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Recommendation 4.2 To prevent the development of tuberculosis among individuals with latent tuberculosis infection, the committee recommends that

• Tuberculin skin testing be required as part of the medical evaluation for immigrant visa applicants from countries with high rates of tuberculosis, a Class B4 immigration waiver designation be created for persons with normal chest radiographs and positive tuberculin skin tests, and all tuberculin-positive Class B immigrants be required to undergo an evaluation for tuberculosis and, when indicated, complete an approved course of treatment for latent infection before receiving a permanent residency card (“green card”). Implementation should be in a stepwise fashion and pilot programs should evaluate and assess costs.

• Tuberculin testing be required of all inmates of correctional facilities and completion of an approved course of treatment, when indicated, be required, with referral to the appropriate public health agency for all inmates released before completion of treatment.

• Programs of targeted tuberculin skin testing and treatment of latent infection be increased for high-incidence groups, such as HIV-infected individuals, undocumented immigrants, homeless individuals, and intravenous drug abusers, as determined by local epidemiological circumstances.

BACKGROUND AND INTRODUCTION

The recent success of tuberculosis control efforts indicates that, given adequate resources, the traditional control program that focuses on the treatment of active tuberculosis is once again functioning effectively and that a steady decline in cases should be expected. However, to make significant progress toward the elimination of tuberculosis in the United States, efforts to prevent cases from occurring must be amplified. Without an effective vaccine for the prevention of pulmonary tuberculosis, the most effective means of preventing new cases is to take advantage of the relatively long period between infection and the development of active