---
title: "Impact of Post‑TB Consequences on Effectiveness and Cost‑effectiveness of Immigrant TB Prevention"
id: "cdc-emerging-infectious-diseases-journal-0-posttuberculosis-consequences-on-tuberculosis-prevention-effectiveness-and-cost"
canonical_url: "https://medichelpline.com/clinical-feed/cdc-emerging-infectious-diseases-journal-0-posttuberculosis-consequences-on-tuberculosis-prevention-effectiveness-and-cost"
content_type: "clinical_feed_article"
specialty: "Infectious Disease"
source_name: "CDC Emerging Infectious Diseases Journal"
source_url: "https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article"
published_at: "2026-08-17T04:00:00.000Z"
evidence_level: "Agency Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Impact of Post‑TB Consequences on Effectiveness and Cost‑effectiveness of Immigrant TB Prevention
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/cdc-emerging-infectious-diseases-journal-0-posttuberculosis-consequences-on-tuberculosis-prevention-effectiveness-and-cost
- **Specialty:** [Infectious Disease](https://medichelpline.com/clinical-feed/infectious-disease.md)
- **Primary Source:** CDC Emerging Infectious Diseases Journal
- **Source URL:** [Original Journal Publication](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article)
- **Published At:** 2026-08-17T04:00:00.000Z
- **Evidence Rating:** Agency Feed
## Executive GIST (TL;DR)
- This modelling study evaluated how including **post‑TB consequences** (long‑term illness, healthcare use, and death after TB treatment) affects estimated effectiveness and cost‑effectiveness of tuberculosis (TB) prevention among new immigrants to Canada. - The authors used a Markov microsimulation of 400,000 persons arriving in 2025, structured by age and country of origin, and compared current postarrival screening (0.5% coverage) with a scaled program reaching 68% coverage. - Screening used the tuberculin skin test and preventive therapy was 4 months of daily **rifampin**; 68% participation for the intervention was assumed based on other immigrant follow‑up adherence data. - Analyses used a 25‑year horizon and a 1.5% annual discount rate and took a TB services perspective for costs (all in 2023 CAD). - Including long‑term TB consequences increased estimated TB‑related QALYs lost by 2.1‑fold (95% uncertainty range 1.7–2.5) compared with modelling only acute consequences. - When long‑term consequences were included, the estimated QALYs gained from expanded screening increased 2.4‑fold (95% uncertainty range 1.6–4.4), lowering the cost per QALY from CAD $235,088 to CAD $100,742. - The study highlights that nearly all previous cost‑effectiveness analyses omit post‑TB morbidity and mortality, which can substantially underestimate benefits of **TB infection screening** and **TB preventive treatment (TPT)** among migrants. - Context: Canada reported 2,508 TB cases in 2024 (incidence 6.1/100,000), and 83% of TB cases were born outside Canada; currently only 0.5% of at‑risk new immigrants receive postarrival screening. - Model inputs were drawn from systematic reviews, high‑quality trials, Canadian surveillance and costing data; acute QALY loss parameter used an annualized loss of 0.057 (excluding death). - Authors conclude that future evaluations of preventive interventions should incorporate post‑TB consequences because ignoring them substantially underestimates effectiveness and cost‑effectiveness.
## Clinical Analysis & Structured Key Points
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[EID Journal](https://wwwnc.cdc.gov/eid/) 2. [Volume 32](https://wwwnc.cdc.gov/eid/early-release) 3. [Early Release](https://wwwnc.cdc.gov/eid/early-release#issue-1345) 4. [Main Article](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article) * [Facebook](https://www.facebook.com/sharer/sharer.php?u=%2Feid%2Farticle%2F32%2F9%2F26-0473_article "Share to Facebook") * [Twitter](http://twitter.com/share?url=%2Feid%2Farticle%2F32%2F9%2F26-0473_article&text= "Share to Twitter") * [LinkedIn](https://www.linkedin.com/shareArticle?url=%2Feid%2Farticle%2F32%2F9%2F26-0473_article&title= "Share to LinkedIn") * [Syndicate](https://tools.cdc.gov/medialibrary/index.aspx#/sharecontent//eid/article/32/9/26-0473_article "Embed this Page") [ Emerging Infectious Disease journal ISSN: 1080-6059 ](https://wwwnc.cdc.gov/eid/) _Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released._ #### Volume 32, Number 9—September 2026 ##### _Research_ ### Posttuberculosis Consequences on Tuberculosis Prevention Effectiveness and Cost-effectiveness among New Immigrants, Canada On This Page [Methods](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article) * * * [Results](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article) * * * [Discussion](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article) * * * [Suggested Citation](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article) Figures [Figure](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-f1) Tables [Table 1](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-t1) * * * [Table 2](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-t2) * * * [Table 3](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-t3) Downloads [Appendix ](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-app1.pdf) * * * [RIS [TXT - 2 KB] ](https://wwwnc.cdc.gov/eid/article/32/9/26-0473.ris) Article Metrics [Metric Details](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article) Related Articles [Pediatric Tuberculosis Care Outcomes in a Tertiary Care Center, France, 2014–2024](https://wwwnc.cdc.gov/eid/article/32/9/26-0600_article) * * * [_Mycobacterium abscessus_ in Hospital, Maryland](https://wwwnc.cdc.gov/eid/article/32/9/26-0093_article) * * * [Books and Media](https://wwwnc.cdc.gov/eid/article/32/8/26-0497_article) * * * [More articles on Tuberculosis](https://wwwnc.cdc.gov/eid/spotlight/tuberculosis) Aotikuer Ainiwaer, Aashna Uppal, Kevin Schwartzman, Kamila Romanowski, Sarah K. Brode, James C. Johnston, and Jonathon R. Campbell[![Comments to Author](https://wwwnc.cdc.gov/eid/content/images/icon/email.gif)](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#comment) Author affiliation: McGill University, Montreal, Quebec, Canada (A. Ainiwaer, K. Schwartzman, J.R. Campbell); University of Oxford, Oxford, UK (A. Uppal); Research Institute of the McGill University Health Centre, Montreal (K. Schwartzman, J.R. Campbell); McGill International TB Centre, Montreal (K. Schwartzman, J.R. Campbell); University of British Columbia, Vancouver, British Columbia, Canada (K. Romanowski, J.C. Johnston); British Columbia Centre for Disease Control, Vancouver (K. Romanowski, J.C. Johnston); University of Toronto, Toronto, Ontario, Canada (S.K. Brode); West Park Healthcare Centre, Toronto (S.K. Brode) [Suggested citation for this article](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#suggestedcitation) ### Abstract Cost-effectiveness analyses of tuberculosis (TB) preventive treatment rarely consider long-term TB consequences. We examined how long-term TB consequences influence the effectiveness and cost-effectiveness of TB prevention among persons who immigrate to Canada. By using a Markov microsimulation model of 400,000 persons immigrating to Canada in 2025, we compared current postarrival TB infection screening levels (0.5%) with a screening level of 68% among new immigrants. Modelling scenarios included acute TB consequences and long-term TB-related death, illness, and healthcare costs (25-year horizon, 1.5% discount rate). Including long-term TB-related consequences increased the estimated TB-related quality-adjusted life years (QALYs) lost by 2.1-fold (95% uncertainty range 1.7–2.5-fold). When long-term TB-related consequences were included, estimated QALYs gained from expanded screening increased 2.4-fold (95% uncertainty range 1.6–4.4-fold), reducing the cost per QALY from $235,088 to $100,742 CAD. Ignoring long-term TB consequences substantially underestimates the effectiveness and cost-effectiveness of preventive interventions; such consequences should be incorporated into future evaluations. Tuberculosis (TB) is the world’s leading cause of death from a single infectious agent, killing an estimated 1.23 million persons worldwide in 2024 ([_1_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r1 "1")). Shifts in global migration patterns have changed the epidemiologic landscape for TB in low-incidence regions, and migrant populations bear disproportionately high TB effects ([_2_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r2 "2")). In migrant populations, most TB disease occurs from the progression of TB infection acquired before immigration ([_3_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r3 "3")). Therefore, providing TB preventive treatment (TPT) to persons who recently immigrated should be considered among other TB elimination strategies ([_4_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r4 "4")). However, results of cost-effectiveness analyses evaluating systematic screening and treatment for TB infection among persons who recently immigrated to low-incidence settings have been mixed ([_5_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r5 "5"),[_6_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r6 "6")), and the implementation of such programs is rare ([_7_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r7 "7")). Also, there is substantial variability in how existing studies consider the risks and consequences of TB disease and TPT ([_8_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r8 "8")). Nearly all studies only consider the acute consequences (disease and death) of TB during the treatment period, omitting the long-term illness and death associated with post-TB consequences ([_9_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r9 "9")). However, emerging research has highlighted that healthcare utilization spikes in the years after TB treatment ([_10_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r10 "10")), and TB survivors are at substantially higher risk for illness and death compared with those who never had TB ([_11_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r11 "11"),[_12_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r12 "12")). Failure to account for the long-term consequences of TB disease might underestimate the quality-adjusted life years (QALYs) gained and cost-effectiveness of TB infection screening and TPT. A global analysis of disability-adjusted life years associated with TB suggests post-TB consequences account for half of the total TB-related health issues ([_9_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r9 "9")). Similarly, an analysis of a hypothetical preventive intervention in high-incidence, low-middle-income settings found considering post-TB consequences substantially reduced estimated incremental cost-effectiveness ratios (ICERs) ([_13_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r13 "13")). However, those analyses were only illustrative and focused primarily on low-middle-income settings. Understanding how post-TB consequences might inform public health decisions in a low-incidence, high-income setting would be useful. We conducted a modeling analysis to evaluate how post-TB consequences might affect effectiveness and cost-effectiveness of TB prevention among persons who recently immigrated to Canada. We model how incorporating post-TB health consequences affects QALYs lost because of TB and the cost-effectiveness of TB prevention programs under different assumptions. ### Methods ##### Setting and Model Overview Canada is a low TB incidence country, reporting 2,508 persons with TB disease in 2024, corresponding to an incidence of 6.1/100,000 population ([_14_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r14 "14")). Overall, 83% of all persons with TB in Canada were born outside the country; most of those persons are now permanent residents and citizens of Canada ([_15_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r15 "15")). Currently, the Canada immigration medical exam focuses on detection of TB disease before entry into Canada. No provincial or territorial programs provide systematic screening and treatment for TB infection for all recently immigrated persons ([_16_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r16 "16")), and only 0.5% of persons with clinical risk factors for TB receive screening ([_17_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r17 "17")). Because of that context, we developed a microsimulation model to evaluate the costs, effectiveness, and cost-effectiveness of a systematic postarrival TB infection screening program in persons who recently and permanently migrated to Canada. We adapted a Markov microsimulation model by using TreeAge Pro Healthcare 2025 (TreeAge Software, LLC, [External Link](https://www.treeage.com)) (A. Uppal et al., unpub. data). Canada immigration targets for 2025 were 395,000 persons ([_18_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r18 "18")). We rounded that target to 400,000 persons and simulated a hypothetical cohort structured according to the age and country of origin of new permanent residents of Canada in 2024 ([_19_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r19 "19")). We used a previous modeling study to estimate the prevalence of TB infection among persons who recently immigrated to Canada, according to age and TB incidence in country of origin ([Appendix](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-app1.pdf) Table 1). We estimated the risk for progression to TB disease by using the Public Health Agency of Canada data detailing time to development of TB disease after immigration ([Appendix](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-app1.pdf)) ([_15_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r15 "15")). The model compares the existing level of TB infection screening and treatment among persons who recently immigrated to Canada (status quo) with a scaled-up TB infection screening and treatment program (intervention). In the intervention strategy, all new permanent residents whose country of origin has an annual TB incidence of >50/100,000 persons would be asked to participate in TB infection screening after arrival in Canada. If the person tested positive for TB infection, they would be given TPT. We assumed 68% of persons would comply with the request on the basis of adherence evidence from other postarrival follow-up activities among immigrants ([_20_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r20 "20")). In both status quo and intervention strategies, the tuberculin skin test is used for screening, and 4 months of daily rifampin is the TPT regimen ([_21_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r21 "21")). A simplified model structure, including health states, is provided ([Appendix](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-app1.pdf) Figure 1). The primary outcomes were QALYs, TB episodes, TB deaths, and TB-related costs accrued over the 25-year time horizon for both strategies. We took a TB services perspective for this analysis. All outcomes were discounted at a rate of 1.5% per annum, in line with recommendations from Canada ([_22_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r22 "22")). ##### Model Parameters Whenever possible, we used systematic reviews and, if unavailable, high quality randomized trials and data from Canada to source all model parameters and set their distributions for probabilistic analysis ([Table 1](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-t1); [Appendix](https://wwwnc.cdc.gov/eid/article/32/9/26-0473-app1.pdf) Table 2). Most costs associated with TB came from a pan-Canada costing study ([_23_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r23 "23")). All cost parameters are expressed in 2023 Canadian dollars; we used consumer price indices to inflate costs to this year. We parameterized QALYs lost during acute TB consequences by using an estimated annualized loss of 0.057 (excluding death) ([_24_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r24 "24")) and age-specific risk for death during acute TB by using surveillance data from Canada ([_15_](https://wwwnc.cdc.gov/eid/article/32/9/26-0473_article#r15 "15")
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