The potential effect of a geographically focused intervention against tuberculosis in the USA: a simulation modelling study

BACKGROUND: In the USA, major disparities in tuberculosis incidence and mortality persist, particularly among historically disadvantaged racial and ethnic populations. We aimed to estimate the potential effect of an intervention to identify and treat latent tuberculosis infection in US counties with a high burden of tuberculosis among racially minoritised populations. METHODS: In this simulation modelling study, the intervention consisted of a one-time targeted testing and treatment for latent tuberculosis for three populations at elevated risk of tuberculosis: people born outside the USA, people living with HIV, and people experiencing homelessness. The first step (county targeting) limited the intervention to counties with high tuberculosis incidence among racially minoritised people. The second step (individual targeting) offered the intervention to all people with selected risk factors included in US latent tuberculosis infection testing and treatment guidelines, regardless of race or ethnicity. A Markov cohort model was used to simulate lifetime health and economic outcomes under the intervention and status quo scenarios using 2011-19 tuberculosis surveillance data and published literature. FINDINGS: We designated 157 counties as intervention counties. The intervention was estimated to avert 17 359 (95% uncertainty interval 8853-32 315) tuberculosis cases and 2700 (1207-5189) tuberculosis deaths over the lifetime of the people receiving the intervention. It was estimated to lead to 14 951 (7087-28 098) quality-adjusted life-years (QALYs) gained at a cost of $86 177 (42 458-156 927; 2022 US$) per QALY gained. Compared with the status quo projection (continuation of current practices), the intervention scenario was associated with a 2·8% (1·3-5·6) reduction in the tuberculosis incidence rate ratio for racially minoritised people relative to White people during 2025-40 and a 5·5% (2·6-10·6) reduction in the incidence rate difference. INTERPRETATION: The intervention was estimated to have a large overall effect on health and a small but statistically significant effect on racial and ethnic disparities. Sustainable progress will require complementary initiatives that address structural determinants beyond access to testing and treatment. FUNDING: US Centers for Disease Control and Prevention.