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Recommendations and Conclusion TABLE 3 Latent TB References as of 2021 for SOF Medics and
Medical Providers
The most recent CDC guidelines recommend the IGRA as the
preferred test in both low-risk and high-risk individuals. We Operational
19
also prefer IGRA testing when available in favor of the TST MEDCOM Reg 40-64: The Tuberculosis Surveillance and Control
8
because it (1) avoids practitioner-dependent variability in ad- Program 2013
ministration and interpretation, (2) requires only one visit by USCENTCOM MOD Fourteen Individual Protection and
Individual Unit-Deployment Policy 2019
9
the Soldier, (3) avoids (rare, but serious) hypersensitivity reac- 10
tions that can occur with TSTs, and (4) is a more specific test. Army Regulation 40-501: Standards of Medical Fitness 2019
Any Soldier exhibiting signs of active TB disease (e.g., chronic Epidemiology
cough, hemoptysis, weight loss, night sweats, fevers, abnormal National Center for Medical Intelligence:
chest imaging) should be immediately isolated and evaluated https://www.intelink.gov/ncmi (DOD Only) 2
by a physician experienced in the diagnosis and treatment of World Health Organization Global Tuberculosis Report 2020
active TB disease. Unit- or branch-specific references depending on clearance level
Diagnosis
In accordance with AR 40-501, we recommend treatment of Diagnosis of Tuberculosis in Adults and Children IDSA/ATS
all Soldiers in the USSOF community who test positive for Guideline 2017 18
LTBI because (1) all USSOF Soldiers are potential medical Management
providers and while risk of progression is low, active disease Guidelines for the Treatment of Latent Tuberculosis Infection
can be catastrophic, (2) USSOF Soldiers are often required to (CDC) 2020 15
cohabitate in enclosed, close-quartered housing for prolonged
periods, and (3) documentation of LTBI treatment is often re-
quired for credentialing and specialized schools. Author Contributions
AS drafted the original manuscript. ST, JE, and AV contributed
additional sections and references. All authors reviewed and
We recommend treatment with once-weekly INH and rifapen-
tine as described here and in Table 2. This regimen is endorsed approved the final manuscript.
as a preferred regimen by the CDC and in recent experience
has had excellent adherence and tolerability among Soldiers. References
We recommend supplementation with pyridoxine in any Sol- 1. Gutierrez MC, Brisse S, Brosch R, et al. Ancient origin and gene
mosaicism of the progenitor of Mycobacterium tuberculosis. PLoS
diers who receive INH to avoid neuropathy. Pathogens. 2005;1(1):0055–0061.
2. World Health Organization. WHO Global Tuberculosis Report.
Although the rate of TB disease in the military remains low, di- 2020. https://apps.who.int/iris/bitstream/handle/10665/336069/9
agnosis and treatment remain critical components to optimize 789240013131-eng.pdf. Accessed 24 July 2021.
medical fitness and ability to deploy. Birth abroad remains 3. Poulsen A. Some clinical features of tuberculosis. Acta Tuberc
Scand. 1957;33(1–2).
the primary risk factor for TB disease in the military. How- 4. World Health Organization. WHO Global Tuberculosis Report
ever, exposure through military service in a TB-endemic coun- 2020. 2020.
try remains an important, though uncommon, source of TB 5. Office of the Surgeon General. The Army Latent Tuberculosis In-
infection. USSOF and enablers often operate in TB- endemic fection (LTBI) Surveillance and Control Program. Department of
countries and are at highest risk of TB exposure as an inher- the Army; 2003.
ent consequence of their mission sets. USSOF providers and 6. Mancuso JD, Tobler SK, Keep LW. Pseudoepidemics of tuberculin
medics should perform targeted testing in Soldiers with high- skin test conversions in the U.S. Army after recent deployments.
Am J Respir Crit Care Med. 2008;177:1285–1289. doi:10.1164/
risk exposures and when possible, treat LTBI with the short rccm.200802-223OC
treatment regimens recommended by the CDC. SOF medical 7. Mancuso JD, Keep LW. Deployment-related testing and treat-
planners should consult their command-specific policies, in ad- ment for latent tuberculosis infection, Part II. Mil Med. 2011;176
dition to national guidelines, whenever preparing operational (10):1088–1092. doi:10.7205/MILMED-D-11-00141
medical plans. Highlighted references for deploying units are 8. Mancuso JD. Tuberculosis screening and control in the US military
summarized in Table 3. in war and peace. Public Health. 2017;107(1):60–67.
9. US Medical Command. MEDCOM Regulation 40-64: The Tuber-
culosis Surveillance and Control Program. https://armypubs.army.
Conflict of Interest mil/epubs/DR_pubs/DR_a/pdf/web/ad2015_20.pdf. Accessed 24
The authors have no conflicts of interest to disclose. July 2021.

TABLE 2 Preferred Regimens for Treatment of Latent Tuberculosis Infection
Medication Duration Dose for Adults Frequency Total doses Adverse Effects
Isoniazid and 3 months INH: 15mg/kg Once Weekly 12 INH: Hepatitis, peripheral neuropathy
rifapentine (900mg max) Rifapentine: drug, interactions, orange colored body fluids,
Rifapentine: 900mg hepatitis, flulike symptoms, thrombocytopenia
Rifampin 4 months 10mg/kg Daily 120 Rifampin: drug interactions, orange colored body fluids,
(600mg max) hepatitis, flulike symptoms, thrombocytopenia
Isoniazid and 3 months INH: 5mg/kg Daily 90 INH: Hepatitis, peripheral neuropathy
rifampin (300mg max) Rifampin: Drug interactions, orange-colored body fluids,
Rifampin: 10mg/kg hepatitis, flulike symptoms, thrombocytopenia
(600mg max)
Adapted from Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from the National Tuberculosis Controllers
Association and CDC, 2020. 16

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