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Treating latent TB in immigrants. (Bottom Line).

Identification of latent TB infections in immigrants to the United States and subsequent treatment with isoniazid is generally the best way to save money and reduce the number of cases of active TB, said Dr. Kamran Khan of Cornell University and Columbia University, New York, and associates.

The optimal strategy for detecting and treating latent TB infections in immigrants from the developing world should involve treatments that correspond to each immigrant's former nation or geographic region. With few exceptions, isoniazid therapy results in both health benefits and financial savings, the researchers said (N. Engl. J. Med. 347[23]: 1850-59, 2002).

The researchers' model predicted that the use of this strategy would avoid about 9,000-10,000 active cases of TB during a single year. (See table.) This approach would save $60 million to $90 million over the immigrants' lifetimes; about half of thc savings would accrue in the first 6 years.

Isoniazid treatment would save money over the long term--by averting cases of active TB and gaining quality-adjusted life years (QALYs)--for immigrants from most developing nations and geographic regions with high rates of TB infections (Mexico; China, South Korea, and other countries in East Asia and the Pacific; India and other South Asian nations; and sub-Saharan Africa).

In those countries and regions, treatment with rifampin plus pyrazinamide would be effective but would cost money rather than save it. Rifampin monotherapy would never be more cost effective than isoniazid or rifampin plus pyrazinamide, Dr. Khan and colleagues said.

For immigrants from Vietnam, the Philippines, and Haiti, however, treatment with rifampin plus pyrazinamide would save more money over the long term than use of isoniazid.

In regions where neither isoniazid nor rifampin plus pyrazinamide would save money (Eastern Europe and Central Asia; Middle East and North Africa; and Latin America and the Caribbean, except for Mexico), it would always be less expensive to use isoniazid than rifampin plus pyrazinamide to avert a case of active TB and to add a QALY.

The projected financial savings may substantially underestimate the true benefits of screening because the model did not include costs from directly observe therapy or from secondary transmission of infection.

The most probable total costs of treating a person for 1 year would be lowest with isoniazid plus pyridoxine ($528) and highest with rifampin plus pyrazinamide ($696).

Dr. Khan is now at the University of Toronto.
Comparison of TB Treatment Strategies *

 Future Active Quality-Adjusted
Treatment TB Cases Life Years Gained

None 13,933 0
Isoniazid 4,342 26,763
therapy ** 3,697 28,562

* Treatment strategies were compared for immigrants from all developing
nations combined.

** Uses the most effective treatment for each region not costing more
than $10,000 per quality-adjusted life year.

Source: N. Engl. J. Med. 347(23): 1850-59, 2002
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Title Annotation:tuberculosis
Author:Evans, Jeff
Publication:Internal Medicine News
Date:Mar 1, 2003
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