Domestic returns from investment in the control of tuberculosis in other countries

N Engl J Med. 2005 Sep 8;353(10):1008-20. doi: 10.1056/NEJMsa043194.


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 dollars 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 dollars 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 dollars. 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 dollars investment to expand the DOTS program in Haiti and the Dominican Republic would result in net U.S. savings of 20 million dollars 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.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antitubercular Agents / economics
  • Antitubercular Agents / therapeutic use
  • Cost Savings
  • Decision Support Techniques
  • Directly Observed Therapy / economics*
  • Dominican Republic
  • Emigration and Immigration*
  • Haiti
  • Health Care Costs
  • Humans
  • Incidence
  • International Cooperation*
  • Investments
  • Lung / diagnostic imaging*
  • Markov Chains
  • Mass Screening*
  • Mexico / epidemiology
  • Models, Economic
  • Radiography, Thoracic / economics
  • Tuberculin Test / economics*
  • Tuberculosis, Pulmonary / diagnosis
  • Tuberculosis, Pulmonary / economics
  • Tuberculosis, Pulmonary / mortality
  • Tuberculosis, Pulmonary / prevention & control*
  • United States / epidemiology


  • Antitubercular Agents