Roadmap for Advancing TB Elimination in the United States through Scale up of Testing 

and Treatment of Latent TB Infection 

Recommendations of the Advisory Council for the Elimination of Tuberculosis (ACET) 

Prepared by: ACET Latent Tuberculosis Infection Workgroup 

Summary 

This statement from the Advisory Council for the Elimination of Tuberculosis updates the strategy to 

eliminate tuberculosis (TB) in the United States (2, 7). The report provides new recommendations to 

prevent TB, specifically through focus on identifying individuals at risk and testing and treating latent TB 

infection (LTBI). To scale up testing and treatment of latent TB infection, recommendations include: 1) 

identifying and engaging individuals at risk and their providers, 2) encouraging prevention using focused, 

effective testing and treatment strategies, 3) developing streamlined LTBI surveillance and monitoring 

systems to measure and optimize outcomes and 4) securing new funding to support these new 

activities. Effective communication strategies and outreach to affected communities and healthcare 

providers are crucial components for success of each strategy. Research to improve diagnostics and 

treatment and advance vaccine development will also be essential to reach TB elimination. 

BACKGROUND/INTRODUCTION 

The Advisory Council for the Elimination of Tuberculosis (ACET) provides advice and recommendations 

regarding the elimination of tuberculosis to the Health and Human Services (HHS) and the Centers for 

Disease Control and Prevention (CDC). The ACET Latent Tuberculosis Infection (LTBI) Workgroup was 

established to develop a strategy document with concrete recommendations to address latent 

tuberculosis infection (LTBI) with the goal of ultimately eliminating tuberculosis (TB) within the United 

States. 

This report provides a major update to the 1989 Strategic Plan publication (7). In the past 2 decades, the 

epidemiology of TB in the US has changed. To date, strategies to control TB in the United States have 

focused on rapidly finding and treating patients with active TB disease and testing and treating their 

contacts with minimal focus on the larger reservoir of persons with latent TB infection. 

Today untreated LTBI is the main generator of new TB cases in the US and is responsible for a significant 

slowing in the decline of TB disease. Persons with LTBI are not ill and have no clinical evidence 

compatible with TB disease, but can become sick in the future and develop active disease. In 2014, the 

World Health Organization published guidance for the scale up of LTBI testing and treatment in low 

incidence countries. In addition, in 2016, the US Preventive Services Task Force (USPSTF) released 

findings calling for routine LTBI testing and treatment of non-US-born (non-USB) adults and those 

residing in congregate settings (27), yet these recommendations are only slowly being adopted. These 

recent recommendations emerged in tandem with the introduction of a more accurate test for LTBI (the 

interferon-ɣ release assays [IGRAs]) and shorter, safer treatment regimens for LTBI (9, 16). In addition, 

expansion of healthcare access has created new opportunities for care of populations at high-risk for 

LTBI and development of TB disease. While these opportunities can help us advance to TB elimination, 

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
the need for strategies to promote widespread adoption of LTBI testing and treatment requires update 

of the TB elimination roadmap. Scaling up prevention efforts by improving our ability to conduct LTBI 

testing and treatment and measure LTBI outcomes is the focus of this strategy document. 

While modeling studies have suggested we cannot make substantial progress toward eliminating TB 

without an LTBI-focused approach (10), the barriers to LTBI scale-up must first be addressed. Individuals 

with LTBI feel well and may be unaware of their risk of developing TB disease and the benefit of testing 

and treatment, resulting in minimal patient-driven demand for testing and treatment. Although many 

non-USB persons are in routine care, LTBI risk assessment and testing are often overlooked by clinicians 

because of competing health priorities and a knowledge gap related to TB/LTBI. Many healthcare 

providers are unaware of the USPSTF LTBI recommendations and are unclear about who to test and 

treat; they also are unfamiliar with the new and better tests, and the shorter and safer drug regimens 

for treating LTBI. Across healthcare settings, there are currently few systems to help busy physicians 

with LTBI testing and treatment; most electronic health records do not include TB risk factor questions 

as a part of routine health maintenance screening and changing electronic health records (EHRs) to 

include elements important for TB risk assessment, such as country of birth, is not straightforward. 

Public health department resources for LTBI testing and treatment are often meager, and there has 

been no unified effort to promote LTBI testing and treatment scale-up to community providers who care 

for large volumes of high-risk patients. Lack of designated funding and effective local, regional and 

national TB prevention initiatives and LTBI awareness campaigns have impeded public health 

department action. Finally, the complementary roles of public health departments and primary care 

providers in TB prevention have not been well-articulated. As a result, many national and communitybased organizations that support high-risk patients are not yet fully focused on the need for, and 

benefits of, TB prevention. 

Most patient and provider education about LTBI and TB disease has come from health departments and 

academia. While these sources have provided valuable information, they have not always been 

effective. New active strategies are needed that reach out to the target populations, address the needs 

and concerns of high-risk individuals and their healthcare providers and provide practical action steps 

that will lead to engagement in LTBI care. It will be essential to engage key community partners both to 

design new strategies, produce culturally tailored materials and motivate at-risk individuals to seek 

appropriate testing and treatment. Community-based and medical professional organizations play an 

important role in this process. Providers in all settings need to be empowered to identify and evaluate 

their clients at risk for LTBI (22). Finally, while education is necessary, it also important to develop a 

marketing approach tailored to specific high-risk groups of patients and providers to encourage 

engagement and action. 

Healthcare access poses an additional barrier for many individuals who would benefit from TB 

prevention services. Patients who are at risk for TB may not be in care or may experience prohibitive 

out-of-pocket costs for LTBI assessment and treatment (e.g., IGRA testing, medical evaluation, chest 

radiograph, and medications). Most public and private healthcare settings have limited budgets for LTBI 

diagnostics and treatment. Although many healthcare settings routinely screen patients for infections 

such as HIV and Hepatitis B and C, many fewer routinely assess for LTBI and there usually is no synergy 

between these screening activities even though many patients are at risk for all of these infections. 

Many Federally Qualified Health Centers (FQHCs) that provide care to high-risk clients do not have 

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
adequate funding for LTBI testing and treatment. Health departments have been unable to focus on LTBI 

because of the absence of designated funding and the need to prioritize attention on TB disease. With 

TB disease waning in much of the country, many healthcare providers lack experience and knowledge 

about TB and LTBI, especially of the newer tests and treatment regimens, and the essential step of 

excluding TB disease prior to LTBI treatment. Systems for supporting adherence of patients throughout 

treatment, particularly in community healthcare settings, are typically undeveloped. Finally, the return 

on investment and future savings incurred by LTBI testing and treatment by reducing future costly 

disease has not yet ignited activity. 

To measure progress in expanding LTBI testing and treatment, LTBI monitoring and surveillance are 

critical activities to target and evaluate the success of public health interventions. Local and nationwide 

LTBI surveillance and monitoring systems are needed that support data flow among varied healthcare 

settings, local and state health departments, and the CDC. LTBI is an asymptomatic condition that can be 

detected only through diagnostic testing (the tuberculin skin test [TST] or IGRA) and through the 

exclusion of active disease via chest imaging. Ironically, while many high-risk individuals go unevaluated, 

much of the testing for LTBI in the US currently is done through administrative or employment testing of 

low-risk populations. Although LTBI is reported in some areas, public health agency resource constraints 

limit the proportion of LTBI reports that can be investigated. 

At both local and national levels, monitoring the success of interventions is critical. A major impediment 

to adoption of LTBI testing and treatment in healthcare settings is that there is no national requirement 

for quality improvement of LTBI testing and treatment or no required national LTBI performance 

metrics. There is a clear need for measuring LTBI burden over time and establishing a system for 

monitoring LTBI practices and outcomes. Several first steps that will allow better measurement of LTBI 

testing and treatment have occurred in the U.S: 1) minimum data elements for LTBI surveillance (26, 19) 

have been established, 2) informatics infrastructure (Tuberculosis Latent Infection Surveillance System 

[TBLISS]) has been developed and 3) a growing number of states now mandate LTBI reporting and 4) the 

National Health and Nutrition Examination Survey (NHANES) LTBI testing has also provided key 

estimates of LTBI in the US. Establishing national metrics for federally funded clinical settings, 

disseminating tools for tracking LTBI care steps, and supporting data exchange will help spur further 

progress. 

METHODS 

In January 2018, ACET convened a workgroup comprised of ACET members and subject matter experts 

to review existing evidence on strategies to achieve TB elimination and approaches for LTBI testing and 

treatment scale-up. A review of both program experience and the published literature was synthesized 

on strategies to accelerate the decline of TB cases in the US. The most recently published LTBI testing 

and treatment recommendations of the Institute of Medicine, USPSTF and CDC were considered. 

Experiences of US health departments in TB elimination planning and successful LTBI testing and 

treatment programs were analyzed. 

Both current epidemiology and published modeling studies forecasting results of specific interventions 

were reviewed. Published reports on the facilitators and barriers for identifying and engaging high-risk 

populations and establishing systems for successful testing and treatment were examined. 

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
While prior US TB strategic plans have emphasized diagnosis, treatment and contact investigation for 

individuals with TB disease as the top priorities for TB elimination, these ACET recommendations 

highlight the new, additional priority of LTBI testing and treatment in high-risk persons to prevent TB 

disease as an equally important and necessary strategy to achieve further TB case decline. Building on 

USPSTF recommendations published in 2016 (27), the recommendations in this document can be 

applied by the CDC and state and local health departments in partnership with medical care settings, 

industry, and community organizations. 

FINDINGS/RECOMMENDATIONS 

There are four major activities required for scaling up LTBI testing and treatment in the United States: 1) 

identify and engage individuals at-risk and their providers; 2) increase testing of at-risk individuals and 

increase treatment of infected individuals; 3) measure outcomes of LTBI testing and treatment scale-up, 

and 4) secure funding for these TB disease prevention activities. Effective outreach, communication, 

education and partnership are crucial cross-cutting components for implementing these activities. Two 

additional high-priority interventions include research to improve diagnosis and treatment of LTBI and 

policies that implement targeted testing and treatment of LTBI in adult migrants before arrival in the US. 

To support each activity, ACET recommends the actions described below: 

Identify and engage individuals at risk and their providers 

Community outreach 

1) Launch a marketing strategy targeted at public and community-based organizations to raise

awareness about who is at risk for LTBI and TB disease and who needs testing, and to create demand

for testing in healthcare settings:

• Engage community organizations to endorse/encourage TB screening

• Provide web-based tools for the public to determine individual risk (“Know Your TB

Status/Risk”), to locate testing sites by zip code and to generate a risk assessment record for

individuals to keep and to trigger testing by their healthcare provider

• Develop community-specific and culturally competent messages and education tools for specific

patient groups at risk for TB

2) Use evidence-based strategies tailored to settings and risk groups to bring people at risk into care for

testing and treatment

3) Build on and HIV/Hepatitis B and C/Sexually Transmitted Disease screening initiatives to replicate

successful models of how to motivate patients and providers through engagement, linkage to care,

testing (e.g., blood draw/chest radiograph) and treatment

4) Work with homeless organizations to implement risk-based testing and treatment

Provider outreach

5) Engage medical professional organizations to endorse/encourage TB screening

6) Identify and disseminate a list of provider groups and health plans serving large numbers of non-USB

individuals to local health departments so they can focus their LTBI testing and treatment scale-up

efforts

7) Encourage LHDs to engage with providers to communicate with local high-risk groups and give them

the tools to do this effectively; as an example, academic detailing has been successful and used to

outreach to clinicians on focused topics

8) Disseminate efficient models of LTBI risk-based testing and treatment work flows and protocols to

clinics serving high risk patients

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
Increase LTBI testing and treatment with the most effective tools 

1) Initiate an awareness campaign to educate and disseminate effective tools for providers including:

• Methods for effectively communicating to patients about the need for LTBI testing and

• treatment

• Simple educational products about risk assessment (including who to test among non-USB

• populations), testing and treatment

• Recommendations about additional key risk groups warranting testing (e.g.,

• immunocompromised, contacts)

• Messages that explain the USPSTF recommendation

• Information about use of new short-course regimens

• Steps for ruling out TB disease before beginning LTBI treatment

• Steps for reporting LTBI to their jurisdiction, if mandated

2) Disseminate adherence strategies, for example, treatment support networks for patients, tailored

case management strategies for specific patient groups, electronic Directly Observed Therapy (eDOT)

strategies and electronic telemedicine follow-up models

3) Support documentation of treatment completion within healthcare systems, including adding an

ICD-11 code for treatment completion documentation and ensure that patients have these records

as they move across health systems and locations

4) Incentivize healthcare providers and plans to perform routine risk assessment to identify high-risk

patients, including simple EHR tools to determine individual risk, including test order sets

• Engage companies that provide EHRs to develop capacity for recording, using and analyzing TB

• risk factors including country of birth

• Disseminate standardized elements for TB risk assessment, testing, and treatment for EHR

• systems and support EHR user networks for systematic changes

5) Facilitate outreach to and provide incentives for populations and their providers undergoing

required testing (status adjusters) to promote linkage to and completion of treatment

6) Initiate a program for pre-departure LTBI testing and treatment for adults who are migrating to the

US

7) Describe roles of local, state, federal, health department and health care providers for TB prevention

8) Build consultative capacity within public health departments, regional centers and the CDC Centers

of Excellence for access by community providers and organizations

Measure success and outcomes of LTBI testing and treatment scale-up 

1) Establish national, state and local LTBI surveillance systems that, to the extent feasible, exchange

data among healthcare settings, state and local health departments, and the CDC to measure and

improve outcomes of LTBI testing and treatment

• Define the core elements and approaches for simple effective LTBI surveillance and monitoring

systems

• Determine and incorporate the needs and capabilities of local/state health departments for

successful surveillance

• Engage public health and community providers in the system design and implementation

• Create systems that respond to healthcare setting, local and state needs and feasibility

constraints

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
• Implement laboratory reporting of the TB blood test results (IGRAs) for surveillance purposes as

an important first step

2) Establish and track simple national, state and local quality improvement and performance metrics

that measure (1) the percent of non-USB tested for LTBI, (2) the percent of LTBI treatment

completion for those who test positive and (3) the percentage of active TB cases meeting criteria for

potentially being preventable (e.g. were at known risk and not tested and/or not offered treatment)

• Work with the Health Resources and Services Administration (HRSA) and Centers for Medicare

and Medicaid Services (CMS) to establish national performance measures

• Include these measures in the CMS Adult and Child Core Set and Medicare Quality Improvement

requirements

• Assess whether risk criteria were met for testing

3) Work with state and local health departments to launch rigorous evaluation and improvement of

newcomer testing and treatment (status adjusters and persons with TB B-notification)

Secure TB prevention funding for education, testing, treatment, surveillance and research 

1) Establish private and public partnerships involving philanthropy, industry, governmental, and

nongovernmental

health organizations for a national TB prevention/elimination initiative

2) Identify new funding streams to offset patient financial burden for the uninsured, as well as those

insured with high co-pays

• Recommended strategies include making testing available for free, supporting a USPSTF review

of LTBI treatment as prevention activity so that both testing and treatment have cost-sharing

removed, and dissemination of financial analyses of the return on investment of LTBI testing and

treatment to policymakers and health plans

• Ancillary actions that could remove financial barriers for programs and patients include allowing

use of federal cooperative agreement funds for LTBI treatment and stimulating drug

manufacturers to lower costs

3) Create a budget and secure funding for LTBI surveillance system

• Funding support should include electronic DOT/telemedicine adherence and follow-up to ensure

treatment completion and create efficiency through electronic case reporting directly from

electronic health records

4) Support research to advance needed tools

• While intensifying TB prevention through increased LTBI testing and treatment is an important

step toward TB elimination, ending TB will require novel interventions; even though LTBI

diagnostics and treatment regimens and our understanding of LTBI have improved, they are far

from perfect

• Ongoing investment in research is critical to reach elimination and the workgroup identified five

of the eight research priorities articulated by WHO (28) as the most critical to advance our

ability to prevent TB in the US

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
Recommended Priorities for Research 

1. Define the rate of progression to active TB among those with LTBI generally and for specific

subgroupsto inform the risk/benefit ratio of LTBI testing and treatment to aid clinical decisionmaking

2. Develop more predictive diagnostics to identify those with LTBI who will progress to TB disease

3. Conduct trials to assess effective shorter treatment options

4. Identify interventions that promote treatment adherence and prevent attrition during the LTBI care

cascade

5. Identify the most cost-effective approaches and populations to focus screening testing and treatment

DISCUSSION 

The expected impact of these new policy recommendations, if fully adopted, will be a successful 

expansion of LTBI testing and treatment and prevention of TB disease for those at risk. Modeling results 

have predicted that with a 4-fold to 8-fold increase in targeted testing and treatment using the most 

effective tools (e.g., IGRA and short course treatment regimens) (11), we can realize a substantial 

reduction of TB cases in the US and achieve pre-elimination targets (10). These tools provide us with the 

opportunity to save lives and reduce TB-related costs, morbidity, and deaths. 

Useful lessons can be gleaned from the successful national “Know Hepatitis B Campaign” developed by 

CDC and the Hep B United coalition (14). The challenges for hepatitis B prevention were addressed by 

reaching Asian Americans for testing in their communities, in their language and with trusted leaders. 

The plan for accomplishing this was through partnerships with Asian American organizations, CDC 

funding of a cooperative agreement and providing linkage to care and integrating hepatitis B with other 

important conditions. Similarly, progress in ending HIV has occurred through federal commitment and 

funding. The national LTBI initiative can build on and learn from these successes. 

In addition to domestic expansion of LTBI testing and treatment, advancing policy and action outside the 

US in parallel is crucial. Successfully addressing and reducing TB globally in high-burden countries is a 

critical component for elimination of this disease. In addition, policies should promote testing and 

encourage referral for LTBI treatment of immigrants applying for permanent residency during health 

examinations done before US entry and at the time of visa status change in the US. The current overseas 

requirement for pre-departure screening of immigrants should be expanded to include those requesting 

student, worker, and extended tourist visas with the goals of TB case detection as well as diagnosis for 

LTBI with encouragement of LTBI treatment (22). LTBI diagnosis and treatment can be successful and 

efficient with new tests and short-course treatment. While many activities must occur in parallel, 

prioritizing and staging actions to advance TB elimination may be needed in the context of limited 

resources. The workgroup recommended tackling the following high-priority interventions first, shown 

in the following graphic. 

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
High-Priority Interventions 

1. Create a visible national TB prevention and elimination plan focused on LTBI testing and

treatment

2. Secure funding and partnerships for CDC and health department-led activities and

stimulatesupport needed by community organizations and persons at risk and

healthcare providers

3. Launch marketing strategy targeted at public and community-based organizations to raise

awareness of who is at risk for LTBI and TB disease and to create demand for testing in

healthcaresettings public and community based organizations

4. Disseminate evidence-based strategies tailored to risk groups and settings to bring

people at riskinto care for testing and treatment

5. Disseminate efficient models and tools for LTBI risk-based testing and treatment in clinical

settings(e.g., template for systematic approach to LTBI care cascade steps, workflows,

protocols, EHR triggers)

6. Facilitate outreach to and provide incentives for newcomers (status adjusters and those

with B-notification) who test positive to promote linkage to and completion of treatment

7. Establish and track simple national state and local quality improvement and performance

metricsto stimulate improvement

8. Specifically, establish measure in CMS Child and Adult Core set which will be required of

federally funded providers/clinics (FQHCs, Medicaid, and Medicare healthcare providers)

9. Work with state and local health departments to launch rigorous evaluation and

improvement ofnew comer testing and treatment (e.g., status adjusters and TB Bnotifications)

10. Support a prioritized LTBI research agenda advancing 2-3 high impact studies in next 5

years

High-Priority Interventions: Future Steps 

1. Create streamlined exchange of LTBI data for monitoring and action across healthcare

settings,local and state health departments and CDC.

2. Initiate a program for adult pre-departure LTBI testing and treatment building on the

Vietnampilot experience

3. Implement new research findings that can lead to faster adoption of best practices and

speed TBdecline

CONCLUSION 

Substantial progress has been made in reducing tuberculosis in the United States, but the decline has 

stalled, with persistent morbidity, cost and transmission of TB. A commitment to achieve TB elimination 

is crucial for progress and requires effective partnerships across diverse organizations and health system 

components. TB decline can be accelerated by a robust investment in targeted testing and treatment of 

latent TB infection added to strong core TB infrastructure for TB disease diagnosis and treatment. In 

parallel, global TB prevention efforts and research are vital to realizing TB elimination. 

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
Summary Recommendations 

• Resource and commit to a national TB elimination plan

• Engage and motivate providers and health systems

• Outreach to high-risk populations

• Conduct research to advance tools for LTBI testing and treatment

• Measure and improve outcomes of the LTBI care cascade

ACKNOWLEDGEMENTS 

This report includes contributions by Shama Ahuja, Lisa Armitige, Justin Davis, Hazel Dean, Jenna Feraud, 

Jennifer Flood, David Horne, Robert Horsburgh, Eric Houpt, Thomas Navin, Diana Nilsen, Randall Reves, 

Margie Scott-Cseh, Jeffrey Starke, Zelalem Temesgen and Donna Wegener. 

RECOMMENDED CITATION

Advisory Council for the Elimination of Tuberculosis (ACET). Roadmap for Advancing TB Elimination in 

the United States through Scale up of Testing and Treatment of Latent TB Infection. In ACET Minutes of 

the Meeting June 16, 2020, Addendum 1, pages 40-51: US Department of Health and Human Services, 

Centers for Disease Control and Prevention; 2021. https://www.cdc.gov/faca/committees/pdfs/acet/

acet-minutes-20200616-508.pdf.

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
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Tuberc Lung Dis. 2016;20(12):1625-32. 

Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).
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Originally published in Advisory Council of Tuberculosis Minutes of the Meeting June 16, 2020, Addendum 1, pages 40-51. 

https://www.cdc.gov/faca/committees/pdfs/acet/acet-minutes-20200616-508.pdf (see recommended citation at end of document).