Screening for Latent Tuberculosis Infection Among Non–US-Born Adults in the US

Abstract

Preventive care for one of the world's leading infectious disease killers has received a much-needed push forward. In this issue of JAMA, the US Preventive Services Task Force (USPSTF) updates its recommendation to screen asymptomatic adults at increased risk for tuberculosis infection and highlights the critical role of primary care in tuberculosis prevention. The importance of this recommendation, particularly for immigrant communities who bear the disproportionate burden of this disease, cannot be overstated. In the US, more than half of indiv iduals diagnosed w ith tuberculosis are hospitalized, 1,2 and almost 1 in 10 will die of the disease. 3 The toll encompassing survival following tuberculosis treatment reveals that 1 in 5 diagnosed with tuberculosis will die within 5 years. 4 These statistics are grim for a preventable and curable disease. The new USPSTF recommendation, rooted in updated evidence, calls for collective action to provide high-quality tuberculosis preventive care for immigrants and other marginalized populations.While tuberculosis disease can be prevented through screening, testing, and treatment of tuberculosis infection, preventive services have not consistently reached those who need these interventions the most. The distribution of tuberculosis disease in the US reveals striking disparities, with approximately 80% of all cases occurring among racial or ethnic minority populations and approximately 70% occurring in individuals who were born or have lived outside of the US, primarily in countries with a high burden of tuberculosis disease. 5 Non-US-born Asian persons in the US, for example, have more than 70 times the tuberculosis incidence rate of US-born White persons. 3 Unfortunately, screening and testing of the millions of at-risk individuals in immigrant communities estimated to be at risk for latent tuberculosis infection (LTBI) is lagging. These gaps remain, despite growing evidence that tuberculosis prevention cannot only save lives but avert costs. 6 The 2023 USPSTF recommendation emphasizes the importance of screening asymptomatic adults at increased risk of LTBI. While seemingly simple, this recommendation includes several important nuances that, if operationalized, will mitigate gaps in tuberculosis preventive care that inhibit

Losses in the Care Cascade for Latent Tuberculosis Infection in the Tracing Contact Studies

“…The main factors associated with a lower adherence and greater cascade losses were immigrant status and risky alcohol use. Social problems in some groups of immigrants make them more susceptible to treatment non-adherence, as reported by a number of studies [23][24][25][26]. Immigrants thus need to be especially targeted by TB programmes [3,8,27,28], as health provider proactiveness and the direct monitoring of treatment adherence could reduce the corresponding losses in the LTBI care cascade [9].…”

“…Public health services need to address the serious health risks associated with TB and the potential sequelae for the respiratory system [23]. Public health teams and community health agents are crucial in order to, first of all, register all cases of pulmonary TB and any contacts that may be candidates for LTBI screening, and then to ensure that LTBI testing is exhaustive [3,8,9].…”

“…Treatment prescription is also crucial to the goal of ultimately eliminating TB, so public health services need to have clear and explicit protocols in place [23,31] and health providers need to scrupulously apply protocol recommendations. Finally, LTBI-positive contacts receiving treatment need to be followed up in TB control programmes to identify and treat possible side effects and ensure adherence.…”