{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"medRxiv"}],"indexed":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T10:46:05Z","timestamp":1785926765560,"version":"3.56.0"},"posted":{"date-parts":[[2026,7,16]]},"group-title":"Health Economics","reference-count":25,"publisher":"openRxiv","license":[{"start":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T00:00:00Z","timestamp":1784160000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"NIH","award":["K01AI167733-01"],"award-info":[{"award-number":["K01AI167733-01"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2026,8,3]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                <jats:sec>\n                  <jats:title>Importance<\/jats:title>\n                  <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>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Objective<\/jats:title>\n                  <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>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Design<\/jats:title>\n                  <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>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Setting<\/jats:title>\n                  <jats:p>US TB and primary care clinics (healthcare-sector perspective), using observed data from the Boston Medical Center\/Boston Public Health Commission tuberculosis clinic and published literature.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Participants<\/jats:title>\n                  <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 non-recent (immigrated 25 years earlier) immigrants at ages 35 and 65 years.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Interventions<\/jats:title>\n                  <jats:p>Rifampin daily for 4 months, isoniazid daily for 9 months, or no preventive therapy.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Main Outcomes and Measures<\/jats:title>\n                  <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>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <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 non-recent immigrants, rifampin remained the dominant strategy (optimal in 53.41% of simulations), followed by no treatment. In 65-year-olds who did not immigrate recently, no treatment was optimal in 94.7% of simulations. ICERs for treatment versus no treatment were unfavorable ($193 600 and $412 857 per DALY averted for rifampin and isoniazid, respectively, at age 65).<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Conclusions and Relevance<\/jats:title>\n                  <jats:p>In this decision analytical model, rifampin was cost-effective for recent immigrants, whereas no treatment was optimal for older immigrants with remote arrival date. Age and time since immigration may help risk-stratify tuberculosis infection treatment and reduce unnecessary treatment in lower-risk populations.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Key Points<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Question<\/jats:title>\n                    <jats:p>Among immigrants from high\u2013tuberculosis-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>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Findings<\/jats:title>\n                    <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>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Meaning<\/jats:title>\n                    <jats:p>Age and time since immigration may inform tuberculosis infection treatment decisions and reduce unnecessary treatment in lower-risk immigrants.<\/jats:p>\n                  <\/jats:sec>\n                <\/jats:sec>","DOI":"10.64898\/2026.07.13.26357974","type":"posted-content","created":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T21:20:49Z","timestamp":1784236849000},"source":"Crossref","is-referenced-by-count":0,"title":["Optimizing Latent Tuberculosis Treatment Strategies Among Immigrants From High-Burden Settings"],"prefix":"10.64898","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-4704-4778","authenticated-orcid":false,"given":"Alexa","family":"Tabackman","sequence":"first","affiliation":[{"name":"Section of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meagan","family":"Karoly","sequence":"additional","affiliation":[{"name":"Boston Medical Center, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4239-3685","authenticated-orcid":false,"given":"Karen R.","family":"Jacobson","sequence":"additional","affiliation":[{"name":"Boston Medical Center, Boston, Massachusetts"},{"name":"Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"suffix":"Jr.","given":"C. Robert","family":"Horsburgh","sequence":"additional","affiliation":[{"name":"Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts"},{"name":"Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benjamin","family":"Linas","sequence":"additional","affiliation":[{"name":"Boston Medical Center, Boston, Massachusetts"},{"name":"Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey","family":"Campbell","sequence":"additional","affiliation":[{"name":"Section of Pediatric Infectious Diseases, Boston Medical Center"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlos","family":"Acu\u00f1a-Villaordu\u00f1a","sequence":"additional","affiliation":[{"name":"Boston Medical Center, Boston, Massachusetts"},{"name":"Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pranay","family":"Sinha","sequence":"additional","affiliation":[{"name":"Boston Medical Center, Boston, Massachusetts"},{"name":"Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts"},{"name":"Center on Emerging Infectious Diseases, Boston University, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"54368","reference":[{"key":"2026080503050732000_2026.07.13.26357974v2.1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1002152"},{"key":"2026080503050732000_2026.07.13.26357974v2.2","doi-asserted-by":"publisher","DOI":"10.1093\/aje\/kwy094"},{"key":"2026080503050732000_2026.07.13.26357974v2.3","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(15)00323-2"},{"key":"2026080503050732000_2026.07.13.26357974v2.4","unstructured":"Clinical Overview of Latent Tuberculosis Infection | Tuberculosis (TB) | CDC. https:\/\/www.cdc.gov\/tb\/hcp\/clinical-overview\/latent-tuberculosis-infection.html. Accessed March 11, 2025."},{"key":"2026080503050732000_2026.07.13.26357974v2.5","doi-asserted-by":"publisher","DOI":"10.1093\/aje\/kwt246"},{"key":"2026080503050732000_2026.07.13.26357974v2.6","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/ciac248"},{"key":"2026080503050732000_2026.07.13.26357974v2.7","doi-asserted-by":"publisher","DOI":"10.1164\/rccm.201101-0181OC"},{"key":"2026080503050732000_2026.07.13.26357974v2.8","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2023.4899"},{"key":"2026080503050732000_2026.07.13.26357974v2.9","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.k2738"},{"key":"2026080503050732000_2026.07.13.26357974v2.10","doi-asserted-by":"publisher","DOI":"10.1101\/2023.07.03.23292111"},{"key":"2026080503050732000_2026.07.13.26357974v2.11","doi-asserted-by":"publisher","DOI":"10.1097\/EDE.0000000000001271"},{"key":"2026080503050732000_2026.07.13.26357974v2.12","doi-asserted-by":"publisher","DOI":"10.1016\/j.eclinm.2022.101815"},{"key":"2026080503050732000_2026.07.13.26357974v2.13","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.091824"},{"key":"2026080503050732000_2026.07.13.26357974v2.14","doi-asserted-by":"publisher","DOI":"10.1164\/rccm.200404-478OC"},{"key":"2026080503050732000_2026.07.13.26357974v2.15","unstructured":"Global Burden of Disease. GBD Results Database 2019. https:\/\/vizhub.healthdata.org\/gbd-results\/. Accessed June 12, 2025."},{"key":"2026080503050732000_2026.07.13.26357974v2.16","doi-asserted-by":"publisher","DOI":"10.7326\/M17-0609"},{"key":"2026080503050732000_2026.07.13.26357974v2.17","doi-asserted-by":"publisher","DOI":"10.5588\/ijtldopen.24.0336"},{"key":"2026080503050732000_2026.07.13.26357974v2.18","doi-asserted-by":"publisher","DOI":"10.5588\/ijtld.25.0237"},{"key":"2026080503050732000_2026.07.13.26357974v2.19","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1714283"},{"key":"2026080503050732000_2026.07.13.26357974v2.20","doi-asserted-by":"publisher","DOI":"10.22037\/ghfbb.v16i1.2685"},{"key":"2026080503050732000_2026.07.13.26357974v2.21","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.rr6901a1"},{"key":"2026080503050732000_2026.07.13.26357974v2.22","doi-asserted-by":"publisher","DOI":"10.7326\/ANNALS-24-00870"},{"key":"2026080503050732000_2026.07.13.26357974v2.23","doi-asserted-by":"publisher","DOI":"10.1007\/s10903-020-01065-8"},{"key":"2026080503050732000_2026.07.13.26357974v2.24","unstructured":"TB by Age Group, Non-U.S.\u2013Born: 1993\u20132024, Tuberculosis (TB) | CDC. https:\/\/www.cdc.gov\/tb-surveillance-report-2024\/data\/age-group-non-us-born.html. Published December 19, 2025. Accessed August 2, 2026."},{"key":"2026080503050732000_2026.07.13.26357974v2.25","doi-asserted-by":"publisher","DOI":"10.5588\/ijtld.25.0629"}],"container-title":[],"original-title":[],"link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.64898\/2026.07.13.26357974","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T10:05:24Z","timestamp":1785924324000},"score":1,"resource":{"primary":{"URL":"http:\/\/medrxiv.org\/lookup\/doi\/10.64898\/2026.07.13.26357974"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,16]]},"references-count":25,"URL":"https:\/\/doi.org\/10.64898\/2026.07.13.26357974","relation":{},"subject":[],"published":{"date-parts":[[2026,7,16]]},"subtype":"preprint"}}