Tuberculosis (TB) persists in the United States, Canada, and other high-income, low-incidence countries largely because of ongoing reactivation of latent TB infection (LTBI). • TB elimination in low-incidence countries, defined as an annual incidence of ≤1 case per million, will require extensive screening and treatment of LTBI, including in people for whom the harms of LTBI treatment outweigh the likely benefits: for example, older foreign-born individuals with no recent travel/exposure. Ongoing migration from higher-incidence countries, as well as pockets of transmission in vulnerable subgroups such as prisoners, homeless persons, and drug users, will also continue to pose challenges for TB elimination. • Policymakers in low-incidence countries face a choice between a utilitarian approach that tolerates individual net harm to advance public health goals and a patient-centered approach that values shared decision-making but will predictably result in failure to achieve TB elimination. • While TB elimination is an important aspirational vision, the ethical implications of this goal—namely the implicit requirement to offer LTBI screening and treatment to individuals who are more likely to experience harm than good—merit careful reflection.
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