27, 2003. Correspondence

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