Reply.

We argue for universal latent tuberculosis infection (LTBI) screening prior to administration of biologic or targeted synthetic DMARDs (b/tsDMARDs). First, though evidence about the risk of LTBI reactivation for newer b/tsDMARDs is accumulating these studies are conducted in populations in which patients have been screened and treated for LTBI meaning the true risk of reactivation is difficult to assess with current studies. Second, while there are algorithms to predict the risk of active TB in non-endemic populations, these models use a broad category of immunosuppression and the result of LTBI screening limiting their utility for identifying who to screen. Critically, there are limits to screening based on demographic characteristics alone. Third, Center for Medicare and Medicaid Services has a stated goal of zero preventable harm in patients and the U.S. is experiencing increasing rates of TB since COVID. Immunosuppression is a strong risk factor suggesting screening should be universal.