Modeling the Impact of Recommendations for Primary Care-Based Screening for Latent Tuberculosis Infection in California

Public Health Rep. 2020 Jul/Aug;135(1_suppl):172S-181S. doi: 10.1177/0033354920927845.


Objective: Targeted testing and treatment of persons with latent tuberculosis infection (LTBI) is a critical component of the US tuberculosis (TB) elimination strategy. In January 2016, the California Department of Public Health issued a tool and user guide for TB risk assessment (California tool) and guidance for LTBI testing, and in September 2016, the US Preventive Services Task Force (USPSTF) issued recommendations for LTBI testing in primary care settings. We estimated the epidemiologic effect of adherence to both recommendations in California.

Methods: We used an individual-based Markov micro-simulation model to estimate the number of cases of TB disease expected through 2026 with baseline LTBI strategies compared with implementation of the USPSTF or California tool guidance. We estimated the risk of LTBI by age and country of origin, the probability of being in a targeted population, and the probability of presenting for primary care based on available data. We assumed 100% adherence to testing guidance but imperfect adherence to treatment.

Results: Implementation of USPSTF and California tool guidance would result in nearly identical numbers of tests administered and cases of TB disease prevented. Perfect adherence to either recommendation would result in approximately 7000 cases of TB disease averted (40% reduction compared with baseline) by 2026. Almost all of this decline would be driven by a reduction in the number of cases among non-US-born persons.

Conclusions: By focusing on the non-US-born population, adherence to LTBI testing strategies recommended by the USPSTF and the California tool could substantially reduce the burden of TB disease in California in the next decade.

Keywords: LTBI; guidelines; simulation modeling; tuberculosis; tuberculosis elimination.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Age Factors
  • Antitubercular Agents / therapeutic use
  • California
  • Emigrants and Immigrants
  • Guideline Adherence
  • Humans
  • Immunocompromised Host
  • Latent Tuberculosis / diagnosis*
  • Latent Tuberculosis / drug therapy
  • Latent Tuberculosis / ethnology
  • Markov Chains
  • Mass Screening
  • Practice Guidelines as Topic
  • Primary Health Care / organization & administration*
  • Primary Health Care / standards
  • Residential Facilities
  • Risk Assessment
  • Tuberculosis / ethnology


  • Antitubercular Agents