Latent tuberculosis infection and the EndTB Strategy: ethical tensions and imperatives

Latent tuberculosis infection (LTBI) is increasingly recognised as central to programmatic TB activity, and a critical element in global progress towards TB elimination. LTBI affects a much larger group of people than active disease, who by definition are asymptomatic. Furthermore, while LTBI represents a state of risk, there remains significant uncertainty regarding which individuals will progress to active disease. Therefore, the development and implementation of LTBI management policies within the End TB Strategy requires careful ethical consideration. This article reviews ethical issues related to developments in LTBI diagnosis and management, including new tools and emerging policies and practice. Implications of LTBI management practices in specific settings are discussed, including healthcare worker infection and management of likely multidrug-resistant (MDR) LTBI. Better prediction of progression to active disease and less burdensome treatments would allow ethically appropriate expansion of testing programmes in future. However, even with existing tools there is a strong ethical imperative to provide the most effective and least burdensome therapy possible to those with LTBI, particularly those at highest risk of progression and/or poor outcomes from active disease. Greater community engagement is required in designing optimal LTBI management programmes, and ensure harms and benefits are appropriately balanced in specific settings.