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Background We hypothesized that investments to improve the control of tuberculosis in selected high-incidence countries would prove to be cost saving for the United States by reducing the incidence of the disease among migrants.
Methods Using decision analysis, we estimated tuberculosis-related morbidity, mortality, and costs among legal immigrants and refugees, undocumented migrants, and temporary visitors from Mexico after their entry into the United States. We assessed the current strategy of radiographic screening of legal immigrants plus current tuberculosis-control programs alone and with the addition of either U.S.-funded expansion of the strategy of directly observed treatment, short course (DOTS), in Mexico or tuberculin skin testing to screen legal immigrants from Mexico. We also examined tuberculosis-related outcomes among migrants from Haiti and the Dominican Republic using the same three strategies.
Results As compared with the current strategy, expanding the DOTS program in Mexico at a cost to the United States of $34.9 million would result in 2591 fewer cases of tuberculosis in the United States, with 349 fewer deaths from the disease and net discounted savings of $108 million over a 20-year period. Adding tuberculin skin testing to radiographic screening of legal immigrants from Mexico would result in 401 fewer cases of tuberculosis in the United States but would cost an additional $329 million. Expansion of the DOTS program would remain cost saving even if the initial investment were doubled, if the United States paid for all antituberculosis drugs in Mexico, or if the decline in the incidence of tuberculosis in Mexico was less than projected. A $9.4 million investment to expand the DOTS program in Haiti and the Dominican Republic would result in net U.S. savings of $20 million over a 20-year period.
Conclusions U.S.-funded efforts to expand the DOTS program in Mexico, Haiti, and the Dominican Republic could reduce tuberculosis-related morbidity and mortality among migrants to the United States, producing net cost savings for the United States.
Source Information
From the Respiratory Epidemiology Unit, Montreal Chest Institute (K.S., O.O., D.M.), and the Department of Economics (F.G.), McGill University, Montreal; the Departments of Medicine and Epidemiology, Columbia University Medical Center, New York (R.G.B.); the National Tuberculosis Control Program, Santo Domingo, Dominican Republic (I.A., R.E.M.); Centro Nacional de Investigaciones en Salud Materno Infantil, Santo Domingo, Dominican Republic (J.B.); the National Tuberculosis Action Program, Mexico City, Mexico (E.F., A.C.S.); the National Tuberculosis Control Program, Port-au-Prince, Haiti (W.M., V.J.); the Divisions of Global Migration and Quarantine (S.M.) and Tuberculosis Elimination (K.L.), Centers for Disease Control and Prevention, Atlanta; and the World Health Organization, Geneva (A.P.M.).
Address reprint requests to Dr. Menzies at the Respiratory Epidemiology Unit, Montreal Chest Institute, 3650 St. Urbain, Rm. K1.24, Montreal, QC H2X 2P4, Canada, or at dick.menzies{at}mcgill.ca.
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