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berculosis control with other public health programs while maintaining the capacity and focus to ensure program effectiveness.

The changes outlined above will enable a continuation of the decline in the number and rates of tuberculosis; however, because they fall well short of the goal of elimination, the nation will continue to be susceptible to another resurgence when interest inevitably wanes or perturbations in epidemiological circumstances occur. To begin advancing toward the elimination of tuberculosis, aggressive new efforts must be implemented to identify those who are at the greatest risk of disease through targeted programs of tuberculin skin testing coupled with treatment for latent tuberculosis infection. The highest priority is the identification and treatment of infected contacts of individuals with infectious cases of active tuberculosis. In many parts of the country foreign-born individuals from countries with high rates of tuberculosis also make up a high-priority group; however, because the epidemiology of the disease varies from place to place within the United States, other high-risk groups must be identified locally. Prevention of tuberculosis in foreign-born immigrants from countries with high rates of tuberculosis presents a challenge. The proportion of U.S. cases among individuals in this group is steadily increasing, and soon more than half of all cases of tuberculosis in the United States will be among foreign-born individuals. To address the disease among some foreign-born individuals with tuberculosis, those applying for immigrant visas could be required to undergo tuberculin skin testing as part of the medical examination already required for immigrants to the United States and could be required to complete examination and treatment for tuberculosis or latent tuberculosis infection (when indicated) before receiving documents for permanent U.S. residency. This takes advantage of procedures already required at the time of immigration and identifies individuals during their period of highest risk for tuberculosis, the immigrant's first 5 years in the United States.

Unquestionably, such a policy will be difficult to implement. New resources will be required for health departments to review or conduct medical examinations for newly arrived immigrants and to ensure that treatment is appropriately prescribed and supervised. The Centers for Disease Control and Prevention (CDC) and the Immigration and Naturalization Service (INS) will also require new resources to provide the training and quality assurance necessary to conduct the overseas screening and to ensure the efficient flow of information to health departments. Approaches to implementation of this program should proceed in a stepwise fashion through a series of pilot studies, with each demonstrating effective implementation procedures. Despite the recognized difficulty, an analysis of the effect of this approach demonstrates that it is likely to have a substantial impact on the decline in the rate of tuberculosis in the United States. Not only will screening and treatment of foreign-



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