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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.

With nearly one billion migrants worldwide, migration is both a dynamic and a divisive phenomenon facing the world today. Migrants are a heterogeneous group, and the conditions surrounding migration pathways often pose risks to the physical, mental and social well-being of migrants, with certain subgroups being more vulnerable than others. Several determinants of health and tuberculosis (TB) interplay to increase the vulnerability of migrants to tuberculous infection, TB disease and poor treatment outcomes, making them a key population for TB. This article is the first in the State-of-the-Art series of the International Journal of Tuberculosis and Lung Disease on TB and migration. It provides an overview of migration trends, migration pathways and social determinants, and impact on TB. This article outlines a framework for the prevention and reduction of the TB burden among migrants, adapted from the World Health Organization's End TB Strategy, and in accordance with the Stop TB Partnership's Global Plan and the Sustainable Development Goals (SDGs) agenda. The framework highlights the need for migrant-inclusive national TB plans, and calls for action across all three pillars of the End TB Strategy for migrant-sensitive care and prevention, bold intersectoral policies and systems supportive of migrants, and operational research. More research is needed on the TB burden and challenges faced by migrants and on the feasibility and effectiveness of approaches proposed here and the scaling up of models already underway. Political commitment at the highest national and international levels will be critical to intensify action for promoting the health of migrants on the road to achieving the end TB targets.

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The purpose of this viewpoint is to summarize the advantages and constraints of the tools and strategies available for reducing the annual incidence of tuberculosis (TB) by implementing the World Health Organization (WHO) End TB Strategy and the linked WHO TB Elimination Framework, with special reference to Oman. Methods: The case-study was built based on the presentations and discussions at an international workshop on TB elimination in low incidence countries organized by the Ministry of Health, Oman, which took place from September 5 to September 7, 2019, and supported by the WHO and European Society of Clinical Microbiology and Infectious Diseases (ESCMID). Results: Existing tools were reviewed, including the screening of migrants for latent TB infection (LTBI) with interferon-gamma release assays, clinical examination for active pulmonary TB (APTB) including chest X-rays, organization of laboratory services, and the existing centres for mandatory health examination of pre-arrival or arriving migrants, including examination for APTB. The need for publicprivate partnerships to handle the burden of screening arriving migrants for active TB was discussed at length and different models for financing were reviewed. Conclusions: In a country with a high proportion of migrants from high endemic countries, screening for LTBI is of high priority. Molecular typing and the development of public-private partnerships are needed.