Tuberculosis (TB) notifications in the UK continue to rise due to disease in the foreign-born immigrant population. UK guidelines on immigrant screening have recently been revised but accurate calculation of cost-effectiveness is hampered by a lack of empiric data on the comparative performance of tuberculin skin test (TST) and interferon-γ release-assays (IGRA) in immigrants arriving from countries with varying TB incidence.Methods
Prospective evaluation of TST and two commercially available IGRAs (QuantiFERON Gold in-tube (QFN-GIT) and T-SPOT.TB) in recent immigrants aged =16 years to quantify test positivity, concordance and factors associated with a positive result for all three tests. We computed yields at different incidence thresholds and the relative cost-effectiveness, using a decision-analysis-model stratified by HIV/drug-resistance, of screening using different latent TB infection (LTBI) screening modalities at varying incidence thresholds supplemented with/without port-of-arrival chest radiography.Results
231 immigrants included; median age 29 (IQR 24–37). TST accepted by 80.9%, read in 93.6%; 30.3% positive. QFN-GIT and T-SPOT.TB positive in 16.6% and 22.5% respectively. Positive TST, QFN-GIT and T-SPOT.TB independently associated with increasing TB incidence in immigrants' countries of origin (p=0.008, 0.007 and 0.01 respectively). Implementing current guidance (depending on test) would identify 98%–100% of LTBI but also require 97%–99% of the immigrant cohort to be tested; raising the threshold to 150/100 000 (includes immigrants from Indian Subcontinent) would identify 49%–71% of LTBI but require half the cohort to be screened. The three most cost-effective screening strategies (which were more cost-effective than current guidance) were: no CXR at port-of-entry and screen with single-step QFN-GIT at 250/100 000 (Incremental cost-effective ratio (ICER) £21 565.3/per case averted), no CXR at port-of-entry and screen with single-step QFN-GIT at 150/100 000 (averted additional 7.8 cases of active TB, ICER of £31 867.1/per case averted) and no CXR at port-of-entry and screen with single-step QFN-GIT at 40/100 000 which averted a further 9.4 cases (ICER £34 753.5/per case averted).Conclusions
Immigrant screening in the UK could cost-effectively and safely eliminate mandatory CXR on arrival by emphasising systematic screening for LTBI with single-step IGRA. An intermediate incidence threshold for screening balances the need to identify as much imported LTBI as possible against limited service capacity.