Abstract
<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Importance</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Objective</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Design</jats:title> <jats:p>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%.</jats:p> </jats:sec> <jats:sec> <jats:title>Setting</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Participants</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Interventions</jats:title> <jats:p>Rifampin daily for 4 months, isoniazid daily for 9 months, or no preventive therapy.</jats:p> </jats:sec> <jats:sec> <jats:title>Main Outcomes and Measures</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>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).</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions and Relevance</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec> <jats:title>Key Points</jats:title> <jats:sec> <jats:title>Question</jats:title> <jats:p>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?</jats:p> </jats:sec> <jats:sec> <jats:title>Findings</jats:title> <jats:p>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).</jats:p> </jats:sec> <jats:sec> <jats:title>Meaning</jats:title> <jats:p>Age and time since immigration may inform tuberculosis infection treatment decisions and reduce unnecessary treatment in lower-risk immigrants.</jats:p> </jats:sec> </jats:sec>