title: Towards tuberculosis elimination: an action framework for low-incidence countries.
abstract: 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.
authors: Global TB Programme, World Health Organization, Geneva, Switzerland Both authors contributed equally.
authors: Knut
authors: K
authors: Lönnroth
authors: WHO Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, IRCCS, Tradate, Italy Both authors contributed equally.
authors: Giovanni Battista
authors: GB
authors: Migliori
authors: TB Section, University College London and Public Health England, London, UK.
authors: Ibrahim
authors: I
authors: Abubakar
authors: WHO Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, IRCCS, Tradate, Italy.
authors: Lia
authors: L
authors: D'Ambrosio
authors: KNCV Tuberculosis Foundation, The Hague, The Netherlands.
authors: Gerard
authors: G
authors: de Vries
authors: University Hospital Schleswig Holstein, Institute for Epidemiology, Kiel, Germany.
authors: Roland
authors: R
authors: Diel
authors: Global Health Borders Refugee and Onshore Services, Dept of Immigration and Border Protection, Sydney, Australia.
authors: Paul
authors: P
authors: Douglas
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Dennis
authors: D
authors: Falzon
authors: Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Montreal, QC, Canada.
authors: Marc-Andre
authors: MA
authors: Gaudreau
authors: National Institute for Infectious Diseases, Rome, Italy.
authors: Delia
authors: D
authors: Goletti
authors: Research and Surveillance Group on TB, Leprosy and ARI, Epidemiology Board, Institute of Tropical Medicine "Pedro Kourí", Havana, Cuba.
authors: Edilberto R
authors: ER
authors: González Ochoa
authors: Division of TB Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors: Philip
authors: P
authors: LoBue
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Alberto
authors: A
authors: Matteelli
authors: Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Montreal, QC, Canada.
authors: Howard
authors: H
authors: Njoo
authors: TB Dept, National Institute for TB, Respiratory Diseases and Thoracic Surgery, Vysne Hagy, Catholic University, Ružomberok, Slovakia.
authors: Ivan
authors: I
authors: Solovic
authors: Find and Treat, London, UK.
authors: Alistair
authors: A
authors: Story
authors: National TB Control Programme, Ministry of Health, Riyadh, Saudi Arabia.
authors: Tamara
authors: T
authors: Tayeb
authors: European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
authors: Marieke J
authors: MJ
authors: van der Werf
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Diana
authors: D
authors: Weil
authors: Swiss Lung Association, Bern, Switzerland.
authors: Jean-Pierre
authors: JP
authors: Zellweger
authors: WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt.
authors: Mohamed
authors: M
authors: Abdel Aziz
authors: Ministry of Health, Muscat, Oman.
authors: Mohamed R M
authors: MR
authors: Al Lawati
authors: Università degli Studi di Milano - Bicocca, UO Clinica Pneumologica, AO San Gerardo, Monza, Italy.
authors: Stefano
authors: S
authors: Aliberti
authors: Belgian Lung and Tuberculosis Association, Brussels, Belgium.
authors: Wouter
authors: W
authors: Arrazola de Oñate
authors: Ministry of Health, Brasilia, Brazil.
authors: Draurio
authors: D
authors: Barreira
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Vineet
authors: V
authors: Bhatia
authors: Dipartimento Fisiopatologia Medico-Chirurgica e dei Trapianti, University of Milan, IRCCS Fondazione Cà Granda, Milan, Italy.
authors: Francesco
authors: F
authors: Blasi
authors: US Agency for International Development, Washington, DC, USA.
authors: Amy
authors: A
authors: Bloom
authors: Unit of Infectious Diseases, Institution of Medicine, Karolinska Institute Solna and Karolinska University Hospital, Stockholm, Sweden.
authors: Judith
authors: J
authors: Bruchfeld
authors: University of Brescia, Brescia, Italy.
authors: Francesco
authors: F
authors: Castelli
authors: WHO Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, IRCCS, Tradate, Italy.
authors: Rosella
authors: R
authors: Centis
authors: Ministry of Health, Jerusalem, Israel.
authors: Daniel
authors: D
authors: Chemtob
authors: IRCCS San Raffaele Scientific Institute, Milan, Italy.
authors: Daniela M
authors: DM
authors: Cirillo
authors: Advocates for Health International, San Diego, CA, USA.
authors: Alberto
authors: A
authors: Colorado
authors: TB and M/XDR-TB Control Programme, WHO Regional Office for Europe, Copenhagen, Denmark.
authors: Andrei
authors: A
authors: Dadu
authors: Norwegian Institute of Public Health, Oslo, Norway.
authors: Ulf R
authors: UR
authors: Dahle
authors: Médecins sans Frontières, Rome, Italy.
authors: Laura
authors: L
authors: De Paoli
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Hannah M
authors: HM
authors: Dias
authors: General Directorate of Health, Lisbon, Portugal.
authors: Raquel
authors: R
authors: Duarte
authors: Istituto Superiore di Sanita, Rome, Italy.
authors: Lanfranco
authors: L
authors: Fattorini
authors: National Referral Centre for Mycobacteria, Athens Chest Hospital, Ministry of Health, Athens, Greece.
authors: Mina
authors: M
authors: Gaga
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Haileyesus
authors: H
authors: Getahun
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Philippe
authors: P
authors: Glaziou
authors: International Federation of Red Cross and Red Crescent Societies, Geneva, Switzerland.
authors: Lasha
authors: L
authors: Goguadze
authors: WHO Regional Office for the Americas, Washington, DC, USA.
authors: Mirtha
authors: M
authors: Del Granado
authors: Dept of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
authors: Walter
authors: W
authors: Haas
authors: Finnish Lung Health Association, Helsinki, Finland Helsinki University Central Hospital, Division of Infectious Diseases, Helsinki, Finland.
authors: Asko
authors: A
authors: Järvinen
authors: Korea Centers for Disease Control and Prevention (KCDC), Ministry of Health and Welfare, Seoul, Republic of Korea.
authors: Geun-Yong
authors: GY
authors: Kwon
authors: International Organization for Migration, Geneva, Switzerland.
authors: Davide
authors: D
authors: Mosca
authors: University of California, San Francisco, CA, USA American Thoracic Society (ATS), New York, NY, USA.
authors: Payam
authors: P
authors: Nahid
authors: Stop TB and Leprosy Elimination, WHO Regional Office for the Western Pacific, Manila, Philippines.
authors: Nobuyuki
authors: N
authors: Nishikiori
authors: Instituto de Salud Carlos III, Madrid, Spain.
authors: Isabel
authors: I
authors: Noguer
authors: HSE Health Protection Surveillance Centre, Dublin, Ireland.
authors: Joan
authors: J
authors: O'Donnell
authors: Ministry for Health, Valletta, Malta.
authors: Analita
authors: A
authors: Pace-Asciak
authors: Ministry of Health, Rome, Italy.
authors: Maria G
authors: MG
authors: Pompa
authors: Pneumology Institute Marius Nasta, Bucharest, Romania.
authors: Gilda G
authors: GG
authors: Popescu
authors: Coimbra University Hospital, Coimbra, Portugal.
authors: Carlos
authors: C
authors: Robalo Cordeiro
authors: Norwegian Institute of Public Health, Oslo, Norway.
authors: Karin
authors: K
authors: Rønning
authors: Statens Serum Institut (SSI), Copenhagen, Denmark.
authors: Morten
authors: M
authors: Ruhwald
authors: Institut Jules Bordet (ULB), Brussels, Belgium.
authors: Jean-Paul
authors: JP
authors: Sculier
authors: Croatian National Institute of Public Health, Zagreb, Croatia.
authors: Aleksandar
authors: A
authors: Simunović
authors: Health Protection Scotland, Glasgow, UK.
authors: Alison
authors: A
authors: Smith-Palmer
authors: Clinical Epidemiology and Medical Statistics Unit, Dept of Biomedical Sciences, University of Sassari, Research, Medical Education and Professional Development Unit, AOU Sassari, Sassari, Italy.
authors: Giovanni
authors: G
authors: Sotgiu
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Giorgia
authors: G
authors: Sulis
authors: Asociacion Latinoamericana de Torax (ALAT) - Fundacion Neumologica Colombiana, Bogota, Colombia.
authors: Carlos A
authors: CA
authors: Torres-Duque
authors: Ministry of Health, Labour and Welfare, Tokyo, Japan.
authors: Kazunori
authors: K
authors: Umeki
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Mukund
authors: M
authors: Uplekar
authors: KNCV Tuberculosis Foundation, The Hague, The Netherlands.
authors: Catharina
authors: C
authors: van Weezenbeek
authors: Finnish Lung Health Association, Helsinki, Finland.
authors: Tuula
authors: T
authors: Vasankari
authors: Caritas Internationalis, Geneva, Switzerland.
authors: Robert J
authors: RJ
authors: Vitillo
authors: Ministry of Health, Nicosia, Cyprus.
authors: Constantia
authors: C
authors: Voniatis
authors: Fonds des Affections Respiratoires (FARES), Brussels, Belgium.
authors: Maryse
authors: M
authors: Wanlin
authors: Global TB Programme, World Health Organization, Geneva, Switzerland.
authors: Mario C
authors: MC
authors: Raviglione
mesh_terms: D000995:Antitubercular Agents / Q000008:administration & dosage*; D003140:Communicable Disease Control / Q000458:organization & administration*; D019049:Developed Countries; D005260:Female; D014943:Global Health; D006801:Humans; D015994:Incidence; D007391:International Cooperation; D008297:Male; D009936:Organizational Innovation; D014376:Tuberculosis / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control*; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control
chemical_list: D000995:Antitubercular Agents