Chest radiography for active tuberculosis case finding in the homeless: a systematic review and meta-analysis

Diagnosis, Treatment, and Prevention of Tuberculosis Among People Experiencing Homelessness in the United States: Current Recommendations

OBJECTIVE

Tuberculosis (TB) is a public health problem, especially among people experiencing homelessness (PEH). The Advisory Council for the Elimination of Tuberculosis issued recommendations in 1992 for TB prevention and control among PEH. Our goal was to provide current guidelines and information in one place to inform medical and public health providers and TB programs on TB incidence, diagnosis, and treatment among PEH.

METHODS

We reviewed and synthesized diagnostic and treatment recommendations for TB disease and latent TB infection (LTBI) as of 2022 and information after 1992 on the magnitude of homelessness in the United States, the incidence of TB among PEH, the role of public health departments in TB case management among PEH, and recently published evidence.

RESULTS

In 2018, there were 1.45 million estimated PEH in the United States. During the past 2 decades, the incidence of TB was >10 times higher and the prevalence of LTBI was 7 to 20 times higher among PEH than among people not experiencing homelessness. TB outbreaks were common in overnight shelters. Permanent housing for PEH and the use of rapid TB diagnostic tests, along with isolation and treatment, reduced TB exposure among PEH. The use of direct observation enhanced treatment adherence among PEH, as did involvement of social workers to help secure shelter, food, safety, and treatment for comorbidities, especially HIV and substance use disorders. Testing and treatment for LTBI prevented progression to TB disease, and shorter LTBI regimens helped improve adherence. Federal agencies and the National Health Care for the Homeless Council have helpful resources.

CONCLUSION

Improvements in TB diagnosis, treatment, and prevention among PEH are possible by following existing recommendations and using client-centered approaches.

Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials

BACKGROUND

Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population.

METHODS

Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted.

RESULTS

Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant.

CONCLUSION

While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.

Health and access to healthcare in homeless people: Protocol for a mixed-methods study

BACKGROUND

Homelessness is a more complex problem than the simple lack of a place to live. Homeless people (HP) often suffer from poor health and premature death due to their limited access healthcare, and are also deprived of basic human and social rights. The study protocol described here aims to evaluate the complex relationship between homelessness and health, and identify the barriers and facilitators that impact access to healthcare by HP.

METHODS

This is a mixed-methods study that uses an explanatory sequential design. The first phase will consist of a cross-sectional study of 300 HP. Specific health questionnaires will be used to obtain information on health status, challenges during the COVID-19 pandemic, self-reported use of healthcare, diagnoses and pharmacologic treatments, substance abuse (DAST-10), diet quality (IASE), depression (PHQ-9), and human basic needs and social support (SSQ-6). The second phase will be a qualitative study of HP using the "life story" technique with purposive sampling. We will determine the effects of different personal, family, and structural factors on the life and health status of participants. The interviews will be structured and defined using Nussbaum's capability approach.

DISCUSSION

It is well-known that HP experience poor health and premature death, but more information is needed about the influence of the different specific social determinants of these outcomes and about the barriers and facilitators that affect the access of HP to healthcare. The results of this mixed methods study will help to develop global health strategies that improve the health and access to healthcare in HP.

Management and control of tuberculosis control in socially complex groups: a research programme including three RCTs

Background

Socially complex groups, including people experiencing homelessness, prisoners and drug users, have very high levels of tuberculosis, often complicated by late diagnosis and difficulty in adhering to treatment.

Objective

To assess a series of interventions to improve tuberculosis control in socially complex groups.

Design

A series of observational surveys, evaluations and trials of interventions.

Setting

The pan-London Find&Treat service, which supports tuberculosis screening and case management in socially complex groups across London.

Participants

Socially complex groups with tuberculosis or at risk of tuberculosis, including people experiencing homelessness, prisoners, drug users and those at high risk of poor adherence to tuberculosis treatment.

Interventions and main outcome measures

We screened 491 people in homeless hostels and 511 people in prison for latent tuberculosis infection, human immunodeficiency virus, hepatitis B and hepatitis C. We evaluated an NHS-led prison radiographic screening programme. We conducted a cluster randomised controlled trial (2348 eligible people experiencing homelessness in 46 hostels) of the effectiveness of peer educators (22 hostels) compared with NHS staff (24 hostels) at encouraging the uptake of mobile radiographic screening. We initiated a trial of the use of point-of-care polymerase chain reaction diagnostics to rapidly confirm tuberculosis alongside mobile radiographic screening. We undertook a randomised controlled trial to improve treatment adherence, comparing face-to-face, directly observed treatment with video-observed treatment using a smartphone application. The primary outcome was completion of ≥ 80% of scheduled treatment observations over the first 2 months following enrolment. We assessed the cost-effectiveness of latent tuberculosis screening alongside radiographic screening of people experiencing homelessness. The costs of video-observed treatment and directly observed treatment were compared.

Results

In the homeless hostels, 16.5% of people experiencing homelessness had latent tuberculosis infection, 1.4% had current hepatitis B infection, 10.4% had hepatitis C infection and 1.0% had human immunodeficiency virus infection. When a quality-adjusted life-year is valued at £30,000, the latent tuberculosis screening of people experiencing homelessness was cost-effective provided treatment uptake was ≥ 25% (for a £20,000 quality-adjusted life-year threshold, treatment uptake would need to be > 50%). In prison, 12.6% of prisoners had latent tuberculosis infection, 1.9% had current hepatitis B infection, 4.2% had hepatitis C infection and 0.0% had human immunodeficiency virus infection. In both settings, levels of latent tuberculosis infection and blood-borne viruses were higher among injecting drug users. A total of 1484 prisoners were screened using chest radiography over a total of 112 screening days (new prisoner screening coverage was 43%). Twenty-nine radiographs were reported as potentially indicating tuberculosis. One prisoner began, and completed, antituberculosis treatment in prison. In the cluster randomised controlled trial of peer educators to increase screening uptake, the median uptake was 45% in the control arm and 40% in the intervention arm (adjusted risk ratio 0.98, 95% confidence interval 0.80 to 1.20). A rapid diagnostic service was established on the mobile radiographic unit but the trial of rapid diagnostics was abandoned because of recruitment and follow-up difficulties. We randomly assigned 112 patients to video-observed treatment and 114 patients to directly observed treatment. Fifty-eight per cent of those recruited had a history of homelessness, addiction, imprisonment or severe mental health problems. Seventy-eight (70%) of 112 patients on video-observed treatment achieved the primary outcome, compared with 35 (31%) of 114 patients on directly observed treatment (adjusted odds ratio 5.48, 95% confidence interval 3.10 to 9.68; p < 0.0001). Video-observed treatment was superior to directly observed treatment in all demographic and social risk factor subgroups. The cost for 6 months of treatment observation was £1645 for daily video-observed treatment, £3420 for directly observed treatment three times per week and £5700 for directly observed treatment five times per week.

Limitations

Recruitment was lower than anticipated for most of the studies. The peer advocate study may have been contaminated by the fact that the service was already using peer educators to support its work.

Conclusions

There are very high levels of latent tuberculosis infection among prisoners, people experiencing homelessness and drug users. Screening for latent infection in people experiencing homelessness alongside mobile radiographic screening would be cost-effective, providing the uptake of treatment was 25–50%. Despite ring-fenced funding, the NHS was unable to establish static radiographic screening programmes. Although we found no evidence that peer educators were more effective than health-care workers in encouraging the uptake of mobile radiographic screening, there may be wider benefits of including peer educators as part of the Find&Treat team. Utilising polymerase chain reaction-based rapid diagnostic testing on a mobile radiographic unit is feasible. Smartphone-enabled video-observed treatment is more effective and cheaper than directly observed treatment for ensuring that treatment is observed.

Future work

Trials of video-observed treatment in high-incidence settings are needed.

Trial registration

Current Controlled Trials ISRCTN17270334 and ISRCTN26184967.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Medicine in the Penal System

BACKGROUND

Infectious diseases, substance dependencies, and dental diseases are the most important health problems affecting incarcerated persons. In Germany, for example, prisoners are 48 to 69 times more likely to be infected with the hepatitis C virus (HCV) than the general population, and 7 to 12 times more likely to be infected with the human immunodeficiency virus (HIV). The prevalence of mental illnesses is also markedly higher in the incarcerated than in the general population.

METHODS

This review is based on pertinent publications retrieved by a selective search in two databases (PubMed and Google Scholar) for any of the terms "health care," "primary health care," "mental health care"; "infectious disease," "opioid maintenance treatment," and "severe mental disorder" in conjunction with "prison," "jail," "detention," and "incarceration."

RESULTS

Among prisoners in German prisons, approximately 20% consume heroin, 20-50% suffer from alcohol dependency and abuse, and 70-85% smoke. The prevalence of tuberculosis in German prisons in 2002 was 0.1%. The provision of needles to incarcerated persons has a preventive effect on infection with hepatitis C, hepatitis B, and HIV, yet programs of this type have been discontinued in most penal facilities. In a systematic review, psychotic disorders were found in 3.6% (95% confidence interval [CI]: [3.1; 4.2]) of male inmates and 3.9% [95% CI: 2.7; 5.0] of female inmates. 25% of incarcerated persons suffer from attention-deficit-hyperac- tivity disorder. Persons recently released from prison have an above average mortality, largely due to drug intoxication.

CONCLUSION

An analysis of medical prescribing data reveals deficiencies in the provision of HCV treatment to all affected persons and in the provision of substitution treatment to persons with opiate dependency. In view of the known risks associated with imprisonment, greater emphasis should be placed on the provision of treatment for infectious diseases, substance dependencies, and mental illness, both in prison and in outpatient care after release.

Effectiveness of interventions for reducing TB incidence in countries with low TB incidence: a systematic review of reviews

AIMS

What is the evidence base for the effectiveness of interventions to reduce tuberculosis (TB) incidence in countries which have low TB incidence?

METHODS

We conducted a systematic review of interventions for TB control and prevention relevant to low TB incidence settings (<10 cases per 100 000 population). Our analysis was stratified according to "direct" or "indirect" effects on TB incidence. Review quality was assessed using AMSTAR2 criteria. We summarised the strength of review level evidence for interventions as "sufficient", "tentative", "insufficient" or "no" using a framework based on the consistency of evidence within and between reviews.

RESULTS

We found sufficient review level evidence for direct effects on TB incidence/case prevention of vaccination and treatment of latent TB infection. We also found sufficient evidence of beneficial indirect effects attributable to drug susceptibility testing and adverse indirect effects (measured as sub-optimal treatment outcomes) in relation to use of standardised first-line drug regimens for isoniazid-resistant TB and intermittent dosing regimens. We found insufficient review level evidence for direct or indirect effects of interventions in other areas, including screening, adherence, multidrug-resistant TB, and healthcare-associated infection.

DISCUSSION

Our review has shown a need for stronger evidence to support expert opinion and country experience when formulating TB control policy.

ACR Appropriateness Criteria® Imaging of Possible Tuberculosis

Pulmonary tuberculosis remains a major cause of disease worldwide and an important public health hazard in the United States. The imaging evaluation depends to a large degree on clinical symptoms and whether active disease is suspected or a subject is at high risk for developing active disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Comparing different technologies for active TB case-finding among the homeless: a transmission-dynamic modelling study

Homeless persons have elevated risk of tuberculosis (TB) and are under-served by conventional health services. Approaches to active case-finding (ACF) and treatment tailored to their needs are required. A transmission-dynamic model was developed to assess the effectiveness and efficiency of screening with mobile Chest X-ray, GeneXpert, or both. Effectiveness of ACF depends upon the prevalence of infection in the population (which determines screening 'yield'), patient willingness to wait for GeneXpert results, and treatment adherence. ACF is efficient when TB prevalence exceeds 78/100,000 and 46% of drug sensitive TB cases and 33% of multi-drug resistant TB cases complete treatment. This threshold increases to 92/100,000 if additional post-ACF enhanced case management (ECM) increases treatment completion to 85%. Generally, the most efficient option is one-step screening of all patients with GeneXpert, but if too many patients (>27% without ECM, >19% with ECM) are unwilling to wait the 90 minutes required then two-step screening using chest X-ray (which is rapid) followed by GeneXpert for confirmation of TB is the most efficient option. Targeted ACF and support services benefit health through early successful treatment and averting TB transmission and disease. The optimal strategy is setting-specific, requiring careful consideration of patients' needs regarding testing and treatment.

What works in inclusion health: overview of effective interventions for marginalised and excluded populations

Inclusion health is a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations. We did an evidence synthesis of health and social interventions for inclusion health target populations, including people with experiences of homelessness, drug use, imprisonment, and sex work. These populations often have multiple overlapping risk factors and extreme levels of morbidity and mortality. We identified numerous interventions to improve physical and mental health, and substance use; however, evidence is scarce for structural interventions, including housing, employment, and legal support that can prevent exclusion and promote recovery. Dedicated resources and better collaboration with the affected populations are needed to realise the benefits of existing interventions. Research must inform the benefits of early intervention and implementation of policies to address the upstream causes of exclusion, such as adverse childhood experiences and poverty.

Comparing yield and relative costs of WHO TB screening algorithms in selected risk groups among people aged 65 years and over in China, 2013

OBJECTIVE

To calculate the yield and cost per diagnosed tuberculosis (TB) case for three World Health Organization screening algorithms and one using the Chinese National TB program (NTP) TB suspect definitions, using data from a TB prevalence survey of people aged 65 years and over in China, 2013.

METHODS

This was an analytic study using data from the above survey. Risk groups were defined and the prevalence of new TB cases in each group calculated. Costs of each screening component were used to give indicative costs per case detected. Yield, number needed to screen (NNS) and cost per case were used to assess the algorithms.

FINDINGS

The prevalence survey identified 172 new TB cases in 34,250 participants. Prevalence varied greatly in different groups, from 131/100,000 to 4651/ 100,000. Two groups were chosen to compare the algorithms. The medium-risk group (living in a rural area: men, or previous TB case, or close contact or a BMI <18.5, or tobacco user) had appreciably higher cost per case (USD 221, 298 and 963) in the three algorithms than the high-risk group (all previous TB cases, all close contacts). (USD 72, 108 and 309) but detected two to four times more TB cases in the population. Using a Chest x-ray as the initial screening tool in the medium risk group cost the most (USD 963), and detected 67% of all the new cases. Using the NTP definition of TB suspects made little difference.

CONCLUSIONS

To "End TB", many more TB cases have to be identified. Screening only the highest risk groups identified under 14% of the undetected cases,. To "End TB", medium risk groups will need to be screened. Using a CXR for initial screening results in a much higher yield, at what should be an acceptable cost.

Active case-finding for tuberculosis by mobile teams in Myanmar: yield and treatment outcomes

Background

Since 2005, the Myanmar National Tuberculosis Programme (NTP) has been implementing active case finding (ACF) activities involving mobile teams in hard-to-reach areas. This study revealed the contribution of mobile team activities to total tuberculosis (TB) case detection, characteristics of TB patients detected by mobile teams and their treatment outcomes.

Methods

This was a descriptive study using routine programme data between October 2014 and December 2014. Mobile team activities were a one-stop service and included portable digital chest radiography (CXR) and microscopy of two sputum samples. The algorithm of the case detection included screening patients by symptoms, then by CXR followed by sputum microscopy for confirmation. Diagnosed patients were started on treatment and followed until a final outcome was ascertained.

Results

A total of 9 349 people with symptoms suggestive of TB were screened by CXR, with an uptake of 96.6%. Of those who were meant to undergo sputum smear microscopy, 51.4% had sputum examinations. Finally, 504 TB patients were identified by the mobile teams and the overall contribution to total TB case detection in the respective townships was 25.3%. Among total cases examined by microscopy, 6.4% were sputum smear positive TB. Treatment success rate was high as 91.8% in study townships compared to national rate 85% (2014 cohort).

Conclusions

This study confirmed the feasibility and acceptability of ACF by mobile teams in hard-to-reach contexts, especially when equipped with portable, digital CXR machines that provided immediate results. However, the follow-up process of sputum examination created a significant barrier to confirmation of the diagnosis. In order to optimize the ACF through mobile team activity, future ACF activities were needed to be strengthened one stop service including molecular diagnostics or provision of sputum cups to all presumptive TB cases prior to CXR and testing if CXR suggestive of TB.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-017-0291-5) contains supplementary material, which is available to authorized users.

Screening for tuberculosis in an urban shelter for homeless in Switzerland: a prospective study

Background

Whereas high risk groups such as asylum seekers are systematically screened for active tuberculosis (TB) upon entry in Switzerland, this strategy does not apply to homeless persons despite a reported high risk. Geneva health and social authorities implemented an intersectoral project to screen for active TB in homeless persons. We aimed to assess acceptability of this program and prevalence of active TB in this group.

Methods

This prospective study targeted all homeless adults registering for shelter accommodation in Geneva during winter 2015. Applicants were proposed a questionnaire-based screening (www.tb-screen.ch) exploring epidemiological and clinical risk factors for active TB. Participants with a positive score underwent diagnostic procedures at Geneva University Hospital. Enhanced TB surveillance targeting homeless persons in the community was continued 3 months after the study termination.

Results

Overall, 726/832 (87.3%) homeless persons accepted the screening procedure. Most were young male migrants without access to care in Switzerland. Male gender (adjusted OR: 2.14; 95% confidence interval: 1.27–3.62), age below 25 years (aOR: 4.16; 95% CI: 1.27–13.64) and short duration of homelessness (aOR: 1.75; 95% CI: 1.06–2.87) were predictors of acceptance. Thirty (4.1%) had positive screening scores but none of the 24 who underwent further testing had active TB. Post-study surveillance did not identify any incident case in Geneva.

Conclusions

Active TB screening targeting highly mobile homeless persons in shelters was well accepted and feasible. The participants’ sociodemographic profile highlighted the heterogeneity of homeless groups in Europe and the null TB prevalence the variability of their active TB risks. These findings underline the feasibility of health programs targeting this hard to reach group and the need for close monitoring of this social group considering the rapid changes in international mobility patterns to tailor preventive and screening strategies to the local context.

Effectiveness of interventions for diagnosis and treatment of tuberculosis in hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review

Tuberculosis is over-represented in hard-to-reach (underserved) populations in high-income countries of low tuberculosis incidence. The mainstay of tuberculosis care is early detection of active tuberculosis (case finding), contact tracing, and treatment completion. We did a systematic review with a scoping component of relevant studies published between 1990 and 2015 to update and extend previous National Institute for Health and Care Excellence (NICE) reviews on the effectiveness of interventions for identifying and managing tuberculosis in hard-to-reach populations. The analyses showed that tuberculosis screening by (mobile) chest radiography improved screening coverage and tuberculosis identification, reduced diagnostic delay, and was cost-effective among several hard-to-reach populations. Sputum culture for pre-migration screening and active referral to a tuberculosis clinic improved identification. Furthermore, monetary incentives improved tuberculosis identification and management among drug users and homeless people. Enhanced case management, good cooperation between services, and directly observed therapy improved treatment outcome and compliance. Strong conclusions cannot be drawn because of the heterogeneity of evidence with regard to study population, methodology, and quality.

Infectious Disease Issues in Underserved Populations

Infectious disease has a major impact on the health outcomes of underserved populations and is reported at significantly higher rates among these populations compared with the general population. Overcoming barriers and obstacles to health care access is key to addressing the disparity regarding the prevalence of infectious disease. Enhancing cultural competency and educating practitioners about underserved populations' basic health needs; optimizing health insurance for the underserved; increasing community resources; and improving access to comprehensive, continuous, compassionate, and coordinated health care are strategies for diminishing the burden of infectious disease in underserved populations.

Effectiveness of peer educators on the uptake of mobile X-ray tuberculosis screening at homeless hostels: a cluster randomised controlled trial

TRIAL DESIGN

Cluster randomised controlled trial.

OBJECTIVE

To compare current practice for encouraging homeless people to be screened for tuberculosis on a mobile digital X-ray unit in London, UK, with the additional use of volunteer peer educators who have direct experience of tuberculosis, homelessness or both.

PARTICIPANTS

46 hostels took part in the study, with a total of 2342 residents eligible for screening. The study took place between February 2012 and October 2013 at homeless hostels in London, UK.

INTERVENTION

At intervention sites, volunteer peer educators agreed to a work plan that involved moving around the hostel in conjunction with the hostel staff, and speaking to residents in order to encourage them to attend the screening.

RANDOMISATION

Cluster randomisation (by hostel) was performed using an internet-based service to ensure allocation concealment, with minimisation by hostel size and historical screening uptake.

BLINDING

Only the study statistician was blinded to the allocation of intervention or control arms.

PRIMARY OUTCOME

The primary outcome was the number of eligible clients at a hostel venue screened for active pulmonary tuberculosis by the mobile X-ray unit.

RESULTS

A total of 59 hostels were considered for eligibility and 46 were randomised. Control sites had a total of 1192 residents, with a median uptake of 45% (IQR 33-55). Intervention sites had 1150 eligible residents with a median uptake of 40% (IQR 25-61). Using Poisson regression to account for the clustered study design, hostel size and historical screening levels, there was no evidence that peer educators increased uptake (adjusted risk ratio 0.98; 95% CIs 0.80 to 1.20). The study team noted no adverse events.

CONCLUSIONS

This study found no evidence that volunteer peer educators increased client uptake of mobile X-ray unit screening for tuberculosis. Further qualitative work should be undertaken to explore the possible ancillary benefits to peer volunteers.

TRIAL REGISTRATION NUMBER

ISRCTN17270334.

Towards tuberculosis elimination: an action framework for low-incidence countries

This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards "pre-elimination" (<10 cases per million) and eventually the elimination of TB as a public health problem (less than one case per million). TB epidemiology in most low-incidence countries is characterised by a low rate of transmission in the general population, occasional outbreaks, a majority of TB cases generated from progression of latent TB infection (LTBI) rather than local transmission, concentration to certain vulnerable and hard-to-reach risk groups, and challenges posed by cross-border migration. Common health system challenges are that political commitment, funding, clinical expertise and general awareness of TB diminishes as TB incidence falls. The framework presents a tailored response to these challenges, grouped into eight priority action areas: 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) undertake screening for active TB and LTBI in TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. The overall approach needs to be multisectorial, focusing on equitable access to high-quality diagnosis and care, and on addressing the social determinants of TB. Because of increasing globalisation and population mobility, the response needs to have both national and global dimensions.