The potential effect of a geographically focused intervention against TB in the USA

Who

• Study population: People aged ≥15 years diagnosed with tuberculosis (TB) in the USA.

• Data source: National TB Surveillance System (NTSS).

• Time period: 2011–2019.

• Key subgroups: Racially and ethnically minoritised populations (Black, Hispanic, Asian, American Indian or Alaska Native [AIAN], and other non-White groups).

• Exclusions: People incarcerated at TB diagnosis (3.9% of racially minoritised cases).

• Intervention-eligible groups: People born outside the USA, people living with HIV, and people experiencing homelessness.

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What

• Objective: To estimate the health impact, cost, cost-effectiveness, and equity effects of a one-time targeted latent tuberculosis infection (LTBI) testing and treatment intervention.

• Key findings:

  • Targeting the top 5% of US counties with the highest TB risk among racially minoritised populations captured 47.4% of all TB cases.

  • The intervention was estimated to avert:

    • 17,359 TB cases

    • 2,700 TB deaths

    • 14,951 QALYs gained over participants’ lifetimes.

  • 94.1% of people with LTBI in intervention counties were racially minoritised.

  • The intervention reduced TB incidence across most racial and ethnic groups and modestly reduced racial and ethnic disparities, especially for Black people.

  • Cost-effectiveness: $86,177 per QALY gained (2022 USD).

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When

• TB surveillance data: 2011–2019.

• Projection period for impact on incidence and disparities: 2026–2040.

• Post-2020 data excluded due to COVID-19–related disruptions in TB diagnosis.

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Where

• Geographic scope: All 50 US states and the District of Columbia.

• Intervention focus: 157 counties (top 5% by a TB risk score combining TB incidence among racially minoritised people and their population share).

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Why

• Rationale: TB incidence remains disproportionately high among racially and ethnically minoritised populations in the USA.

• Policy challenge: Current US guidelines do not allow LTBI testing to be restricted by race or ethnicity, necessitating a strategy that:

  • Reduces disparities,

  • Maximizes population health impact,

  • Remains guideline-concordant and cost-effective.

• Goal: Inform resource allocation and decision making for TB elimination efforts.

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How

• Design: Modeling study combining surveillance data, statistical smoothing, and economic simulation.

• Targeting approach:

  1. County-level targeting: Selected counties with highest TB burden among racially minoritised populations.

  2. Individual-level targeting: Offered LTBI testing to all people with guideline-recommended risk factors, regardless of race or ethnicity.

• LTBI estimation: Back-calculated from TB incidence using published reactivation rates and spatially smoothed generalized additive models.

• Intervention: Interferon gamma release assay testing, followed by 3 months of weekly isoniazid plus rifapentine.

• Analysis:

  • Markov cohort model for lifetime health and economic outcomes.

  • Incremental cost-effectiveness ratios (ICERs) estimated from a TB health services perspective.

  • Quasi-Poisson models projected future TB incidence and disparities.

• Oversight: Analysis of de-identified surveillance data reviewed by the Centers for Disease Control and Prevention, classified as research not involving human participants.

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Overall conclusion

A geographically focused, guideline-concordant LTBI testing and treatment intervention could produce substantial health gains, be moderately cost-effective, and achieve small but meaningful reductions in racial and ethnic TB disparities, supporting its use as a strategic tool for TB elimination in the USA.

Source: Regan, M., Cui, H., Swartwood, N.A., Li, Y., Marks, S.M., Barham, T., Khan, A., Winston, C.A., Cohen, T., Horsburgh, C.R. and Salomon, J.A., 2026. The potential effect of a geographically focused intervention against tuberculosis in the USA: a simulation modelling study. The Lancet Public Health, 11(2), pp.e82-e91.