Priorities for screening and treatment of latent tuberculosis infection in the United States

Am J Respir Crit Care Med. 2011 Sep 1;184(5):590-601. doi: 10.1164/rccm.201101-0181OC.


Rationale: To improve the effectiveness of tuberculosis (TB) control programs in the United States by identifying cost-effective priorities for screening for latent tuberculosis infection (LTBI).

Objectives: To estimate the cost-effectiveness of LTBI screening using the tuberculin skin test (TST)and interferon-g release assays (IGRAs).

Methods: A Markov model of screening for LTBI with TST and IGRA in risk-groups considered in current LTBI screening guidelines.

Measurements and main results: In all risk-groups, TST and IGRA screening resulted in increased mean life expectancy, ranging from 0.03–0.24 life-months per person screened. IGRA screening resulted in greater life expectancy gains than TST. Screening always cost more than not screening, but IGRA was cost-saving compared with TST in some groups. Four patterns of cost-effectiveness emerged, related to four risk categories. (1) Individuals at highest risk of TB reactivation (close contacts and those infected with HIV): the incremental cost-effectiveness ratio (ICER) of IGRA compared with TST was less than $100,000 per quality-adjusted life year (QALY) gained. (2) The foreign-born: IGRA was cost-saving compared with TST and cost-effective compared with no screening (ICER ,$100,000 per QALY gained). (3) Vulnerable populations (e.g., homeless, drug user, or former prisoner): the ICER of TST screening was approximately $100,000–$150,000 per QALY gained, but IGRA was not cost-effective. (4) Medical comorbidities (e.g., diabetes): the ICER of screening with TST or IGRA was greater than $100,000 per QALY.

Conclusions: LTBI screening guidelines could make progress toward TB elimination by prioritizing screening for close contacts, those infected with HIV, and the foreign-born regardless of time living in the United States. For these groups, IGRA screening was more cost-effective than TST screening.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Child
  • Contact Tracing / economics
  • Contact Tracing / methods
  • Cost Savings
  • Cost-Benefit Analysis
  • Female
  • Humans
  • Incidence
  • Interferon-gamma / metabolism
  • Latent Tuberculosis / diagnosis
  • Latent Tuberculosis / epidemiology*
  • Latent Tuberculosis / therapy
  • Male
  • Mass Screening* / economics
  • Mass Screening* / methods
  • Mass Screening* / standards
  • Middle Aged
  • Models, Economic*
  • Morbidity / trends
  • Practice Guidelines as Topic
  • Prevalence
  • Quality-Adjusted Life Years
  • Retrospective Studies
  • Tuberculin Test / economics*
  • United States / epidemiology
  • Young Adult


  • Interferon-gamma