Acceptability of TB Screening Among At-Risk and Vulnerable Groups

DRAFT-NOT FOR DISTRIBUTION

Acceptability of TB Screening Among At-Risk and Vulnerable Groups:

A Systematic Qualitative/Quantitative Literature Metasynthesis

Ellen M. H. Mitchell Adrienne Shapiro Jonathan Golub Kathrina Kranzer Ana Victoria Portocarrero Camilo Antillón Najlis Jintana Ngamvithayapong-Yanai Knut Lönnroth

DRAFT-NOT FOR DISTRIBUTION

Table of Contents Acceptability of Screening among At-Risk and Vulnerable Groups: A Systematic Literature Review ...... 5 Acknowledgements ...... 6 ABSTRACT ...... 7 Structured summary ...... 7 INTRODUCTION ...... 10 Study Rationale...... 10 Study Objective ...... 10 Review Protocol ...... 11 Introduction ...... 11 Search Strategy for PICOT: What is the acceptability of systematic screening for active TB among x population in the 1985-April 2011 period? ...... 13 Inclusion Criteria ...... 13 Data collection process ...... 15 Quantitative search strategy ...... 15 Data items ...... 15 Qualitative data search strategy ...... 15 Risk of bias in individual studies ...... 16 Summary measures ...... 16 Data analysis ...... 16 Results...... 17 Study selection ...... 17 Study characteristics ...... 19 Risk of bias within studies ...... 19 Synthesis of results ...... 19 Qualitative Results on Acceptability of Screening ...... 20 Incentives and enablers as a determinant of acceptability of TB screening ...... 20 A note on gender as a determinant of TB screening acceptability ...... 21 1. Adolescents ...... 22 2. Alcohol dependent ...... 22 3. Attendees of health care facilities ...... 23 4. Children under 5 ...... 23 5. Diabetics ...... 24 6. Drug dependent ...... 24 7. Elderly ...... 25

DRAFT-NOT FOR DISTRIBUTION

8. Malnourished ...... 25 9. Mentally Ill ...... 26 10. Persons with Previous TB...... 26 11. PLHIV ...... 26 12. Pregnant women ...... 27 13. Persons seeking VCT ...... 28 14. Smokers ...... 28 15. Factory & Farm workers ...... 29 16. Health care workers ...... 30 17. Miners ...... 31 18. Orphans and minors in congregate settings...... 31 19. Prisoners ...... 32 20. Refugees and internally displaced persons...... 33 21. Residents of Urban poor areas ...... 34 22. Soldiers and Military personnel ...... 34 23. Transportation workers ...... 34 24. Homeless ...... 35 25. Indigenous...... 36 26. Migrants ...... 37 27. Marginalized Men who have Sex with Men (MSM) ...... 38 28. Nomadic /Pastoralist populations ...... 38 29. Sex workers ...... 38 30. Street children / abandoned children/ out of school youth ...... 39 31. Transgender ...... 39 32. Screening of Contacts of a TB Case ...... 40 Risk of bias across studies ...... 42 DISCUSSION ...... 42 Limitations ...... 44 Conclusions ...... 45 FUNDING ...... 45 Appendices ...... 45 Appendix 2 Search Strategy for : What is the acceptability of universal TB screening among specific risk groups in the 1985-April 2011 period? ...... 46 Appendix 3 ACRONYMS ...... 53 Appendix 4 Operational Definitions of Risk Groups for the purposes of Screening ...... 54 Risk Groups found in health services ...... 54 Congregate/Occupational/Environmental Risk Groups ...... 55 Behavioral/marginalized Risk Groups ...... 56

DRAFT-NOT FOR DISTRIBUTION

Appendix 5: data extraction form ...... 58 References ...... 59

Section/topic

DRAFT-NOT FOR DISTRIBUTION

List of Tables and Figures

Table 1: Average Weighted Proportion of Persons Accepting TB screening in 218 studies ...... 7 Table 2: Acceptability of Contact Tracing by Type ...... 8 Figure 3: Hypothesized Potential Components of Acceptability of Screening ...... 12 In Table X examples of each of the domains of acceptability derived from the literature on other types of sensitive screening are provided. Not all domains are equally salient for all risk groups...... 12 Table 3: Domains of Acceptability of Screening for other Diseases ...... 12 Table 4: Results of the Searches by Risk Group and Database ...... 17 Table 5: Yield of Screening and Selection Procedures for Qualitative Information ...... 18 Table 6: Average Consent (Recruitment) Rates by Risk Group...... 19 Table 7 Consent for TB Screening among Risk Groups found in health services ...... 21 Table 7: Common Screening Algorithms for TB diagnosis of children Under 5 ...... 23 Table 8 Common Screening Algorithms used to diagnose TB among Substance abusers by Setting ...... 24 Table 9: common screening algorithms used to screen elderly in congregate settings...... 25 Table 10 Common Screening Algorithms used to diagnose TB among PLWHA by Setting ...... 27 Table 11 Common Screening Algorithms used to diagnose TB among Pregnant Women by Setting ...... 28 Table 12. Consent for TB Screening among Congregate/Occupational Risk Groups ...... 29 Table 13 Common Screening Algorithms used to diagnose TB among Healthcare Workers by Setting ...... 30 Table 14 Common Screening algorithms for Miners ...... 31 Table 15: Common Screening algorithms for Prisoners by Setting ...... 32 Table 16 Common Screening Algorithms used to diagnose TB among Refugees and IDPs by Setting ...... 33 Table 17: Common Screening algorithms used in diagnosis of TB in Military Populations ...... 34 Table 18 Consent for TB Screening Among Marginalized Groups ...... 35 Table 19: Common Screening algorithms for diagnosis of TB among Homeless persons ...... 36 Table 20 : Acceptability of Contact Tracing by Type ...... 40 Table 21 Common Screening Algorithms used to diagnose TB among Contacts by Setting ...... 40 Table 22 Changes in Screening Uptake over time in Yemen ...... 42 Table 23 . Groups with Weighted mean Acceptability above 80% in Rank order ...... 42 Table 24 . Groups with Weighted mean Acceptability above 50% in Rank order ...... 43 Table 25 . Groups with Weighted mean Acceptability below 70% in Rank order ...... 43 Table 26: Search Sub-Strategies for Identifying Risk Groups Within the TB Screening Document Universe ...... 48 Table 27 Transgender Expanded Search...... 51 Table 28 Expanded Search strategy for street children ...... 52

DRAFT-NOT FOR DISTRIBUTION

Acceptability of Screening among At-Risk and Vulnerable Groups: A Systematic Qualitative/Quantitative Literature Metasynthesis

Contact person: Ellen M.H. Mitchell, Senior Epidemiologist Knowledge, Research & Policy Unit KNCV TB Foundation [email protected] Conducted March 1, 2011-May 22, 2012.

Acknowledgements

This report benefitted from the expertise of a wide range of individuals and institutions. Debby Kramer provided expert librarian services. Ieva Lemaine screened the published and grey literature (guidelines, norms, and standards) and extracted data for 7 at-risk and vulnerable groups. Randall Reves of ATS contributed to the search for relevant publications on elderly populations. Pedro Suarez summarized screening information on attendees at health facilities. Nico Nagelkerke provided key references on TB in sex workers. Pippa Grenfell, R. Baptista-Leite , L. Platt, R. Garfein, Smiljka de Lussigny, and Tim Rhodes shared their very useful unpublished systematic literature review on integrated TB care of injection drug users. Esther Buregyeya provided key references and an unpublished manuscript on TB screening of health care workers. All errors and omissions are attributable to the authors.

DRAFT-NOT FOR DISTRIBUTION

ABSTRACT

Structured summary

The acceptability of screening/active case finding (ACF) among populations at-risk for TB was previously unknown and under-researched. Despite the rapid proliferation of screening efforts worldwide, documentation of acceptability of TB testing has lagged. To assess the acceptability of targeted screening among 31 risk groups, a team of reviewers queried 5 databases, sought references from experts of specific risk groups, and scrutinized the grey literature (guidances, norms, standards) produced by technical agencies. There were 468 Tb screening studies reviewed, and 218 (47%) of these were voluntary screening efforts and contained detailed information on proportion of eligible individuals who freely accepted. Table 1 shows the range and weighted average proportion of eligible persons who consented to undergo TB screening in rank order. TB screening was well accepted by 21 out of 33 groups considered. Only Indigenous populations, Persons testing for HIV (VCT), Attendees of Health centers , men who have sex with men (MSM) , and Health Care Workers (HCW) had consent rates below 80%,but their median rates of uptake were still above the 80% mark.1

Table 1: Average Weighted Proportion of Persons Accepting TB screening in 218 studies Mea w. Std.

n mea Deviation Minimum Maximum Median Range Risk Groups % n % N % % % % % Soldiers/Military* 96 99 2 0.05 93 100 96 7 Farm & Factory* 97 97 3 0.02 95 98 98 3 Homeless* 66 96 5 0.24 41 97 75 56 Mentally Ill 94 96 3 0.02 93 95 94 2

Diabetics 96 94 2 0.03 94 98 96 4

ED Pregnant women 85 94 6 0.12 68 96 90 28 Drug Dependent* 84 93 3 0.13 69 94 89 25 Residents of Urban poor areas 87 91 11 0.12 59 99 88 40 Sex Workers 86 84 2 .12 84 88 88 4 Children Under 5 87 87 2 - 84 91 86 6 85 86 3 0.13 73 98 84 25 HIGHLY ACCEPT HIGHLY Transport workers* Migrants 77 85 8 0.15 55 96 81 41 PMTCT* 79 81 3 0.14 68 96 88 28 Immigration 73 80 14 0.20 34 96 79 62 Adolescents 72 80 3 .14 58 96 79 38 Transgenders* 77 79 2 0.07 77 91 84 14

PLIHIV 82 78 17 0.13 52 99 83 47

ED Refugee Camps/IDP 41 74 2 0.25 23 58 41 35

WELL WELL ACCEPT Elderly- Institutionalized * 83 72 2 0.17 72 95 83 24

1 If the literature on active screening for TB disease in a risk group included fewer than 5 studies, then we included studies of screening for LTBI. These are indicated with an asterix.

DRAFT-NOT FOR DISTRIBUTION

Prisoners 71 72 16 0.29 18 98 86 80

Miners 81 70 6 0.11 66 93 84 27 Indigenous 82 69 9 0.20 40 97 89 58

Persons testing for HIV (VCT) 73 69 5 0.23 41 97 85 56 Attendees of Health centers* 59 68 3 0.07 52 67 57 14 Men who have sex with men (MSM)* 76 61 2 0.48 64 91 - 14

Health Care Workers (HCW)* 78 59 5 0.14 56 91 80 34 ACCEPTED Orphans/Children in congregate

settings

Alcohol dependent - Malnourished - Persons with Previous TB - Smokers -

UNKNOWN Nomadic/pastoralist populations Street children/ street youth * Includes consent to Tuberculin Skin Testing (TST)

In addition to risk group screening, a review of consent among contact tracing efforts suggests that contact investigation is also acceptable. These studies are very heterogeneous in terms of technique, but broadly speaking contact investigation appears to be a generally accepted practice.

Table 2: Acceptability of Contact Tracing by Type Mean Std. Minimum Maximum Median Range Type of Contact Tracing % N Deviation % % % % Contract Tracing- 80 24 0.17 39 99 85 60 Household Contact Tracing- 88 27 0.12 57 100 91 42 Community Contact Tracing- Health 59 4 0.14 43 73 60 30 care Contact Tracing- Other 87 3 0.07 83 95 84 12

If the TB control community is serious about community engagement and ethical TB control, further attention is needed to the issue of palatability of TB screening. These studies suggest that in some settings and some populations, TB screening is not routinely taking human rights or individuals’ rights into consideration. Although this inference exercise seems to suggest that TB screening and active case finding are widely acceptable to almost all risk groups, it is important to emphasize that the issue of acceptability as a concept has not been studied in all cases. These acceptability proportions are really simply recruitment rates in studies which are biased by a series of incentives and disincentives which may not reflect acceptability of routine screening practice. Nevertheless, there are several major findings:

1. Simple TB screening (i.e. a one-step point of care process) appears to be more acceptable to

DRAFT-NOT FOR DISTRIBUTION

almost all groups studied than referral or multiple, return visits, but the evidence is weak.2 2. Simple TB screening appears to be more acceptable than more complex, invasive screening involving blood draws, gastric aspiration, or over-night hospital admission, but evidence for this is weak[2]. 3. Inclusion of HIV-testing in the TB screening algorithm (or fear of inclusion) is a potential deterrent in some risk groups (e.g. HCW) but not others, but the evidence is weak3 [3] 4. TB screening and treatment are a low priority for groups facing housing insecurity, nutritional insecurity, addiction, the threat of violence, deportation, etc. 5. There is limited evidence in a small number of settings that screening in hard to reach street population populations (homeless/IDU) is more acceptable if the benefits are immediate and tangible (e.g. use of incentives and enablers).[1] 6. Certain hidden populations (e.g. homeless/IDU/alcoholics/sex workers/street children/undocumented migrants/residents of poor areas) report similar concerns about the quality and confidentiality of TB screening in health care facilities and may be better served by street-based or bar-based screening alternatives.[4-7] 7. Acceptability of TB screening is dependent on the quality of the human interaction as well as perceived negative consequences – legal, social, political, economic. [8] 8. There is weak evidence to suggest that acceptability of TB screening may be a function of periodicity and may decline over time. So the interval between TB screens should reflect a balance between potential health benefit and potential risk of refusal[9].

2 J Acquir Immune Defic Syndr. 2012 Sep 1;61(1):e6-e8. Test and Treat: A New Standard for Smear- Positive Tuberculosis. Davis JL, Dowdy DW, den Boon S, Walter ND, Katamba A, Cattamanchi A. 3 Including HIV testing in the TB screening exercise does not decrease consent in community-wide screening (see Mitchell et al community screening acceptability literature review).

DRAFT-NOT FOR DISTRIBUTION

INTRODUCTION

Screening is increasingly framed as a potential part of the remedy for stalled case detection rates and diminishing returns from the traditional methods of passive detection of M. Tuberculosis (TB) that rely upon health seeking by symptomatic individuals.4 Indeed TB screening has been shown to detect additional TB cases in several controlled trials. Moreover, its effectiveness in routine use among certain key populations is also suggestive of benefit, though the overall evidence base remains very weak (Kranzer et al 2012). Screening strategies present both opportunities and challenges for the health system. Screening may identify earlier TB disease and a different sort of TB patient than the traditional approaches. Moreover, the range of interventions described as “TB Screening” is very broad, the potential target populations are equally diverse, and the screening and diagnostic algorithms applied vary widely making it challenging to derive broad conclusions about the value and acceptability of TB screening.

Study Rationale One of the issues that is frequently overlooked in the development of screening policy is the potential acceptability of screening among individual target groups. Indeed TB screening is already compulsory for specific at-risk and vulnerable populations for utilitarian public health reasons or political ends , rendering the issue of “acceptability” a rather moot point in practice and perhaps therefore the subject of minimal scholarly concern.[10] Indeed, three comprehensive systematic literature reviews have been published on screening and active case finding in the last three years (among migrants, persons with HIV, and contacts of TB cases) and it is noteworthy that none of them consider the issue of acceptability explicitly. Despite the lack of attention to the acceptability question among policy makers, acceptability is a critical pre-requisite of effective TB control.[11] To inform the development of global policy on TB screening it is crucial to reflect upon the acceptability of potentially invasive, costly or inconvenient measures, and the potential repercussions of voluntary screening in terms of perceived and enacted stigma as well as treatment adherence. [12-13] Compulsory examination, compulsory screening, compulsory detention, compulsory treatment, and compulsory vaccination for TB may be expedient, but their ethical implications are heavily contested. It is necessary therefore to explore the acceptability of targeted screening or active case finding endeavors in specific populations. An in-depth appreciation of these issues is difficult due to the limited information available, however through inference and extrapolation, insights on acceptability may be derived.

Study Objective In this systematic literature review, we address one question on acceptability of screening:

1. What is the acceptability of targeted TB screening among specific risk groups in the

4 For the purposes of this review, screening is understood to mean the “systematic identification, in a predetermined target group, of people with suspected active TB by the application of tests, examinations, or other procedures which can be applied rapidly”. This is in contrast to “Active case finding” which implies diagnosis through diverse outreach activities beyond the health services (Golub 2005). The terms are sometimes used inter-changeably .

DRAFT-NOT FOR DISTRIBUTION

1985-April 2011 period?

Review Protocol

Acceptability of targeted TB screening among specific risk groups in the 1985-April 2011 period

Introduction Although there is widespread recognition that Tuberculosis is not the equal opportunity disease that its air borne transmission route would imply, there has still been a historical tendency to seek one-size-fits all approaches to its prevention, diagnosis and management[14]. A consultative approach to TB strategy development in which communities are full partners has emerged belatedly and persons with TB are increasingly included in policy and planning (e.g. GIPT principle).5 A recent systematic review of delay to diagnosis strongly suggests that the health seeking behavior (i.e. acceptability of TB testing) under the passive case-finding paradigm varies widely by risk group6.[15] We hypothesize therefore that active case finding and screening may also be acceptable to particular populations to varying degrees. There is little written on the acceptability of active case finding and/or TB screening, however a brief review of acceptability studies for other screening tests suggests that there are common factors which come into play in an individual’s assessment of the desirability of undergo health screening. These issues can be grouped into 5 domains (See Figure 3).

5 Priorities in Operational Research to Improve Tuberculosis Care and Control. Geneva, WHO and Stop TB Partnership, 2011 (available at: http://whqlibdoc.who.int/publications/2011/9789241548250_eng.pdf

6 Passive-case finding is less readily embraced by person with: “co-morbidities of the suspect including alcoholism and drug dependence; extrapulmonary TB; rural residence; low access (geographical or “sociopsychological” barriers); elderly; poor; women, history of immigration; low educational level; low awareness of TB; “incomprehensive beliefs”[sic]; self-treatment; and stigma15. Storla, D.G., S. Yimer, and G.A. Bjune, A systematic review of delay in the diagnosis and treatment of tuberculosis. Bmc Public Health, 2008. 8.”.

DRAFT-NOT FOR DISTRIBUTION

Figure 3: Hypothesized Potential Components of Acceptability of Screening

Concerns screener acceptabi individual specific to Contextual Screening characteris lity of factors the risk factors technique tics screening group

In Table X examples of each of the domains of acceptability derived from the literature on other types of sensitive screening are provided. Not all domains are equally salient for all risk groups.

Table 3: Domains of Acceptability of Screening for other Diseases Why me? Individual factors risk perception [16-18] degree of altruism [19] fear of disease[20] Why us? Group’s specific stigma[21-25] concerns cultural appropriateness/clarity of questions[26-27] Where? Contextual factors Cost of screening (direct and opportunity) convenience,[17, 28-29] choice of venue/and the informal and non-medical site to testing[17, 25-26, 30-31] Privacy[18, 24, 31-34] confidentiality[25-26, 33] home visits threatening to some vulnerable groups[35-36] What? Screening safety[29, 33] Technique time to screen[37-38] whether the person has a choice of screening method[25] invasiveness [34] Who? Screener Gender of screener[32] characteristics rapport, empathy/non-judgmental[21, 23, 33, 39-40] the ratio between questioning and listening[35] What now? Implications cost of treatment [32] availability of treatment[40] fear of disclosure of transgression (e.g. infidelity) –routes of transmission[20]

There is little evidence to suggest that the positive predictive value and the negative predictive value of the test enter into individual’s decision making. However, this may be because this information is simply not routinely shared with them.

Study Design Due to the notable absence of published studies of TB screening acceptability in some risk groups, a pragmatic approach to literature assessment was adopted. This review could not be a systematic literature review due to the scope of the assignment, but rather is a qualitative quantitative meta-synthesis of existing guidance and best practices with regard to specific risk groups. A meta-synthesis is broader than a systematic literature review because it includes existing systematic reviews, social science and qualitative work[41].

DRAFT-NOT FOR DISTRIBUTION

Although an imperfect proxy, these bodies of knowledge may provide insights into the acceptability, feasibility, by taking into account what is known about each risk groups’ unique needs, challenges, and enabling characteristics.

Search Strategy for PICOT: What is the acceptability of systematic screening for active TB among x population in the 1985-April 2011 period?

Inclusion Criteria In this review, we considered 30 possible risk groups. We can subcategorize them into groups likely to be encountered in health services, occupational exposure or congregate environments, and finally a residual category of vulnerable populations who face social exclusion and access barriers to health care.

Risk Groups found in health services 1. Adolescents 2. Alcohol dependent 3. Attendees of health care facilities 4. Children under 5 5. Diabetics 6. Drug dependent 7. HIV-infected/PMTCT 8. Malnourished 9. Persons with Previous TB 10. Persons seeking VCT for HIV 11. Pregnant women 12. Smokers

Congregate/occupational/environmental risk groups 13. Elderly (institutionalized) 14. Mentally ill (institutionalized) 15. Factory and farm workers 16. Healthcare workers /Lab staff 17. Military/Soldiers 18. Miners and ex-miners 19. Orphans and institutionalized children 20. Prisoners & prison staff 21. Refugees/internally displaced populations (IDPs) 22. Urban slum residents 23. Transportation workers

Behavioral/marginalized Risk Groups 24. Homeless 25. Indigenous and minority ethnic groups 26. Marginalized men who have sex with men (MSM) 27. Migrants/Immigration 28. Nomads/Pastoralists 29. Sex workers (FSW) 30. Street children/youth

DRAFT-NOT FOR DISTRIBUTION

31. Transgender, intersex

We put particular emphasis on gathering evidence from screening studies from the following countries: Afghanistan, Armenia,* Azerbaijan*, Bangladesh,* Bolivia, Brazil, Cambodia, Democratic Republic of Congo, Djibouti, Dominican Republic,* Ethiopia,* Georgia,* Ghana, Haiti, India,* Indonesia,* Kazakhstan,* Kenya, Kyrgyzstan,* Liberia, Malawi, Mexico, Mozambique, Namibia, Nigeria,* Pakistan,* Peru, The Philippines,* Russia,* Senegal, South Africa,* Southern Sudan, Tajikistan,* Tanzania, Turkmenistan, Uganda, Ukraine,* Uzbekistan,* Zambia, Zimbabwe because of their high burden of TB or their MDR burden. Moreover, in some instances, the inclusion criteria were broadened beyond TB. If the literature on active screening for TB disease in a risk group included fewer than 5 studies, then we included studies of screening for LTBI.

Similarly, if the group had more than ten studies of TB screening, contact tracing studies from this group were excluded. However, if the risk group had less than ten studies on routine TB screening or active case finding, then contact investigation studies in this group were included.

For the qualitative component, if there were no qualitative studies on attitudes toward TB screening, we searched for acceptability of other types of potentially sensitive screening, such as sexually transmitted infection (STI) screening, diabetes screening, alcohol screening, and voluntary counseling and testing for HIV (VCT/ PICT).

Exclusion criteria Please consult Appendix 2 for exclusion criteria because it varied by risk group. Hospitalized patients were not included because this was a combination of passive and active case finding.7

7 . In one study of hospitalized patients, 90% accepted TST but 33.7% were anergic.42. Woeltje, K.F., et al., Tuberculin skin testing of hospitalized patients. Infection Control and Hospital Epidemiology, 1997. 18(8): p. 561-565.

DRAFT-NOT FOR DISTRIBUTION

Data collection process

Quantitative search strategy 1. We conducted 32 literature searches in two databases-ISI WEB of Science & EMBASE (see Appendix 2 Risk Group search strategy) 2. We collaborated with the TB Screening Group at JHU to identify relevant studies. 3. We hand-searched the reference lists, appendices, and supplementary web material of the index article to identify key resources, particularly Kranzer et al 2011. 4. We consulted colleagues to identify manuscripts in preparation on studies in hidden populations and on risk groups for which little was published in peer review journals (e.g. MSM, sex workers, adolescents, )

Screening Step 1: the results section of each study was reviewed to see if the number of screened persons and the number of eligible persons could be extracted. Those with both values were included.

Screening step 2: The abstracts of the selected records were reviewed, and a selection was made for full review.

Screening Step 3: Full papers were read and data were abstracted. The crude recruitment rates were calculated for each study. All studies reporting 100% recruitment were further scrutinized for information on inclusion criteria and consenting procedure. Those stating that screening was mandatory in the study or that did not describe the consenting process were excluded.

Data items

A data extraction form was developed (See Appendix 5). Data were extracted into an Excel spread sheet by a single reviewer per group. When acceptability was not measured or described as a formal topic, the refusal rate in screening studies was considered a proxy for lack of acceptability of screening. If the proportion screened was available from the abstract, the datum was extracted into the data set.

Qualitative data search strategy

1. We relied upon the databases generated through quantitative search above. 2. For groups for whom very little literature was identified on TB and ACF/Screening (n=6), we expanded the strategy to consider acceptability of other types of potentially sensitive or stigmatized screening, such as diabetes screening, alcohol screening, sexually transmitted disease screening, voluntary testing and counseling for HIV (VCT/ PICT), screening for postpartum depression, and intimate partner violence (IPV). 3. We accessed the grey historical literature specific to each group available in the KNCV digital archive (22,000+ records). We identified 220 potentially relevant WHO or STOP TB Partnership TB manuals, guidance, strategies, guidelines, and books dedicated to each group. We expanded to include manuals available on-line in WHO, IULTD, ATS, CDC, KNCV websites.

Qualitative Data Screening Step 1 : Drawing from the databases developed above, the

DRAFT-NOT FOR DISTRIBUTION

authors digitally searched the titles and abstracts of 31 individual risk group databases (11,346 records) for variations of the following ten keywords:

1. Acceptability 6. Satisfaction 2. Utilization 7. Recruitment 3. Screen in 8. Opt 4. Refusal 9. Choice 5. Uptake 10. Consent 4.

Papers identified in this screening step were read in full and relevant findings extracted.

Risk of bias in individual studies

This review is likely to be affected by a significant degree of reporting bias and publication bias which may over estimate the acceptability of screening since studies with high refusal rates face bigger hurdles to publication. To try to overcome this challenge, authors have triangulated data from published and unpublished reports of the same study to detect reporting bias and have included studies that were never published to attempt to mitigate the potential publication bias. These studies were not assessed for quality due to their heterogeneity.

Summary measures The principal summary measure is the proportion of eligible members of the target population who are actually screened. The proportion (screened/eligible) is hypothesized to be a proxy for acceptability of TB screening.

Data analysis The quantitative analysis was descriptive. The average and weighted average consent rates were captured. Given the low numbers of studies in most risk groups and the heterogeneity of the studies, no sensitivity analysis was conducted. The qualitative analysis was simple content analysis using domains of acceptability that were defined a priori. Where possible potential influences on the acceptability of screening, the proportion screened was explored. Where possible, the following questions were explored

1. Are there differences in Acceptability by Region or Context (urban/rural) within a risk group? 2. Are there differences in Acceptability by Gender within a risk group? 3. Are there differences in Acceptability by Incentives and enablers? 4. Is enhanced case finding as acceptable as community-wide screening? 5. Are there differences in Acceptability by Inclusion of HIV testing? 6. Are there differences in Acceptability by Screening algorithm? 7. Are there differences in Acceptability by Study type?

DRAFT-NOT FOR DISTRIBUTION

Results

Study selection

The numbers of studies screened, assessed for eligibility, and included in the review, are outlined in tabular form. Reasons for exclusions at each stage are noted where feasible.

Table 4: Results of the Searches by Risk Group and Database At-Risk or Vulnerable Group # of records in # of Records in Manuals, Duplicate EMBASE ISI Web of guidelines, s Science norms, removed (n=203) Risk Groups found in health services 1. Adolescents 4 4 0 4 2. Alcohol dependent 159 284 5 409 3. Attendees of health care facilities 17 26 5 26 4. Children under 5 1437 622 15 1959 5. Diabetics 196 107 5 131 6. Drug dependent 2573 202 11 297 7. Malnourished 146 102 0 458 8. Persons with Previous TB 0 77 9. PLHIV 2,169 486 36 679 10. Pregnant women 193 106 4 237 11. smokers 247 83 4 262 Congregate/occupational/Institutional/environmental 12. Elderly 364 318 0 517 13. Factory worker 154 93 2 168 14. Health care worker 347 184 15 440 15. Mentally Ill 291 103 3 274 16. Miner 55 98 4 153 17. Orphans/ institutionalized 0 4 69 18. Prisoner 241 291 12 465 19. Residents of Urban Poor Areas 504 495 11 629 20. Soldiers/military 64 0 73 21. Transportation workers 0 27 22. Refugee (camps) IDPs 2 180 Behavioral/marginalized 23. Homeless 71 0 71 24. Indigenous 46 287 3 298 25. Marginalized MSM 24 28 1 31 26. Migrant, 458 18 476 27. Nomadic/pastoralist 0 4 28. Sex worker 14 78 2 92 29. street children/ street youth 0 4 69 30. Transgender 2 2 1 55*

DRAFT-NOT FOR DISTRIBUTION

Table 5: Yield of Screening and Selection Procedures for Qualitative Information At-Risk or Vulnerable Group Universe Selected for Number of studies review in Step 1- with acceptability key word information searching 1. Adolescents 5 4 2. Alcohol dependent 409 13 3. Attendees of health care facilities 26 3 4. Children under 5 1959 47 5. Diabetics 131 5 6. Drug dependent 297 114 7. Malnourished 458 19 8. Persons with Previous TB 77 3 9. PLHIV 679 8 10. Pregnant women 237 4 11. smokers 262 9

12. Elderly 517 23 13. Factory worker 168 12 14. Health care worker 440 29 15. Mentally Ill 274 11 16. Miners 153 1 17. Prisoners 465 11 18. Resident of Urban slum 629 8 19. Soldiers 73 0 20. Transportation workers/ Truck 27 1 drivers/ 21. Internally displaced (IDP)/refugee 180 9 At-risk general 22. Homeless 71 6 23. Indigenous 298 3 24. Marginalized MSM 33 1 25. Migrant, 476** 1 26. Nomadic populations ** 3 4 27. Sex workers 92 7 3 28. street children/ 69 4 2 orphans/abandoned children 29. Transgender 55* 3 1

If a study considered a population that fit more than one risk group, for example pediatric migrants or elderly alcoholics or pregnant factory workers, the study was included in both datasets.8 Checklist item

8 Alvarez, G. G. (2011). "Pediatric tuberculosis immigration screening in high-immigration, low-incidence countries (vol 14, pg 1530, 2010)." International Journal of Tuberculosis and Lung Disease 15(3): 425- 425.

DRAFT-NOT FOR DISTRIBUTION

Study characteristics

Risk of bias within studies

The heterogeneity of the studies included precludes a thorough assessment of the risk of bias of each study .

Synthesis of results

Table 6: Average Consent (Recruitment) Rates by Risk Group

w. Std. Mean mea Deviation Minimum Maximum Median Range Risk Groups % n % N % % % % % Risk Groups found in health services 1. Adolescents 72 80 3 .14 58 96 79 38 2. Alcohol dependent - 3. Attendees of Health 59 3 0.07 52 67 57 14 68 centers 4.Children Under 5 87 87 2 84 91 5. Diabetics 96 94 2 0.03 94 98 96 4 6. Drug Dependent 84 93 3 0.13 69 94 89 25 7.Malnourished - 8. Persons with Previous TB - 9. PLHIV 82 78 17 0.13 52 99 83 47 - PMTCT 79 81 3 68 96 10. Pregnancy 85 94 6 0.12 68 96 90 28 11. Persons testing for HIV 73 5 0.23 41 97 85 56 69 (VCT) 12 Smokers - Institutionalized/Occupational/Congregate Risk Groups 13. Mentally Ill 94 96 3 0.02 93 96 94 2 14. Elderly- Institutionalized 83 72 2 0.17 72 95 83 24 15. Farm & Factory 97 97 3 0.02 95 98 98 3 16. Health Care Workers 78 59 5 0.14 56 91 80 34 17. Miners 81 70 6 0.11 66 93 84 27 18. Orphans/Children in

congregate settings 19. Prisoners 71 72 16 0.29 18 98 86 80 20. Refugee Camps/IDP 41 74 2 0.25 23 58 41 35 21. Residents of Urban poor 87 11 59 99 40 91 areas 22. Soldiers/Military 96 99 2 0.05 93 100 96 7 24. Transport workers 85 3 0.13 73 98 84 25 Marginalized Groups

DRAFT-NOT FOR DISTRIBUTION

25. Homeless 66 96 5 0.24 41 97 75 56 26. Indigenous 82 69 9 0.20 40 97 89 58 27. Migrants 77 85 8 0.15 55 96 81 41 - Immigration 73 80 14 0.20 34 96 79 62 28. MSM 57 - 3 0.48 77 91 85 14 29. Nomadic/pastoralists 30. Sex Workers 86 84 2 .0 84 88 88 4 31. Street children/ youth 32. Transgenders 91 91 1 0 91 91 91 91

*One study—100% consented to TST placement, and 91% agreed to TST reading.

Qualitative Results on Acceptability of Screening Quite a number of studies emphasized the importance of the demeanor of the screener and the quality of the rapport between screener and suspect. Although this has not been rigorously studied for TB screening, it would seem obvious. Moreover patient-provider interaction and satisfaction has been shown to be important for acceptability of TB treatment.[43-44] For street populations (homeless/idu/sex workers/alcoholics/mentally ill/street youth) the benefits and risks of screening could be very wide-ranging, from traumatizing to life saving.[45]the following are quotes from homeless addicts from London, reflecting on the positive consequences of their TB screening which included acquisition of housing, acquisition of substance abuse treatment,

But I end up going in hospital and they say everything for a reason, maybe I needed this TB to get the start I needed, so that I can get a flat. Cause this, bed-sit is a start to getting a flat inat [sic]… (P11)

I had enough of it, and I put my hands out, I need help, and that‘s when I went back to the primary care unit and said, look, I need some help. And then they put me on the methadone program, and stabilised me and it means me not to go out shoplifting anymore, it keeps me out of trouble, so I don‘t have to go shoplifting, keeps me out of prison, just got the alcohol to deal with now (P4)

Swigart V, Kolb R (2004) asked homeless persons in the US the question “Can you tell me about your main reasons for deciding whether to have the TB screening or not?” 51% of participants reported having symptoms or a family history of TB as positively influencing their decision to accept screening, whereas only 27% mentioned the convenience of the screening at the shelter. The participants who did not accept TST screening reported fear of the results (3); disinterest (1); lack of symptoms(1), or desire to sleep (1).[46]

Incentives and enablers as a determinant of acceptability of TB screening Most health behavior theories posit that screening uptake would be higher when the screening takes places as a part of a contact investigation and the imminent personal risk is clear to potential participants. However, there is plenty of evidence to suggest that some of the most

DRAFT-NOT FOR DISTRIBUTION

at-risk populations do not subscribe to this. Indeed health workers are the least enthusiastic about TB screening, despite being perhaps the most cognizant of its benefits.[10] A 2012 Cochrane review[1] of material incentives on TB screening uptake found that

“material incentives may increase the return rate for reading of tuberculin skin test results compared to normal care (two trials, 1,371 participants: RR 2.16, 95% CI 1.41 to 3.29, low quality evidence). Similarly, incentives probably improved clinic re-attendance for initiation or continuation of antituberculosis prophylaxis (three trials, 595 participants: RR 1.58, 95% CI 1.27 to 1.96, moderate quality evidence), and may have improved subsequent completion of prophylaxis in some settings (three trials, 869 participants: RR 1.79, 95% CI 0.70 to 4.58, low quality evidence). The researchers identified 11 eligible studies. Ten were conducted in the United States: in adolescents (one trial), in injection drug or cocaine users (four trials), in homeless adults (three trials), and in prisoners (two trials). One additional trial recruited malnourished men receiving active treatment for TB in Timor-Leste. Material incentives may also be more effective than motivational education at improving return for tuberculin skin test results (low quality evidence), but may be no more effective than peer counseling, or structured education at improving continuation or completion of prophylaxis (low quality evidence). There is limited evidence to support the use of material incentives to improve return rates for TB diagnostic test results and adherence to antituberculosis preventive therapy. The data are currently limited to trials among predominantly male drug users, homeless, and prisoner subpopulations in the United States, and therefore the results are not easily generalized to the wider adult population, or to low- and middle-income countries, where the TB burden is highest. Further high-quality studies are needed to assess both the costs and effectiveness of incentives to improve adherence to long-term treatment of TB.”[1]

A note on gender as a determinant of TB screening acceptability Most studies did not disaggregate recruitment rates by gender. However, we know from other studies that gender does play a role in the diagnostic process.[47]

Table 7 Consent for TB Screening among Risk Groups found in health services studies studies weighted where where average of screening participation Average proportion was was Minimum Maximum proportion who consent mandatory voluntary consenting consenting who consent to TB and/or to TB to TB to TB screening refusal not Screening screening screening reported % % % % Adolescents 0 3 Alcohol dependent 13 0 91 100 Attendees of health 6 3 care facilities 57 78 67 68 Children under 5 4 2 84 91 87 87 Diabetics 2 2 94 98 96 94 Drug dependent 4 5 69 100 89 93 Malnourished 0 0 Persons with 0 0

DRAFT-NOT FOR DISTRIBUTION

Previous TB

PLHIV 36 18 52 100 86 78 PMTCT clients 0 3 68 96 79 81 Pregnant women 0 3 85 95 92 94 People Seeking HIV 2 4 tests 41 97 70 69 Smokers 0 0

Risk Groups found in health services

1. Adolescents

Although previously it was assumed that children above five, constituted a “Golden Age” where the risk of TB was exceedingly low, new information about the social mixing and risk- taking patterns of adolescents has recast this group into a concern for TB control programs. New studies show that adolescents 12-18 year in African settings have only slightly less TB than adults from the same community.[9, 48]9 Three incidence studies among 16, 369 adolescents in South Africa, Uganda and Kenya were recently completed and the acceptability of one time symptom and contact screening ranged from 58 to 96% with a weighted average of 80% consenting to TB screening with symptoms, TST and recent contact as the primary screen and chest x-ray and morning and spot sputum as the secondary screens.[9, 49] One study included IGRA, and this led to the lowest recruitment rate (58%) owing to fear of needles. In Uganda, 68% parents agreed to have their children participate in TB screening every 4 months, and 63% adolescents provided assent. Repeated screening over the course of 18-24 months was acceptable to 63-89%, but frequency of reports of TB symptoms and TB contacts declined over time. [2, 9, 50] This implies that acceptability of TB screening can be expressed in multiple ways – consent, drop out between screening steps, but also under-reporting of symptoms in the primary screen. In the Western Cape of South Africa, (where one study included a passive case finding arm), a trend is seen in greater number of withdrawals among the regularly screened group in the second year, and prior to visits involving a blood draw.[2]. Coly and Morisky (2004) found that foreign born, non-English speaking adolescents in the US were more likely to complete the diagnostic and treatment process that their US peers suggesting that adolescents may not be a homogenous group in all settings.

2. Alcohol dependent Acceptability of conducting screening among persons with alcohol dependency is infrequently studied. One US outbreak investigation of a bar patrons had 100% participation in TST administration, but only 91% return for readings. [51] A total of 13 studies were identified for review, but zero contained information on acceptability. There is limited evidence from contract tracing studies among alcoholics that the quality of the rapport between the vulnerable person and screener may influence acceptability.[52] Yamazachi et al found that

9 In Western Kenya, TB prevalence in 15-90 year olds was 2.5/1,000 (1.6-3.4) for smear-positive PTB and adolescents and adolescents 12-18 were found to have 3.2/1,000 (95% CI 1.9, 4.5) culture confirmed PTB.

DRAFT-NOT FOR DISTRIBUTION

alcoholics tend to postpone screening. [53].

3. Attendees of health care facilities Consent to screen persons in the out-patient department (OPD)of health care facilities ranged from 57-67%. Seven studies were initially flagged as studies of acceptability of conducting TB screening among attendees of health care facilities waiting for other services. However after full screening, three provided refusal rates and none provided further qualitative information on this topic. Although this group is often thought to be an “easy win” for TB control because the costs of screening them and the inconvenience to them are hypothesized to be minimal, acceptability is not that high. Moreover, a positive screen among attendees in health care does not necessarily always lead to a proper TB diagnosis or acceptance of treatment. For example in an Indian study of adult outpatients, 21.5% (477/2210) with cough >2 weeks did not provide a sputum sample or provided fewer than three specimens (Santha, 2005).

4. Children under 5 A total of 47 studies met the initial criteria for inclusion and 11 were suspected of having information relevant to the issue of acceptability of conducting TB screening among children under five. Few studies differentiated between children under five and those under 14. Parental consent to screen in under fives ranged from 84-91%.

Table 7: Common Screening Algorithms for TB diagnosis of children Under 5 Study Settings Examples of Initial screening Examples of Subsequent algorithms Diagnostic steps High Incidence Sx CXR Clinical Sx CXR TST CXR Cx Clinical Other Sx CXR TST Sm Cx Other CXR Sm Clinical Other Sx TST CXR Sm Cx Medium incidence Other Not specified Moderate incidence -- -- Low incidence CXR CXR CXR, TST Other TST

Participation in tuberculin surveys was as high as 95.8% in tribal areas of India but the informed consent was not clearly described. [54] Two Canadian studies described acceptance of TST screening in migrants-children [55-56], with acceptability of 68%. suggesting that acceptability may vary by ethnicity and social position. Acceptability of gastric aspiration and induced sputum among infants has been studied in rural Western Kenya[57]. Particularly problematic for male heads of household was the need for mothers to spend multiple overnight periods with their infant in the hospital for the purposes of TB diagnosis.

“…I would not agree to that because at times he would challenge me that, ‘which disease is that one that has to be taken to hospital at night?’…” FGD3 P9 (female)

DRAFT-NOT FOR DISTRIBUTION

“..…it is the one people are taken at night…why can they not be taken during the day?” One male respondent said

Parents expressed fear of possible harm to their infant during insertion of a gastric tube and the importance of avoiding painful procedures. Fear of potential short-term or long-term adverse events was put forward by discussants and is reflected in the following quotes;

“…you would fear because at times you would think that the child would swallow that thing (the tube)…” FGD1 P4 (female)

“…parents would fear that the child is suffering a lot.” FGD1 P1 (female)

Parents worried that any testing, particularly blood draws, was an HIV test.

Several studies assert that suspects can read TSTs as well as trained clinicians, suggesting that screening with TST might be simplified to 1 visit, and increase acceptability.[58]

5. Diabetics Acceptability of conducting screening among diabetics ranged from 94-96% in the two studies where it was documented. Of five studies selected in the initial screen, none proved to have qualitative insights into diabetic’s attitudes toward TB screening.

6. Drug dependent Consent to TB screening ranged from 69-100% among studies reporting refusal rates. From among 114 studies identified in the initial selection, five studies yielded qualitative information. Acceptability of conducting screening among persons who are drug dependent is challenging to summarize because screening programs tailored to this group may use a wide range of incentives and enablers, introducing a degree of heterogeneity into the screening process that makes generalization precarious or impossible. A total of 114 studies met the inclusion criteria, but only nine studies contained the proportion who accepted screening.

Table 8 Common Screening Algorithms used to diagnose TB among Substance abusers by Setting Study Settings Examples of Initial Examples of Subsequent screening algorithms Diagnostic steps High Incidence - - Medium incidence Sx Sm Clinical Sx Sm Moderate incidence TST IGRA CXR Sm Cx Sx CXR Low incidence CXR CXR Sm Cx TST CXR Sm Cx Clinical Sx CXR TST Sm

DRAFT-NOT FOR DISTRIBUTION

In New York in 1999, rates of return for TST results were 93% when a $15.00 incentive was given to injection drug users in a needle exchange program.[59] A later study in 2011, found less acceptance. Of 809 participants, 530 (66%) accepted a TST and 81% (429/530) returned for TST reading. Moreover, only 2 accepted further screening.[60] The wide range of acceptability in the same context with the same group may be a function of time or implementation , but could also be indicative of the presence of two distinct sub-groups within the drug dependent population—those who participate in harm reduction activities and those who don’t. Efforts to make screening a one step process would enhance acceptability. When TB screening was offered as part of a comprehensive bundle of primary care services to drug users in drug treatment program, 100% accepted and 87% were compliant with prophylaxis[61]. The physical co-location of TB screening within drug treatment programs is cited as a factor in acceptability.[6] In a San Francisco study, injection drug users refused a blood draw for IGRA 7% of the time, but more interestingly, phlebotomists failed to identify a vein in 8% of potential participants.[62]

7. Elderly Only two studies reported consent rates (72%,95%) for TST screening and both were among institutionalized elderly. Acceptability of conducting other types of TB screening among elderly populations is understudied. Of 364 TB studies in the elderly screening sample, 23 were flagged for review. Of these, only one contained information, indicating that nursing home residents are less likely to complete LTBI[63].

Table 9: common screening algorithms used to screen elderly in congregate settings Study Settings Examples of Initial Examples of Subsequent Diagnostic screening steps algorithms High Incidence Sx CXR, Sm, Cx, Other Medium incidence - - Moderate incidence TST CXR, Sm, Cx Low incidence CXR CXR CXR, TST CXR Clinical TST CXR, Sm, Cx, Clinical Sx, CXR, TST CXR, Sm, Cx, Other

Parenthetically, there was one cost effectiveness study.[64]. The aggregate tuberculosis incidence rate for nursing home residents in 29 of the United States was 1.8 times higher than the rate seen in elderly persons who were living in the community (95 percent confidence interval on the relative risk 1.64, 2.02).[65] This may imply that the elderly can be considered two distinct populations, and TB screening programs should be geared differently to ensure acceptability of screening in those in congregate settings.

8. Malnourished There were no studies of TB screening in malnourished populations available to review. Acceptability of conducting screening among malnourished persons has not been described in

DRAFT-NOT FOR DISTRIBUTION

the literature in great detail. A total of nineteen studies were flagged in initial screening, but none contained insights on screening acceptability in this group.

9. Mentally Ill Acceptability of conducting screening among persons with mental illness has not been studied in any depth as most screening programs take place in residential treatment programs or residential housing programs, and are compulsory or near compulsory[66]. Of the 292 records screened in step 1, zero studies appeared to explore acceptability as a subject. Recruitment rates in 3 studies of institutionally mentally ill patients ranged from 93 to 96% with a weighted mean of 95%. Acceptability may differ from ambulatory patients with less severe mental illness.

10. Persons with Previous TB Acceptability of conducting screening among persons with previous TB is understudied even though this is a priority group. There were no studies that gave recruitment rates for TB screening. However, one study of screening for hearing loss conducted in former TB patients had an acceptance rate of 97.6%.[67] A South African study of miners found 100% acceptance of HIV screening in those with previous TB.[68] These studies were used as proxies. In 77 studies in this population, there were none with relevant findings on acceptability of TB screening. In principle, this is a group that has already been TB screened and so one could assume that hypothetically screening was acceptable. On the other hand, relapse cases are more likely to be persons who found completion of TB treatment unacceptable, so special efforts are likely to be necessary to make screening acceptable in this population. Persons with previous TB are likely to be resident in congregate settings, or to have co-morbidities which may impair health seeking behavior and therefore insights for these populations are likely to apply with previous TB patients as well. [67, 69] At least one study of relapsed TB patients reveals a degree of hostility on the part of TB programs. One author asserted that persons with previous TB were “congesting health centers and impeding treatment routines and services”[70]. Another study suggests that this group is often invisible and misclassified as a new case in the passive system.[71] To design screening programs for this population, it may be more helpful to create screening approaches for two sub-populations – those with reinfection and those who relapse due to default. The defaulters will mostly likely need meaningful incentives and enablers to complete screening, diagnosis and treatment.[68]

11. PLHIV Consent to TB screening ranged from 52 to 100% in the 17 studied reviewed. The average was 86% consent, with a weighted average of 78%. Acceptability of conducting TB screening among people living with HIV or AIDS” (PLWHA) is an important issue even though screening guidelines have already been developed. In one study, the use of TST as part of the screening algorithm reduced the uptake of IPT (OR 3.93, 95%CI 1.18–16.04).[72]

DRAFT-NOT FOR DISTRIBUTION

Table 10 Common Screening Algorithms used to diagnose TB among PLWHA by Setting

Study Settings Examples of Initial Examples of Subsequent screening algorithms Diagnostic steps High CXR CXR Sm Incidence TST Sm Clinical Other TST Sm Cx CXR Sm Cx Sx CXR Sm Cx Clinical Sx CXR Cx Clinical Other Sx CXR Sm CXR Sm Cx Other Sx CXR Sm Cx CXR Sm Other Sx CXR Sm Cx Other Cx Sx CXR TST Sm Cx Other Sx CXR TST Other Sx CXR TST Sm Cx Sx CXR TST Sm Other Sx TST IGRA Cx Medium CXR Cx Clinical Other incidence CXR TST CXR Sm CXR TST Sm Cx Other CXR Sm Clinical Sm Sm Clinical Other Sx CXR Sm Cx Sx CXR CXR Sm Cx Clinical Sx CXR Sm Cx Cx Clinical Other Sx CXR Sm Cx Other CXR Sm Other Sx CXR TST Sm CXR TST Sm Cx Other Sx TST Moderate TST CXR Sm incidence Sx CXR Sm Cx Sx CXR Sm Cx Sx CXR TST Low incidence CXR TST CXR Cx Sm Cx CXR Sm Cx TST Clinical Other TST Other Sm Cx

Several studies suggest that TB screening should be bundled with other health care needs of PLHIV. In rural Mozambique a community outreach worker approach that combines HIV, TB, Vitamin A, and malaria screening improved accountability and satisfaction[73] A 2010 qualitative study in South Africa found that many HIV+ clients were not aware that TB could be prevented by IPT and had not been informed or offered TB screening.[74] Lack of clarity on the benefits of TB screening would certainly be a reason for low uptake in some settings.

12. Pregnant women

DRAFT-NOT FOR DISTRIBUTION

Consent to screen for TB ranged from 85-95%, with a weighted mean of 94%. Acceptability of conducting screening among pregnant women has been examined recently in India, South Africa, and Malawi.[75-77]. In five districts in Malawi, the majority of pregnant clients found the introduction of TB screening into antenatal clinics to be acceptable. Some expressed concern at submitting a second sputum specimen, citing transportation/distance as the main obstacle. Other concerns were stigma and fears relating to HIV and taking TB treatment during pregnancy and breast-feeding. Women in Bangladesh were less trusting that the results of TB screening would remain confidential and hence more likely to delay or avoid screening for symptoms[78]. Since there is some evidence that the risk of TB in pregnant women is greater in the post partum period, the timing of TB screening deserves greater scrutiny.[79] In a US study, 89.9% of pregnant women returned for their TST reading.[80] Efforts to make screening a one step process would enhance acceptability among pregnant women.[75]

Table 11 Common Screening Algorithms used to diagnose TB among Pregnant Women by Setting

Study Settings Examples of Initial Examples of Subsequent Diagnostic screening steps algorithms High Incidence TST Sm Cx sx Sm Cx Clinical Other Medium incidence Sx TST CXR Sm Cx CXR Sm Other Moderate incidence - - Low incidence CXR CXR TST CXR clinical Sx CXR Sm Cx Clinical Sx TST

13. Persons seeking VCT

A majority (70%) of persons seeking VCT for HIV accepted TB screening in four studies where the refusal rates were given. In a South African study from KwaZulu-Natal, the location of screening and confidentiality were critical to acceptability of VCT by adolescents: 43% of out of school youth stated a preference for a VCT site or hospital far from home, (or, if they could afford it, a private doctor), to reduce the chances of being seen by someone they knew.[81-82]

14. Smokers Acceptability of conducting screening among smokers is difficult to discern due to a lack of studies. No consent rates were given for the ten studies reviewed. One qualitative study suggested that smokers may refuse TB screening if they feel that a TB diagnosis would lead to additional pressure to give up smoking.

Oh. They worry about what they would find. That they might have it, yeah.

DRAFT-NOT FOR DISTRIBUTION

Because they smoke too much. We got a lot of smokers here. They are afraid they might find out what they have. And they don‘t want to ‘cause they do love to smoke. (53-year-old sheltered female)[46]

One of the barriers to reaching smokers is that there are not a homogenous risk group and may share very few common characteristics beyond their shared addiction. Combining TB screening with screening for other health risks in this population has potential. For example, implementing the ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) that enables early case detection has been widely promoted by WHO.10

Table 12. Consent for TB Screening among Congregate/Occupational Risk Groups studies studies weighted where where average of screening participation Average proportion was was Minimum Maximum proportion who consent mandatory voluntary consenting consenting who consent to TB and/or to TB to TB to TB screening refusal not Screening screening screening reported % % % % Congregate/Occupational/ Institutionalized Risk Groups Institutionalized 5 2 Mentally Ill 93 98 94 95 Institutionalized 4 2 Elderly 72 95 83 72 Factory and Farm 2 5 workers 95 100 98 97 Health care workers 7 5 56 91 78 59 Miners(6) + Ex- 6 6 miners (2) 66 93 81 70 Orphans, 1 1 institutionalized minors 71 71 71 71 Prisoners 18 16 18 98 71 72 Refugees/internally 7 2 displaced (IDP) 23 79 53 74 Residents of Urban 2 11 poor areas 59 99 87 91 Soldiers/Military 3 2 personnel 93 99.9 96 99 Transportation 0 3 workers 73 98 85 80

Congregate/Occupational/Environmental Risk Groups

15. Factory & Farm workers Twelve studies were thought to consider acceptability of conducting screening among factory and farm workers. However, upon closer inspection of abstracts, it became clear that screening was conducted in a compulsory manner in five studies conducted in Qatar, Iran, US, Kuwait,

10 Humeniuk RE, Ali RA, Babor TF, Farrell M, Formigoni ML, Jittiwutikarn J, Boerngen de Larcerda R, Ling W, Marsden J, Monteiro M, Nhiwhatiwa S, Pal H, Poznyak V & Simon S (2008). Validation of the Alcohol Smoking and Substance Involvement Screening Test (ASSIST). Addiction 103(6): 1039-1047

DRAFT-NOT FOR DISTRIBUTION

Taiwan and thus the issue of acceptability was not studied.[83-85] From among the remaining studies, consent ranged from 95-100% with a weighted average of 97%. Several authors have suggested that in certain settings TB screening programs run by industries may be a means of identifying and dismissing ill workers without compensation.[86] To increase uptake, it may be preferable to have screenings conducted by independent local health authorities or with union participation. CDC Recommendations on TB screening among migrant farm workers emphasize the importance of engaging outreach workers from the same cultural/language background as a means of increasing acceptability, but the data to support this recommendation was not provided, perhaps because it is rather commonsensical. [83] In South Africa, the use of lay health workers (LHW)on farms has been shown to be acceptable and cost effective for DOTS and may be also useful for symptom screening.[87-88] One Australian study of office workers found 89.7% (185/205) uptake of screening in the context of a contact investigation.[89]

16. Health care workers Participation rates in TB screening among Healthcare workers (HCWs) has been considered in a systematic literature review in 2007. A total of 25 publications were identified and the participation rates of HCWs in TST surveys ranged from 80 to 100%.[90] However, our review identified studies with acceptability as low as 56% and a weighted mean of 59%. In Edmonton, 72.4% of HCW who received a written letter inviting them to screening participated. Less than three quarters was described as evidence of high participation and acceptability in this population [91]. Compliance with annual screening of emergency workers in New York city was also 75%.[92] In Malaysia 90.8% of HCW accepted screening for LTBI. Across 14 hospitals in Melbourne, participation in LTBI screening varied widely from, 13%-66% suggesting a role of hospital administration and context in determining acceptability.. One study implied that HCW participation in screening was correlated to the perceived risk of TB in the workplace.[93] Another opinion piece implied that the competence of the occupational health nurse was a critical determinant .[94] Even when screening was compulsory among health workers, participation rates could be as low as 85% and not conform to the prescribed periodicity.[95-96] HCW in the US and Canada are less likely to complete LTBI treatment than the general population.[63] The screening steps for detecting a case of TB in health care workers varied in a review of the literature, but the two most common approaches were TST and Chest X-ray.

Table 13 Common Screening Algorithms used to diagnose TB among Healthcare Workers by Setting Study Settings Examples of Examples of Subsequent Initial screening Diagnostic steps algorithms High Incidence - - Medium incidence CXR Sm Cx Clinical Sx CXR TST Moderate incidence TST Sm Cx Other Sx TST IGRA

DRAFT-NOT FOR DISTRIBUTION

Low incidence CXR CXR CXR TST CXR Sm Cx TST TST IGRA Sx TST IGRA

A qualitative study by Joseph et al., 2004 quoted in the NICE reviews, indicated that some health care workers in low burden settings did not feel that the risk of TB merited annually screening. Fear of stigma from a LTBI diagnosis was mentioned by some participants.[97] Stronger sentiments were expressed in a qualitative paper on health care worker attitudes toward TB screening in Uganda by Buregyeya et al.[98] Health care workers expressed concerns that a TB diagnosis would not be maintained confidential by supervisors and colleagues would infer a positive HIV status. Health care workers wanted an off-site one-stop-shop where multiple health care services were offered. Some health care workers conducted screening tests on themselves as a way to mitigate any potential for stigma or breach of confidentiality.[98] In the Uganda survey of health care workers, none reported routine screening for TB, although 89% were willing to participate in a TB screening program

17. Miners Six studies reported recruitment rates varying from 66-93%, yielding a weighted average of 70% consent. Among 55 papers on TB screening among miners, there were no papers that specifically addressed the acceptability of conducting screening among miners qualitatively. This may be because occupational health regulations and best practices require regular TB screening. There were several studies of screening among ex-miners in which screening was voluntary. However, these screenings were often conducted to determine eligibility for monetary compensation for TB disease as an occupational disease, and although voluntary, were perhaps difficult to refuse.[99-100]. The economic implications of screening results are likely to heavily influence the acceptability of screening in this population.

Table 14 Common Screening algorithms for Miners Study Settings Examples of Examples of Subsequent Initial screening Diagnostic steps algorithms High Incidence Sx, CXR Sm, Cx, CXR, Clinical criteria CXR TST CXR sm cx Sx CXR Other Sm Cx Sx CXR Sm Cx Medium incidence - - Moderate incidence - - Low incidence CXR Sm Cx Other Sm, Cx, CXR TST CXR CXR TST Sm Cx

18. Orphans and minors in congregate settings.

DRAFT-NOT FOR DISTRIBUTION

The acceptability of conducting TB screening among orphans and children in congregate settings is difficult to characterize given the diversity in this group. One study found consent rates of 71% among adoptive parental of orphans. Since many countries require TB screening for international adoption, the TB burden among orphans in orphanages is well known, but the acceptability of screening is unexamined because it is compulsory. For example, studies of incarcerated children in Pakistan and youth enrolled in a jobs program in the US applied mandatory TB screening to residents.[101-102] Among older children in primary and secondary boarding schools there is also limited information. Three studies were identified. In Toronto, of 1775 eligible “high risk” students (i.e. foreign-born) 42.9% (761) agreed to participate in TB screening with TST, and 40.6% (720) were screened. Significant skin-test reaction's were detected in 22.5% (162/720) of the participants screened. Of these, 87.7% (142/162) saw a physician; subsequently, 2 cases of TB (1 active and 1 inactive) were detected. Of the remaining 140 students 44.3% (62) were prescribed isoniazid, of whom 9.7% (6/62) refused chemoprophylaxis.[103]

19. Prisoners Acceptability of conducting screening among prisoners is not widely understood because screening is often conducted without informed consent. Among 18 studies listing recruitment rates, the weighted average acceptability of TB screening was 72% with a range from 18 to 100%. A total of 241abstracts of studies were reviewed for acceptability information. In one Pakistani study, TB screening was accepted by 100% of randomly selected inmates, but HIV screening was rejected by 2.2% of the same cohort(8/365)[104] Some anecdotal and ethnographic work suggests that the acceptability of screening may be related to perceived benefits from a positive diagnosis, such as improved food quality or sleeping conditions. Acceptability of TB screening among prison staff and administration has been studied in the United States and Morocco. [105]Only 51% of jail leadership complied with annual TB screening of staff, potentially suggesting limited acceptability of current guidelines in this population.[106]. Similarly, a study in US lock ups reported “no time to screen inmates”.[107] While TB screening may be acceptable while incarcerated, compliance with treatment has been shown to be largely unacceptable for ex-prisoners in many settings.[63] [108-109] This is particularly the case when imprisoned TB patients are deported to a different country during TB treatment.[110] A qualitative evaluation of an educational intervention to improve screening in Honduran prisons concluded that low literacy health education materials, actively engaging prisoners in the campaigns, incorporating the language, values, and experiences encountered within prison culture would facilitate acceptance of TB control activities. Campaign weaknesses included the creation of illustrations that could perpetuate the stigma associated with TB and use of some materials in which the purpose was not apparent.[111] Acceptability in this population may also be related to the quality of screening, which has been shown to have deficits in some settings.[112] The screening steps for detecting a case of TB in prisoners varied, but the two most common approaches were symptom screen and chest X-rays.

Table 15: Common Screening algorithms for Prisoners by Setting Study Settings Examples of Initial Examples of Subsequent Diagnostic

DRAFT-NOT FOR DISTRIBUTION

screening algorithms steps High Incidence Sx CXR Sm Sx, CXR, sm CXR Sm Cx Clinical Sm Sm, Cx

Medium incidence Sx CXR, Sm Clinical Sm, Other Sm Sm Clinical Sm Cx Sm Cx Clinical Sm Cx Clinical Other Moderate Sx CX Sm Cx incidence Sx, CXR CXR Sm Cx Clinical Sx, CXR TST CXR Sm Cx Clinical Other Sx, TST, Sm, Cx Sm Cx Sm Cx Other Low incidence CXR CXR CXR, TST CXR Sm TST CXR Sm Cx Sx, CXR, TST CXR Sm Cx Clinical Sx, TST CXR Sm Cx Clinical Other Sm Cx

20. Refugees and internally displaced persons. Acceptability of conducting screening among refugees and internally displaced persons (IDPs) was a topic of nine studies, but only three gave consent rates, yielding a wide range of acceptability from 23 to 79%, with a weighted average of 74%. Levesque et al found in the Canadian context that acceptability of screening with Mantoux was 76.7% . Interestingly, perceiving tuberculosis as a severe disease (OR 0.29, 95% CI 0.09-0.91) and consulting for an immigration examination (OR 0.42, 95% CI 0.18-0.98) were associated with refusal of TST screening.[113] Two studies noted that although TB screening appears quite feasible, treatment adherence can be low. In one study among internally displaced populations in armed conflict, the ability to access screening depended on whether or not there was a curfew and whether or not the there was a separate examination room for screening to take place.[114] While this may suggest that IDPs are opposed to TB screening, it is likely that there are other operational and logistical factors affecting the uptake in these study contexts. The screening steps for detecting a case of TB in refugees in or coming from camps varied and are listed below.

Table 16 Common Screening Algorithms used to diagnose TB among Refugees and IDPs by Setting Study Settings Examples of Initial Examples of Subsequent Diagnostic screening steps algorithms High Incidence -- -- Medium incidence CXR CXR Sm Cx Sx CXR CXR Sm Cx Clinical Other

DRAFT-NOT FOR DISTRIBUTION

Sx CXR TST Sm Moderate incidence -- -- Low incidence CXR TST CXR Sm Other

21. Residents of Urban poor areas Among 11 studies reviewed, the range of consent for TB screening among urban household residents ranged from 59-99% with a weighted average of 91%. Acceptability of conducting screening among residents in urban poor areas has been researched in various regions. Tupasi et al concluded that symptom screening followed by sputum examination was acceptable in urban settlements in the Philippines.[115] Walton et al found that TB case-finding was acceptable in Haitian poor areas particularly when combined with other health services, such as reproductive health care and ART.[116] what makes this area challenging is that many of the large prevalence surveys do not report what incentives were given, making it hard to assess the generalizability of the findings. For more information, see the companion review on the acceptability of community screening (Mitchell et al 2012)

22. Soldiers and Military personnel Two of five studies reported a consent rate. These were 93 and 99.9%, yielding a weighted average of 99% consent. Acceptability of conducting screening among soldiers is understudied as screening is often compulsory. The screening steps for detecting a case of TB in military personnel varied, but the two most common approaches were TST, either with Chest X-ray or a symptom screen, and Chest X-ray alone.

Table 17: Common Screening algorithms used in diagnosis of TB in Military Populations Study Settings Examples of Examples of Subsequent Initial screening Diagnostic steps algorithms High Incidence - - Medium incidence CXR CXR CXR TST CXR Sm Cx Moderate incidence - - Low incidence CXR CXR CXR TST CXR Sm Cx TST Sm Cx Clinical Sx TST

23. Transportation workers Acceptability of conducting TB screening among transportation workers is under studied. Among three studies among bus and airplane workers with consent rates, the range was 73- 98%, with a weighted average of 80% acceptance. Edelson and Phypers conducted a systematic review of TB transmission on public transportation in 2011.[117] TB outbreaks on buses and trains are increasingly documented[118-119]. Among passengers in the Washington DC area, 92% of bus passengers approached consented to TST.[120]. The acceptability of mobile VCT has

DRAFT-NOT FOR DISTRIBUTION

been heavily studied in long haul truckers who engage in transactional sex, and it is widely acceptable. Gany et al (2005) found that while uptake of symptom screenings was high among immigrant taxi drivers in the UK, only 78(63%) of the 123 returned for TST readings suggesting a limited motivation for TB Screening. Among drivers with positive test results 64% were not treated for latent TB infection.

Table 18 Consent for TB Screening Among Marginalized Groups

studies studies weighted where where average of screening participation Average proportion was was Minimum Maximum proportion who consent mandatory voluntary consenting consenting who consent to TB and/or to TB to TB to TB screening refusal not Screening screening screening reported % % % % Homeless 2 6 41 100 79 96 Indigenous 2 9 40 97 82 69 Migrants 14 12 34 96 66 85 Men who have sex 2 3 with men (MSM) 64 91 85 Nomadic/pastoralis 2 0 t populations Sex workers 3 1 88 88 88 88 street children/ 0 0 street youth 86^ 99^ Transgenders 0 1 91 91 91 91

^HIV screening studies

24. Homeless The acceptability of conducting TB screening among people who are homeless has been studied in low incidence countries. We found a range from 41-100% consent for TB screening among 6 studies, with a weighted average of 96%. Three European studies in Glasgow, South London, and Rotterdam, before and after introduction of incentives for screening, suggest that acceptability is increased when incentives are offered and screening includes mobile digital X- ray units (MXUs).[121-124] One study highlighted two factors in screening uptake a)the quality of the rapport and b)perceived confidentiality as pivotal for women with children.[125] Similarly, a “culturally competent Nurse Case Management(NCM) approach, combined with incentives, was successful in Los Angeles.[126] A study in New Orleans had participation rate of only 52%[127] High acceptance of screening (89.93%) in shelters in Rome, was attributed to the novel use of an “integrated social network” approach.[128] A comparative study of factors associated with uptake of HIV testing among street youth in 2 US cities found that contact with an outreach worker did not necessarily increase acceptability of test.[129] A peer outreach model that embedded screening in a bundle of basic services— shelter, food, clothing appeared to be acceptable in one study, but it was not rigorously evaluated.[130] For some homeless adolescents, testing HIV positive was perceived as

DRAFT-NOT FOR DISTRIBUTION

advantageous in the procurement of basic needs such as food and shelter and screening was therefore highly acceptable.[131] The screening steps for detecting a case of TB in homeless persons in shelters or hostels varied, but the two most common approaches were chest X-ray and tuberculin skin testing. A combination of symptom screening, chest Xray, and tuberculin skin testing was used as frequently as TST alone.

Table 19: Common Screening algorithms for diagnosis of TB among Homeless persons Study Settings Examples of Initial Examples of screening algorithms Subsequent Diagnostic steps High Incidence -- -- Medium incidence -- -- Moderate incidence -- -- Low incidence CXR CXR CXR Sm CXR Cx CXR TST CXR Sm Cx TST CXR Sm Cx Clinical Sx CXR Sm Cx Sm Cx Sx CXR TST Sx CXR TST Sm Cx Sx TST Sx TST Sm Cx

25. Indigenous It is hard to summarize the acceptability of screening in this diverse group. Among nine studies included, the range was 40-97%, with a weighted average of 69%. Among indigenous children, participation rate in TST screening among the Cree in Canada was 94% suggesting it may vary by age cohort.[132] Acceptability of conducting screening among indigenous people is a topic treated in some depth in the Anthropological literature, but relatively neglected in the TB control community.. Two Canadian studies among the Inuit in Labrador and 10 groups in Alberta argued for early and meaningful involvement of the community in planning any screening program.[133] [134] Screening uptake was felt to be better if culturally relevant health education preceded it. Another Canadian study identified “negative memories and experiences relating to the colonial history of TB treatment “as a significant barrier to screening.[135] A study in remote Northern Australia identified discomfort with screening by non- indigenous clinicians. This problem was compounded by communication barriers.[136]. In Paraguay, the limited ability of the national program to address high rates of TB among the Ache were attributed to “hostile intergroup interactions” and “behavioral noncompliance”[137]. Similarly in Brazil, an “inadequate approach to patient during sputum collection” and “inadequate professional training” were felt to reduce the acceptability of screening in indigenous communities.[138] Several authors argue that an intercultural health system must be in place to ensure that the indigenous people will utilize TB screening. Conceptually, there are four fundamental prerequisites that must be present (United Nations, 2009):

DRAFT-NOT FOR DISTRIBUTION

1) Fundamental respect for human rights of indigenous peoples.

2) There must be recognition of indigenous people as unique. Indigenous people are often conflated with groups of “vulnerable people” or “the poor” which erases key differences.

3) There must be political will aiming at improving health of the indigenous group.

4) There must be a conscious decision on the part of the national society to engage in an exchange and sharing of knowledge, value and customs to overcome the mono culturalist structures.

Prior to starting active case finding or TB screening, the existing belief and practice about TB should be well understood and incorporating core elements of traditional belief systems proved useful[139] . Engagement of literate tribal youth volunteers was successful in one study in Tamil Nadu.[140] In an Ecuadorian study, screeners respected the busy hours and agricultural calendar of indigenous families. By conducting screening in early evening hours, acceptability was enhanced.[139]

26. Migrants Twelve studies on the acceptability of conducting screening among migrants were identified out of 169 reviewed. The range of consent was from 34-96% with a weighted average of 85%. Several studies had methodological flaws, most commonly, selection bias: only assessing acceptability of screening among migrants who had agreed to be TB screened. Screening of migrants can be controversial due to the political and international character of the exercise. [10, 141-142] The fact that it is typically compulsory makes it difficult to assess the acceptability of it by the proxy variable proportion screened. Only three studies posed the question of acceptability to migrants. Brewin et al queried migrants in a social service centre for asylum seekers, a hospital clinic for new entrants and primary care setting and found that in Britain TB screening was widely acceptable. This study did not include migrants who did not accept screening and this bias makes the findings hard to embrace. A study in Brescia, Italy found that” being unmarried, of Senegalese nationality, and being interviewed by a health-care worker in the same native language as the immigrant were significantly associated with completion of screening for LTBI. In the multiple logistic regression, being interviewed in the native language (OR 2.5, 95% CI 1.3-4.8, P=0.004) and being of Senegalese origin (OR 2.3, 95% CI 1.4-3.6, P=0.0005) were independently associated with adherence to LTBI screening.”[143] One study asserted that use of a “transcultural” perspective could overcome initial resistance to screening.[144] Evidence for this hypothesis using a pre/post design came from Italian study in which a dedicated nurse and cultural interpreter team were developed. Screening acceptability improved with the team approach, compared to the previous year (89% vs. 68%).[145] Somali migrants in London recommended engagement of Somali volunteers. [146] However a Swedish qualitative study of Somali migrants came to the opposite conclusion with regard to culture-matched/language-matched screeners. Interpreter use was expressed as a barrier particularly if of same female gender due to fear of breach of confidentiality both in the Somali community as well as to immigration authorities. [142]. Coreil et al. (2004) conducted focus

DRAFT-NOT FOR DISTRIBUTION

groups with Haitians living in South Florida and found that fear of confidentiality breach was also a disincentive to screening. A Netherlands study of QFT-GIT for screening found 61% consented to screening. Compared to non-consenters, the consenters were significantly more often from Sub-Saharan Africa (P=0.001) and countries with high TB incidences (P<0.001). Reasons for refusal were predominantly a lack of time and fear of having a blood draw[147].

27. Marginalized Men who have Sex with Men (MSM) The acceptability of conducting TB screening among marginalized men who have sex with men (i.e. MSM) has not been a significant focus of TB programs. Some NTP programs in low and middle income countries are not aware of the role that MSM play in their TB epidemics. Some TB programs staff believe MSM are largely concentrated in high income countries. However, MSM are widely dispersed geographically and are estimated to have 19.3 times higher odds of having 11 an HIV-infection than the general population in low- and middle-income countries. MSM make up a significant proportion of PLHIV studies in some settings with concentrated HIV epidemics, however their participation rates are not commonly disaggregated. Homosexuality has been found to be a risk factor for TB disease in homeless populations in the US. [148]Of thirty three studies of TB screening in MSM were identified, three articles provided information on the proportion who consented to screening in the context of contact tracing—two from the US and one from Bangladesh.[72, 149-150] Acceptability of TB screening ranged from 43% to 91%.[150]. Several large studies of TB screening in MSM did not list consent rates, possible due to the use of snowball sampling .[151-152]. Peer-to-peer referral for TB screening has been shown to be acceptable in MSM sex workers population.[152]

28. Nomadic /Pastoralist populations Although it is often assumed that nomadic populations will not have high rates of M. Tb, in the 2010 Ethiopia Prevalence survey, the point prevalence of smear positive TB among pastoralists was 167/100,000 (95% CI 64-269) among 4255 screened. This is almost three times the TB rate in urban clusters of 77/100,000 (95% CI 0-159) and almost double the rate of rural clusters of 103/100,000(95% CI 62-143). Acceptability of conducting screening among nomadic and pastoralist populations is an important topic, but accessibility of screening is perhaps the bigger obstacle to effective TB screening in this group.[153-155] The acceptability of mobile VCT has been studied in this population and uptake is not high[156-158]. Pastoralists in Kenya have gender differences in rates of MTb reflecting differential access to care and health seeking behavior.[159] The novel use of “TB villages” as TB treatment sites has been successful and could be perhaps modified for TB screening.[160] Screening in this population should not rely solely on smear microscopy or TST because of the high rates of M .bovis in this population.

29. Sex workers

11 Baral S, Sifakis F, Cleghorn F, & Beyrer C. Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000-2006: a systematic review. PLoS Med.2007;4(12):e339.

DRAFT-NOT FOR DISTRIBUTION

Acceptability of conducting TB screening among sex workers has attracted little scholarly attention although the rates of TB are very high[161]. In one US study assessing the willingness of sex workers to be screened for TB in an outbreak investigation among exotic dancers, the uptake was 88%. In a 1997 Kenya study among a cohort 745 female sex workers, the use of TST was abandoned after six months due to its unpopularity among participants, suggesting that other screening techniques are likely to be more acceptable.[161] Peer-to-peer referral for TB screening in Bangladesh has been shown to be highly acceptable in both male and female sex workers population particularly when combined with provision of hygiene facilities.[152] The acceptability of mobile VCT and different modalities of STI screening have been heavily studied in this population and we can infer a high rate of uptake.

30. Street children / abandoned children/ out of school youth Acceptability of conducting TB screening among street children has not been rigorously scrutinized. However, it is clear that screening programs for street children can be complex due to varying legal requirements for parental consent and mandatory disclosure laws in some settings.[162]. The acceptability of mobile VCT and other health services has been heavily studied in this population. The abstracts of one hundred studies were identified and reviewed, however none described acceptability of TB screening specifically. Studies of other types of screening can yield insights into the potential acceptability of TB screening in street children. A number of ethnographic studies identified a non-specific distrust of formal social and health services and harassment by police as negative influences on attitudes toward public health services.[163] In Montreal a cohort of street youth was HIV tested every six months for six years and retention was 86%.[164] This suggests that screening is acceptable when coupled with incentives. In Toronto, as many as 99.7% (695/697) of street youth who were offered incentives provided a saliva or blood specimen for screening, however incentives were not defined.[165] A comparative trial of factors associated with uptake of HIV testing among street youth in 2 US cities found that contact with an outreach worker did not necessarily increase acceptability of test.[129] A peer outreach model that embedded screening in a bundle of basic services— shelter, food, clothing appeared to be acceptable in one study, but it was not rigorously evaluated.[130] For some homeless adolescents, testing HIV positive was perceived as advantageous in the procurement of basic needs such as food and shelter and screening was therefore highly acceptable.[131]

31. Transgender Acceptability of conducting screening among transgender persons has been understudied. One study in an outbreak on the East Coast of the US had a consent rate of 91%, while in Bangladesh 77% of Transgenders with chronic cough were willing to provide sputum samples.[150, 152] Many studies use word of mouth and peer referral which makes a recruitment rate difficult to collect. The acceptability of mobile VCT and STI screening has been heavily studied in this population. Traditional contact investigation has proved inconvenient with transgender people. Instead, CDC reports an experience in the US in which transgender social networks and “houses” were explored. This strategy was accompanied by place-based TB screenings in bars and social spaces.

DRAFT-NOT FOR DISTRIBUTION

Transgender women in New York and Bangladesh felt comfortable when visiting a community-based clinic that did not specify that it treated LGBTQ people because for many of them identifying as a woman was important. The work of the clinic was spread by word of mouth, and by references of other transgender people who made use of its services. The staff refer to the people by their preferred names instead of their legal names, for example, and offer a caring environment to their patients and a holistic approach to their health, which included hormones therapy (Melendez & Pinto, 2009). Transgender people have been successfully trained as TB screeners and sputum collectors in Dhaka.[152]

32. Screening of Contacts of a TB Case

Despite the importance of reaching Contacts of a TB case, the success of outreach efforts often varies widely. In a multicultural setting, acceptability may depend on the ability of the health system to overcome cultural and communication challenges. In the Netherlands TB contact investigations are less likely to be conducted when the index-cases are from non- Western countries (89% vs. 93%, POR 0.6, 95%CI 0.5-0.7).[166-167] Even though a Netherlands study of QFT-GIT found that non-Western suspects (P=0.001) and those from countries with high TB incidences (P<0.001) were more likely to consent to screening. Reasons for refusal were predominantly a lack of time and fear of having a blood draw[147]. There are various speculations as to the causes of disparity including: fear of stigma, unwillingness to participate, concurrent double screening policies (immigration), communication difficulties between health care worker and contacts, and financial barriers to compliance. Contact Tracing in households (91%± 17%) and communities (85%± 12%) may be slightly more acceptable than CT initiated as the result of a health care outbreak 73%(±145), but the number of studies in health settings was low.

Table 20 : Acceptability of Contact Tracing by Type Type of Contact Std. Tracing Mean N Deviation Minimum Maximum Median Range Contract Tracing- 80% 24 0,17 39% 99% 85% 60% Household Contact Tracing- 88% 27 0,12 57% 100% 91% 42% Community Contact Tracing- 59% 4 0,14 43% 73% 60% 30% Health care Contact Tracing- 87% 3 0,07 83% 95% 84% 12% Other

Table 21 Common Screening Algorithms used to diagnose TB among Contacts by Setting

Study Examples of Initial screening Examples of Subsequent Settings algorithms Diagnostic steps High CXR CXR Incidence CXR Sm CXR Clinical CXR Sm Cx CXR Clinical Other CXR TST CXR Cx Clinical Other

DRAFT-NOT FOR DISTRIBUTION

Sm CXR Sm Clinical Sm Cx CXR Sm Clinical Other Sm CXR Sm Cx Sx CXR Sm CXR Sm Cx Clinical Sx CXR TST Cx Sx CXR TST Cx Other Sm Sx CXR TST Sm Cx Other Sm Cx Sx Sm Cx Sx TST Medium CXR CXR incidence CXR TST CXR Clinical CXR TST IGRA CXR Sm Clinical CXR TST Other CXR Sm Cx Sm CXR Sm Cx Clinical TST CXR Sm Cx Clinical Other Sx Sm Sx CXR Sm Cx Sx CXR Sm Sm Cx Other Sx CXR TST Sx CXR TST Sm Sx TST Moderate CXR CXR Sm incidence CXR TST CXR Sm Clinical CXR TST IGRA Other CXR Sm Cx CXR TST IGRA Sm Cx CXR Sm Cx Clinical Sx CXR TST CXR Sm Cx Clinical Other Sx CXR TST Sm CXR Sm Cx Other Sx TST Clinical Sx TST Sm Sm Clinical Other Sm Cx Low CXR CXR incidence CXR TST CXR Clinical CXR TST IGRA CXR Clinical Other CXR TST Other CXR Cx CXR TST Sm CXR Cx Clinical CXR TST Sm Cx CXR Cx Clinical OThe IGRA CXR Other TST CXR Sm TST IGRA CXR Sm Clinical TST Other CXR Sm Cx TST Sm Cx Other CXR Sm Cx Clinical Sx CXR CXR Sm Cx Clinical Other Sx CXR TST CXR Sm Cx Other Sx CXR TST IGRA Cx Sx CXR TST Other Sm Sx TST Sm CX Sx TST IGRA Sx TST Other

Generalizing about acceptability of contact tracing is difficult because there is so much variation in the intensity of the tracing that it may be difficult to aggregate the data meaningfully. The inverse relationship between intensity of tracing and acceptability is illustrated by this example from a TB REACH project

DRAFT-NOT FOR DISTRIBUTION

Yemen where refusal rates increase with a proportional decrease in the number of household visits made by the implementers.

Table 22 Changes in Screening Uptake over time in Yemen Q2: Jan- Q3: Apr- Q4: Jul-Sept Q5: Oct- Mar 11 Jun 11 11 Dec2011 Number of adult index cases invited to 622 902 1084 participate 409 Number of adult index cases who have 622 902 1084 relatives at home 409 384 586 840 1003 Number of Household visits Number of household contacts 1029 2644 3669 5041 screened for symptoms Number of index cases who refused 15 36 62 81 household visit or to bring their HH to be investigated 3.7% 5.7% 6.8% 7.5% Refusal rate of TB Contacts

Risk of bias across studies

There is a very strong likelihood of publication and selection bias in the studies that met the inclusion criteria, but the severity of the bias could not be effectively measured. The likely direction of the bias is towards acceptability of screening.

DISCUSSION

There were 13 groups whose acceptance of TB screening was consistently high.

Table 23 . Groups with Weighted mean Acceptability above 80% in Rank order

Std. Mean weighted. Deviation Minimum Maximum Median Risk Groups % mean % % % % % 22. Soldiers/Military 96 99 0.05 93 100 96 15. Farm & Factory (5) 97 97 0.02 95 98 98 25. Homeless (5) 66 96 0.24 41 97 75 13. Mentally Ill ((2) 94 95 0.02 93 95 94 5. Diabetics (2) 96 94 0.03 94 98 96 10. Pregnancy (3) 85 94 0.12 68 96 90 6. Drug Dependent (5) 84 93 0.13 69 94 89 21. Residents of Urban 87 59 99 poor areas (11) 91 30. Sex Worker(1) 88 88 .0 88 88 88 4.Children Under 5 (2) 87 87 84 91 24. Transport workers (3) 85 86 0.13 73 98 84

27. Migrants (8) 77 85 0.15 55 96 81 - PMTCT (3) 79 81 68 96 - Immigration 73 80 0.20 34 96 79

DRAFT-NOT FOR DISTRIBUTION

3. Adolescents (3) 72 80 .14 58 96 79

There were six groups whose weighted mean acceptability was reasonable, ranging from 70%-79%. TB screening in these groups is acceptable to the majority of those to whom it offered voluntarily, but is not universally embraced. Many of these groups currently undergo mandatory screening due to their extremely high risk of TB disease, so their feelings about screening may have little practical implications. Health care workers have the lowest consent rates for screening of the risk groups included.

Table 24 . Groups with Weighted mean Acceptability above 50% in Rank order

Std. Mean Weighted Deviation Minimum Maximum Median Risk Groups % mean % % % % % Transgenders (2) 77 79 0.07 77 91 84

PLIHIV (18) 82 0.13 52 99 83 78 Refugee Camps/IDP (2) 41 0.25 23 58 41 74 Elderly- Institutionalized (2) 83 0.17 72 95 83 72 Prisoners (16) 71 0.29 18 98 86 72 Miners (6) 81 0.11 66 93 84 70

Indigenous populations, Persons testing for HIV (VCT), Attendees of Health centers , men who have sex with men (MSM) , and Health Care Workers (HCW) had consent rates ranging from 59-69%. This is curious because common sense would suggest that attendees at health care centers, persons testing at VCT centers, and health care workers would seem the easiest and most willing to be TB screened. One possibility is that the lower recruitment rates are more a function of staff screening efforts and less a reflection of individual attitudes toward screening. In other words, this may reflect partial or uneven implementation of recruitment of TB screening more that actual acceptability. Or alternatively, the weighted mean is biased downwards by a few particularly unpopular large screening efforts because the media acceptability is still high in these groups. The proportion of eligible persons who ultimately participate in screening is an imperfect though highly convenient proxy of the acceptability of screening in a population. Consent has been shown to be influenced by the demeanor of the research staff, incentives offered, and other intangibles.

Table 25 . Groups with Weighted mean Acceptability below 70% in Rank order

Std. Mean Weighted Deviation Minimum Maximum Median Risk Groups % mean % % % % % Indigenous (9) 82 0.20 40 97 89 69 Persons testing for HIV (VCT) (4) 73 0.23 41 97 85 69 Attendees of Health centers (3) 59 0.07 52 67 57 68 MSM (2) 76 0.48 64 91 - 61 Health Care Workers (5) 78 0.14 56 91 80 59

Alcohol dependent persons, the Malnourished, Nomadic/pastoralist populations, Orphans/Children in congregate settings, Persons with Previous TB, Smokers, and Street children/ street youth did not have TB screening studies with relevant information, so they were excluded from the quantitative part of this review.

DRAFT-NOT FOR DISTRIBUTION

Bar surveys are a common feature of public health surveillance in many areas and have been shown to be well accepted.[168-169] Otherwise hard-to-reach individuals are often more willing to participate in surveys in a bar setting than in other settings (Ross et al, 2008). Bars often represent an important space for social networking for migrants, ex-prisoners, smokers, alcohol users, immune-compromised persons, the elderly, sex workers, and the homeless (Measure, 2008). Bars may also serve individuals with diabetes and/or mental health issues. The advantage of a place survey over other types of surveys is that it does not explicitly target certain groups or require self-disclosure of hidden or stigmatized populations. Therefore it can avoid some of the problems with stigma, refusal and non-response that clinic-based surveys encounter (Measure, 2008).[170]

Limitations This synthesis has a number of limitations. The most serious limitation of these analyses is the dearth of studies that truly focus on acceptability of screening. The lack of qualitative ethnographic work on reasons for refusal of TB screening, as well as the perceived risks and benefits of screening, and the incomplete descriptions of methods in many TB studies complicates the search for clear answers [10, 171]. Out of necessity a “vote with your feet” proxy for acceptability (% screened among # eligible) has been employed. However, we acknowledge that “Acceptability” is a composite social construct that denotes more complex and inter-related ideas. It is very difficult to quantify and synthesize because acceptability is already a synthesis.[172] . It is unclear if the recruitment rates of well-executed, well-resourced studies found here can be deemed as legitimate proxies for acceptability of screening in routine programmatic settings. Unfortunately the bulk of the published literature concerned TST screening in low incidence settings and this is likely to be a poor proxy for the acceptability of symptom screening and other less invasive and less cumbersome methods. Another limitation is that is includes only cross sectional studies, but a proper answer to the acceptability question might also consider the inclusion of longitudinal cohort studies with periodic screening[173].12 There is preliminary evidence that a population that is subject to too frequent TB screening may under-report symptoms to avoid invasive testing.13 This review is likely to be affected by significant degree of reporting bias and publication bias which may over estimate the acceptability of screening since studies with high refusal rates face bigger hurdles to publication. To overcome this challenge, authors have triangulated data from published and unpublished reports of the same study to detect reporting bias and have included studies that were never published to attempt to mitigate the potential publication bias. Such a high level synthesis in the face of significant methodological diversity is a perennial challenge of the systematic review technique and it was not always possible to report key nuances and make concise summary tables[174-175]. Statistical methods for combination of qualitative and quantitative data, where there are many missing values, such as Bayesian augmentation methods might have been more appropriate for this analysis.[176-177] Marked

12 Quoted in Corbett et al 2010 “In the 12% of ”households randomly selected for survey of tuberculosis” and HIV prevalence, 10 092 adults (81% of 12 426) provided” sputum before intervention and 11 211 (77% of 14 569)”provided sputum after five rounds of intervention, with” lower participation in men (65% [3970/6151] before” intervention, 57% [4061/7185] after intervention) than in” women (98% [6121/6275] before intervention, 97%”[7150/7384] after intervention; web appendix p 5). 13 Nduba VN; Anja Van’t Hoog; Mitchell E.M.H.;, O.P.L.K.B.M.W., The Incidence of Tuberculosis in Adolescents, Western Kenya; Implications for Tuberculosis Vaccine Trials. In preparation.

DRAFT-NOT FOR DISTRIBUTION

differences by age and gender within risk groups in some settings suggest that ACF/screening has other dimensions that preclude broad generalizations about acceptability.[173, 178] Finally, some have argued that it is highly problematic to look at acceptability of the primary screening step in isolation from acceptability of diagnosis and treatment. Where is has been possible (e.g. adolescents) we have included the slope of the drop off between the primary and secondary screening step to try to indicate the full refusal.

Conclusions

Despite a lack of attention to the issue of acceptability in screening and active case finding among populations exposed to is, it can be inferred that community –based screening or active case finding is widely acceptable in most contexts, including hard to reach communities, conflict zones, and among most at-risk and vulnerable groups. This review used a comprehensive strategy and creative approach to identify potential studies on acceptability of screening within a very large literature on active case finding. The main strengths of the analysis are the diverse sources from which the results were drawn and the harmonization of disparate study results into coherent, digestible information. TB screening initiatives are well received by most risk groups (59-99%) and acceptability can be enhanced with the group-specific modifications described in the qualitative literature. Researchers should take greater care in documenting and reporting acceptance and refusal rates. The issue of acceptability among health workers must also be further considered, since they seem to be the least enthusiastic about TB screening, despite being perhaps the most cognizant of its benefits.[10]

FUNDING

This study was funded by the United States Agency for International Development under the USAID Tuberculosis CARE I, Cooperative Agreement No. AID-OAA-A-10-000020. The funder had no role in the design, data collection or interpretation of the results of this review. Appendices

DRAFT-NOT FOR DISTRIBUTION

Appendix 2 Search Strategy for : What is the acceptability of universal TB screening among specific risk groups in the 1985-April 2011 period?

Eligibility criteria

1. TIME SPAN = 1985-April 2011 2. LANGUAGES = English, Spanish, Portuguese, French, Dutch, German, 3. Peer-Review literature: EMBASE or ISI Web of Science 4. Grey Literature: WHO website or KNCV TB Foundation Archive

5. TITLE CONTAINED ONE OF THE FOLLOWING = 42,204  tubercul*  lung tuberculosis  pulmonary consumption  consumption, pulmonary  TB

6. COMBINED WITH ARTICLES ON SUBJECTS BELOW= >100,000

1. case find* 14. pre-employment + 26. outreach 2. mass + radiograph* testing 27. mobiliz* 3. screen* 15. undiagnos* 28. grass-root* 4. contact examin* 16. missed* 29. community + 5. screening survey* 17. delay* involvement 6. cross-sectional 18. contact trac* 30. community + 7. case-detect* 19. incidence particip* 8. detect* 20. checking 31. empower* 9. case-find* 21. pre-entry 32. grass-root$ 10. prevalence + stud* 22. intensified + case 33. civil society 11. contact investigat* 23. active + case 34. engage* 12. algorithm 24. passive 35. reach 13. household + survey 25. TB suspect*

7. The TB Screening/Active case finding universe was 27,230 records

8. ANY ARTICLES WITH TITLES CONTAINING THESES WORDS WERE EXCLUDED:

1. deer 13. survival 24. drug resistance 2. cattle 14. biopsy survey* 3. possum 15. interferon-gamma 25. re-vaccination 4. macaque* 16. pathophysiology 26. candidate 5. guinea pig* 17. mortality 27. bovi* 6. animal 18. clinical + outcome* 28. non-tubercul* 7. vaccine 19. meningitis 29. strain 8. BCG 20. Treatment+ 30. Case+ report 9. mice outcome* 31. dose-response 10. regimen 21. genotyp* 32. adverse 11. fixed-dose 22. bacille Calmette 33. phenotyp* 12. side-effect* 23. Missing+data

6. The TB screening/Active case finding universe was therefore reduced to 14,315 records

DRAFT-NOT FOR DISTRIBUTION

Note: When a search yielded more than 500 hits on a particular risk group, we could not download them from web of science, so we applied these additional exclusion criteria:

EXCLUDE ARTICLES ON Subject Areas=

1. Agriculture, 2. Allergy 30. Microbiology 3. Anatomy & Morphology 31. Multidisciplinary 4. Anesthesiology 32. NephrologyNeuroimaging 5. Applied Radiology, 33. Nuclear Medicine 6. Biochemistry & Molecular Biology 34. Nutrition & Dietetics 7. Biology 35. Oncology 8. Biophysics 36. Ophthalmology 9. Cardiac & Cardiovascular Systems 37. Oral Surgery & Medicine 10. Cell Biology 38. Orthopedics 11. Chemistry, 39. Otorhinolaryngology 12. Chemistry, Medicinal 40. Parasitology 13. Chemistry, Organic 41. Pathology 14. Dentistry, 42. Pharmacology & Pharmacy 15. Dermatology 43. Physical 16. Ecology 44. Rehabilitation 17. Endocrinology & Metabolism 45. Rheumatology 18. Engineering, Biomedical 46. Surgery 19. Environmental Sciences 47. Toxicology 20. Evolutionary Biology 48. Urology 21. Food Science & Technology 49. Veterinary Sciences 22. Gastroenterology & Hepatology 50. Virology 23. Genetics & Heredity 51. Zoology 24. Geriatrics & Gerontology 25. Gerontology 26. Hematology 27. History & Philosophy Of Science 28. Immunology 29. Legal Mathematical & Computational Biology

7. In the case of HIV and children under 5 risk groups, there were over 10,000 results returned, so to concentrate on high burden countries, we excluded the following Countries/Territories=

1. USA 18. Greenland 2. Wales 19. Luxembourg 3. England 20. Norway ) 4. France 5. Switzerland 6. Canada 7. Netherlands 8. Spain 9. Italy 10. Finland 11. Australia 12. Germany 13. Denmark 14. Belgium 15. Ireland 16. Sweden 17. Portugal

DRAFT-NOT FOR DISTRIBUTION

Table 26: Search Sub-Strategies for Identifying Risk Groups Within the TB Screening Document Universe At-Risk or Search strategy modification # of # of Manuals, Vulnerable Group records in Records guidelines, EMBASE in ISI norms, Web of Science Risk Groups found in health services General search for Topic=(acceptability) AND Topic=(screening) AND 71 57 131 qualitative work Topic=(qualitative) 1. Alcohol dependent alcohol.mp. or exp ALCOHOL/ 159 284 5 409 2. Attendees of health TI=(primarySAME care OR waiting SAME room OR out 17* 26 4* 26 care facilities SAME patient OR emergency SAME department) 3. Children under 5 (children or infant or orphan or adoles* 1437 622 15 1959 4. Diabetics (TS=diabetes.mp. or exp diabetes mellitus) 196 107 5 131

5. Drug dependent TS= (drug dependen* OR residential treatment OR refined by: [excluding] subject areas=( 2573* 202 11 297 cannibis OR intraven* drug abuse OR illicit drug OR cell biology or food science & technology detox* OR drug abuse* OR misuse OR injection drug use* or chemistry, organic or microbiology or OR street drug OR recreational drug OR opioid OR oncology or urology & nephrology or methamphetamine OR methadone OR cocaine OR crack parasitology or cardiac & cardiovascular cocaine OR drug-use OR IDU OR marijuana OR substance systems or virology or chemistry, applied use* OR substance abuse* OR drug rehabilitation OR or clinical neurology or toxicology or amphetamine* ) chemistry, medicinal or computer science, interdisciplinary applications or transplantation ) 6. Elderly (older or elder* or senior or geriat*).mp. [mp=title, 364 318 517 abstract, subject headings, heading word, drug trade name, original title, device manufacturer, drug manufacturer] 7. Malnourished TS=(hunger OR malnourish* OR famish* OR underweight refined by: [excluding] subject areas=( 146 102 0 458 OR stunt* OR food insecur* OR nutrition* OR underfed* evolutionary biology or surgery or OR undernourish* OR starv* OR wast* OR famine) gastroenterology & hepatology or urology & nephrology or genetics & heredity or virology or oncology or toxicology or orthopedics or transplantation or parasitology or marine & freshwater biology or agronomy or plant sciences or fisheries or cell biology or soil science or zoology or chemistry, medicinal or

DRAFT-NOT FOR DISTRIBUTION

At-Risk or Search strategy modification # of # of Manuals, Vulnerable Group records in Records guidelines, EMBASE in ISI norms, Web of Science endocrinology & metabolism )

8. Mentally Ill (mental* SAME ill* or mental disease or mental health or 291 103 3 274 psych* or cogniti* or disab*) 9. Persons with TI=(previous OR prior OR relaps* OR re-infect*) 45 54 77 Previous TB 10. PLHIV TI= (HIV or TB/HIV or immunecompromise or human 2,169 486 36 679 immunodeficiency virus or co-infect* or AIDS) 11. Pregnant women (pregnan* OR antenatal OR women of reproductive age 193 106 4 237 OR matern* 12. smokers TS=(nicotine or tobacco or smoke*) refined by: [excluding] subject areas=( 247 83 4 262 biochemistry & molecular biology or obstetrics & gynecology or biology or pathology or cell biology or toxicology or zoology )

Congregate/occupational/environmental 13. Factory worker TS=(factory OR maquila* OR sweat SAME shop OR textile 154 93 2 168 SAME industr* OR garment SAME industr* OR work SAME camp OR plantation OR worker OR labor SAME camp OR occupation*SAME expos* OR labor SAME conditions OR factories) 14. Health care worker TI=(healthcare SAME worker* or nurs* or doctor* or 347 184 15 440 outreach SAME work* or healthcare SAME workforce or occupational or clinician* or occupational exposur* or nosocomial SAME transmission or hospital) 15. Miner TS=((mine* OR silic* OR shaft OR mining ) NOT data 55 98 4 153 SAME mining) 16. orphans/abandoned children 17. Prisoner TS=(prison* or correction* or institutionalized or 241 291 12 465 incarcerat* or jail* or detent* or convict* or offender* or penal or penitent* or reformatory or congregat*) 18. Resident of Urban (shanty or slum or favela or urban or squatter settlement TI= (shant* OR slum OR favela OR urban* 504 495 11 629 slum or housing or crowding or informal settlement or shack OR squatter* SAME settlement OR

DRAFT-NOT FOR DISTRIBUTION

At-Risk or Search strategy modification # of # of Manuals, Vulnerable Group records in Records guidelines, EMBASE in ISI norms, Web of Science or ghetto).mp. [mp=title, abstract, subject headings, housing* OR crowd* OR informal* SAME heading word, drug trade name, original title, device settlement* OR shack OR ghetto OR manufacturer, drug manufacturer] tenament* OR dwell* OR township OR barrio OR densely SAMEpopulat* ) 19. Soldier TS=(soldier* or armed SAME forces or military or 9 64 0 73 veteran* or troop or enlisted or armed SAME service*) 20. Transportation TI=(transport* OR truck* SAME driver* OR bus SAME - 27 0 27 workers/ Truck drive* OR taxi OR public SAME transport OR bus OR drivers/ driver)

21. Refugee, Internally TS=( refugee or internally displaced or traveler or asylum 124 48 2 180 displaced seek*) Behavioral/marginalized 22. At-risk general TI=((vulnerable SAME population* or special SAME refined by: [excluding] subject areas=( 171 population* OR high-risk SAME group* or at-risk or oncology or evolutionary biology or highest risk or risk SAME communit*) NOT TI=factor* cardiac & cardiovascular systems or mathematical & computational biology or immunology or genetics & heredity or nutrition & dietetics or virology or orthopedics or rheumatology or pathology or pharmacology & pharmacy or biology or surgery or urology & nephrology or veterinary sciences )

23. Homeless TI=(homeless OR shelter* OR transient OR non- 74 73 5* 73 residential OR itinerant) 24. Indigenous TS=(indigenous or native* or aboriginal* or ethnic or refined by: [excluding] subject areas=( 46 287 3 298 indigen* or tribal or minorit* or caste or autochthon* ) evolutionary biology or fisheries or geosciences, multidisciplinary or immunology or plant sciences or zoology or urology & nephrology or archaeology or biology or transplantation or veterinary sciences or virology ) 25. Migrant, Migrant or traveler or Roma or tinker or immigra* or 20 458 18 476 seasonal SAME worker

DRAFT-NOT FOR DISTRIBUTION

At-Risk or Search strategy modification # of # of Manuals, Vulnerable Group records in Records guidelines, EMBASE in ISI norms, Web of Science 26. MSM TS=(homosex* OR gay OR queer OR same-sex OR 24 28 1 31 homoero* OR msm OR sexual* OR same sex OR sexual network OR social network OR gay-identified OR bisexual OR bi-sexual) 27. Nomadic pastoralist TS=(nomad* OR itinerant OR pastoralist) populations 28. Sex worker TS= (sex SAME work* OR sex SAME trade OR prostitut* 8 14 2 17 OR escort OR transactional SAME sex OR commercial SAME sex*OR sex SAME traffi* OR courtesan OR sex SAME exchange) 29. street children/ TI=(street child* OR street youth OR child labor OR rag 43 50 4 69 picker* OR out-of-school OR runaway OR child beggar* OR children on the street OR children of the street ) 30. Transgender TS= (transgender* OR transvest* OR transexu* OR See below 2 2 1 55* intersex* OR sexual minority OR female-identif* OR male- identif* OR sexual devian* OR sexual divers* OR gender dysphori* OR transman* OR transwoma* OR hijra OR kathoey

Table 27 Transgender Expanded Search TI= (transgender* OR transvest* OR transexu* OR intersex* OR sexual WEBS OF SCIENCE Databases=SCI-EXPANDED, 2,612 minority OR female-identif* OR male-identif* OR sexual devian* OR sexual SSCI, A&HCI Timespan=1985-2011 divers* OR gender dysphori* OR transman* OR transwoma* OR hijra OR kathoey)

TI= (health care OR health seek*OR barrier*) WEBS OF SCIENCE Databases=SCI-EXPANDED, 48,722 Databases=SCI-EXPANDED, SSCI, A&HCI Timespan=1985-2011 SSCI, A&HCI Timespan=1985-2011 Lemmatization=On

COMBINED ABOVE 39

Checked refs of these cites 16 TOTAL 55

DRAFT-NOT FOR DISTRIBUTION

Table 28 Expanded Search strategy for street children search criteria (and any limitations)

TOPIC = (tubercul* OR lung tuberculosis OR pulmonary consumption OR consumption, pulmonary NOT animal NOT non-tubercul* NOT bovis NOT 34,000+ gene* NOT antibody*) AND TOPIC=(case find* OR mass radiograph* OR screen* OR contact examin* OR screening survey* OR cross-sectional OR case- detect* OR detect* OR case-find* OR prevalence stud* OR contact investigat* OR algorithm OR household OR pre-employment OR testing OR undiagnos* OR missed* or delayed* OR eval* OR incidence OR checking OR assessment OR pre-entry OR care-seeking OR mandatory OR voluntary)

TITLE= TI=(street child* OR street youth OR child labor OR rag picker* OR out-of-school OR # of Records in 0 runaway OR child beggar* OR children on the street OR children of the street ) AND the above ISI Web of Science TITLE= TI=(street child* OR street youth OR child labor OR rag picker* OR out-of-school OR # of Records in 50 runaway OR child beggar* OR children on the street OR children of the street ) AND TI=HIV ISI Web of Science ((street child* or street youth or child labor or rag picker* or out-of-school or runaway or # of records in 0 child beggar* or children on the street or children of the street).m_titl. AND the first row EMBASE ((street child* or street youth or child labor or rag picker* or out-of-school or runaway or # of records in 43 child beggar* or children on the street or children of the street).m_titl. AND TI=HIV EMBASE duplicates REMOVED 24 TOTAL 69

DRAFT-NOT FOR DISTRIBUTION

GFATM Global Fund to Fight AIDS, TBand PLWHA People living with HIV/AIDS Malaria PLWHA, PLWH People living with HIV/AIDS, Appendix 3 ACRONYMS GLC Green Light Committee PPM Public-Private Mix GMP Good Manufacturing Practice PPM-DOTS Public private mix DOTS, a strategy ACSM Advocacy, Communication & social GNP Gross National Product to involve private health care providers in Mobilization GPSTB Global Plan to Stop TB DOTS strategy AFB Acid-fast baccili GTRI Global TB Research Initiative AFRO WHO Regional Office for Africa QA Quality assurance H FA Health For All AIDS Acquired Immunodeficiency Syndrome R Rifampicin H Isoniazid ARTI Annual risk of tuberculosis infection R&D Research and Development HAART Highly Active Antiretroviral Therapy ARV Antiretroviral R&D Research and development HBC High-burden countries AZT Zidovudine RBM Roll Back Malaria HIV Human immunodeficiency virus BCG Bacille Calmette Guérin RICC Regional Interagency Coordination IDU Injection Drug Users CB Coordinating Board Committee IEC Information, education and communication CDC Centers for Disease Control and Prevention RMB Resource Mobilization ILO International Labour Organization CMS Central medical stores S Streptomycin INRUD International Network for the Rational DEWG DOTS Expansion Working Group SBIR Small Business Innovative Research Use of Drugs DFID Department for International SCC Short Course Chemotherapy IPT Isoniazid Preventive Therapy Development SEARO WHO Regional Office for South-East Asia IUATLD International Union Against DOT Directly Observed Treatment SRL Supranational Reference Laboratory Tuberculosis and Lung Disease DOTS branded name of the WHO recommended STB WHO Stop Tuberculosis Department IVR Initiative for Vaccine Research tuberculosis control strategy STI Sexually Transmitted Infection KNCV Royal Netherlands Tuberculosis DOTS Internationally recommended strategy for SW Sex Workers Association TBc ontrol SWAP Sector Wide Approach MDR TB Multi drug resistant Tuberculosis, TB DOTS Plus TB control strategy for multi drug TASO The AIDS Support Organization bacillus resistant to at least Isoniazid and resistant Tuberculosis based on the DOTS TB Tuberculosis Rifampicin scheme TB/HIV TB and HIV co-infection MDR-TB Multidrug-resistant tuberculosis DST Drug susceptibility testing TBCTA TB Coalition for Technical Assistance MOH Ministry of Health E Ethambutol TBDI TB Diagnos tics Initiative MSH Management Sciences for Health ECHO Humanitarian Aid Office of the European TBVIAC Tuberculosis Vaccine Initiative Advisory NGO Nongovernmental organization Union Committee NIAID National Institute of Allergy and FDC Fixed-dose combination TDR Special Programme on Research and Infectious Disease FIND Foundation for Innovative New Training in Tropical Diseases NICC National Interagency Coordination Diagnostics UNAIDS Joint United Nations Programme on Committees GATB Global Alliance for TB Drug Development HIV/AIDS NIH National Institutes of Health (TB Alliance) UNICEF United Nations Children's Fund NRL National Reference Laboratory GAVI Global Alliance for Vaccines and USAID United States Agency for International NTP National Tuberculosis Control Programme Immunization Development OECD Organization for Economic Cooperation GDEP Global DOTS Expansion Plan VCT Voluntary counselling and testing and Development GDF Global Drug Facility WG Working group PIA Phased implementation of activities GDP Gross Domestic Product WHO World Health Organization PIH Partners In Health Z Pyrazinamide

DRAFT-NOT FOR DISTRIBUTION

Appendix 4 Operational Definitions of Risk Groups for the purposes of Screening

Risk Groups found in health services Adolescents Persons aged 12-14

Alcohol dependent Persons with alcohol addiction are individuals with a psychological and/or physical addiction to products containing alcohol

Attendees of health care facilities Attendees are persons who attend health facilities (e.g., health posts, health centers, clinics, hospitals, outpatient departments, etc.) for any physical ailment, particularly suspected TB cases.

Children under 5 Children below the age of 5 are persons who range in age from 0 thru 4 years (WHO, 2010). Orphans and abandoned children (OAC) and street children are discussed separately.

Diabetics Persons with Diabetes mellitus have a chronic disease caused by inherited and/or acquired deficiency in production of insulin by the pancreas, or by the ineffectiveness of the insulin produced

Drug dependent Persons who are drug dependent engage in the harmful or hazardous use of psychoactive substances, including both prescription and illicit drugs.

Elderly The UN agreed cutoff is 60+ years to refer to the elderly population. However, in some settings the chronological age of 65 years is a more readily accepted definition of 'elderly' or older person.

Malnourished According to WHO, severe acute malnutrition is defined as a very low weight for height (below - 3z) scores of the median WHO growth standards.

Mentally Ill Mental illness can be defined as a condition that causes problems in some combination of a person’s thinking abilities, emotional functioning, social functioning, or ability to sustain age- appropriate independence. Persons with mental illness is a generic reference to a very diverse category of individuals ranging from those with short-term psychological illness that is managed with outpatient treatment to those with chronic or severe mental illness that may require institutional or residential care.

Persons with Previous TB Person with previous TB have been diagnosed with tuberculosis but may or may not have been successfully treated.

DRAFT-NOT FOR DISTRIBUTION

PLHIV Persons who are infected with the human immunodeficiency virus, are commonly referred to as “people living with HIV or AIDS” (PLWHA). Pregnant women

For the purpose of this exercise, we refer to women of reproductive age who are currently pregnant, regardless of trimester or obstetric outcome.

Smokers Smokers is reference to persons who are psychologically or physically addicted to the consumption of tobacco via inhalation(smoking).

Congregate/Occupational/Environmental Risk Groups Farm & Factory workers Factory workers refer to individuals who spend several hours in closed and crowded working environments.

Health care workers Healthcare workers (HCWs) are defined as “all people engaged in actions whose primary intent is to enhance health.” They include all persons, paid and unpaid, who provide health services, such as doctors, nurses, pharmacists, and laboratory technicians. They also include management and support workers, such as finance officers, cooks, drivers, cleaners, security guards, community-based care, home-care and informal caregivers.

Miners For the purposes of this exercise, miners are considered to be those who labor underground to excavate compounds and mineral commodities such as coal, gold, or diamonds.

Orphans and institutionalized children The concept of OVC generally refers to orphans and other groups of children who are more exposed to risks than their peers. OVC are groups of children that experience negative outcomes, such as the loss of their parents, education, morbidity, and malnutrition, at higher rates than do their peers.

Prisoners Prisoners are defined as persons who are deprived of their liberty and a detained in residential facilities with other individuals accused or convicted of crimes

Residents of Urban slum s A slum, as defined by United Nations agency UN-HABITAT, is a run-down area of a city characterized by substandard housing and squalor and lacking in tenure security. Slum residents are the people who live in such areas.

Soldiers/Military

Transportation workers/ Truck drivers/ Transportation workers and Truck drivers are hired to drive long or short distances in order to deliver persons and/or goods from one place to another, from the place of pickup to the place of delivery.

DRAFT-NOT FOR DISTRIBUTION

Behavioral/marginalized Risk Groups Homeless “Different definitions of homelessness are used in different contexts. People who are homeless are perhaps unwilling but, more commonly, unable to acquire and maintain regular, safe, and adequate housing, or lack "fixed, regular, and adequate night-time residence.

Indigenous Indigenous people are from communities that live within, or are attached to, geographically distinct traditional habitats or ancestral territories, and who identify themselves as being part of a distinct cultural group, descended from groups present in the area before modern states were created and current borders defined. They generally maintain cultural and social identities, and social, economic, cultural and political institutions, separate from the mainstream or dominant society or culture (WHO, 2011).

Migrant,

IDP, refugee Refugees are people who have crossed an international frontier and are at risk or have been victims of persecution in their country of origin. Internally displaced persons (IDPs), on the other hand, have not crossed an international frontier, but have, for whatever reason, also fled their homes

Marginalized MSM The term "Men who have Sex with Men" (i.e. MSM) is used to describe males who have sex with other males, regardless of their sexual identity, or whether or not they have sex with women as well (UNAIDS, 2009). In this sense, MSM describes a sexual practice and not necessarily an identity. MSM are not a homogenous category in most countries, and thus this exercise focuses only on marginalized MSM.

Nomadic /pastoralist populations

Sex worker Sex worker is an individual engaged in “any occupation in which an individual provides sexual services in exchange for money and/or other items of value” (Morrison and Whitehead, 2007:202).

Street children Street child is a term for a child residing primarily in the streets of a city. It includes children who might not necessarily be homeless or without families, but who live in situations where there is no protection, supervision, or direction from responsible adults.

UNICEF has defined three types of street children:  Street-Living- children 'of' the street, some with no family connections. They sleep, eat and live on the streets.  Street-Working- children who are forced to work on the street to support their families' income by selling or begging. They will return 'home' to sleep and will return to the street the next day. They are children 'on' the street.  Street-Family- children who live on the streets with their families14.

Transgender

14 Study on Street Children in Zimbabwe, http://www.unicef.org/evaldatabase/files/ZIM_01-805.pdf 56

DRAFT-NOT FOR DISTRIBUTION

The term transgender is used to describe a varied group of people. It includes people who identify with the opposite gender assigned to their biological sex, such as biological men who identify as women and the opposite, and people who identify with both genders, or bi- gender. It also includes, but is not restricted to people who undergoes sex reassignment surgeries and people accessing hormone therapy. It is less common, but also happens, that intersex people (whose genitals and reproductive system possess male and female characteristics) are also included in the transgender category

DRAFT-NOT FOR DISTRIBUTION

Appendix 5: data extraction form

1. Number 2. Country 3. Year 4. Authors 5. Eligible to be screened 6. Number screened 7. Reasons for refusal 8. What policies enable effective case-finding in this population?

9. What are the economic considerations impacting case-finding in this group?

10. Are there particular racial, ethnic, linguistic, and/or cultural considerations impacting case-finding in this group?

11. What are the recommended strategies to help @ to reach an appropriate TB care facility? 12. What are the recommended screening and active case finding strategies for @? 13. What are the opportunities and enabling factors that make reaching this group easier?

14. What specific skill sets and cultural competencies (HRM) are necessary to reach this group?

15. Where are the recommended sites or institutions where this population is concentrated?

16. Advice on organizations or institutions should be involved in the strategy?

17. Screening algorithm used

DRAFT-NOT FOR DISTRIBUTION

Appendix 6: Potential locations for TB screening

Potential site of Screening Risk group

Community level High prevalence sub-population (poor areas, urban poor areas, indigenous/tribal pop, etc) Household contacts, other close contacts Hospital out/in-patients & All attendees primary healthcare centers People with HIV / VCTC clinic Chronic respiratory disease Previous TB / CXR abnormality Diabetes mellitus Other immunocompromised Pregnant women Elderly Alcoholics IV drug users Mental health clinic Residential institutions Prisoners Shelters for homeless, alcohol/drug users Other institutions e.g. Immigration and refugee Immigrants from high prevalence settings services Refugee camps Workplace Health care workers Miners Other high prevalence work-places

References

references

1. Lutge, E.E., Wiysonge, C.S., Knight, S.E., Volmink, J.. Material Incentives and Enablers in the Management of Tuberculosis, C.D.o.S. Reviews., Editor. 2012. 2. Mahomed, H., TB incidence among an adolescent cohort in South Africa: A Feasibility Study for Conducting vaccine Trials. 2012. 3. Kruse, G.R., et al., Burnout and use of HIV services among health care workers in Lusaka District, Zambia: a cross-sectional study. Hum Resour Health, 2009. 7: p. 55. 4. Murray, E.J., et al., High levels of vulnerability and anticipated stigma reduce the impetus for tuberculosis diagnosis in Cape Town, South Africa. Health Policy Plan, 2012. 2: p. 2. 5. Murray, E.J., et al., A multidisciplinary method to map potential tuberculosis transmission 'hot spots' in high-burden communities. International Journal of Tuberculosis and Lung Disease, 2009. 13(6): p. 767-774. 6. Sylla, L., et al., Integration and co-location of HIV/AIDS, tuberculosis and drug treatment services. International Journal of Drug Policy, (of Publication: Aug 2007): p. 18 (4) (pp 306-312), 2007. 7. Baker, L.M., P. Case, and D.L. Policicchio, General health problems of inner-city sex workers: a pilot study. J Med Libr Assoc, 2003. 91(1): p. 67-71. 8. Godfreyfaussett, P., et al., RECRUITMENT TO A TRIAL OF TUBERCULOSIS PREVENTIVE THERAPY FROM A VOLUNTARY HIV TESTING CENTER IN LUSAKA - RELEVANCE TO IMPLEMENTATION. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1995. 89(4): p. 354-358. 9. Nduba VN; Anja Van’t Hoog; Mitchell E.M.H.;, O.P.L.K.B.M.W., The Prevalence of Tuberculosis in

DRAFT-NOT FOR DISTRIBUTION

Adolescents, Western Kenya; Implications for Tuberculosis Control Programs. submitted. 10. Brewin, P., et al., Is screening for tuberculosis acceptable to immigrants? A qualitative study. Journal of Public Health, 2006. 28(3): p. 253-260. 11. Coker, R.J., S. Mounier-Jack, and R. Martin, Public health law and tuberculosis control in Europe. Public Health, 2007. 121(4): p. 266-273. 12. Santha, T., et al., Are community surveys to detect tuberculosis in high prevalence areas useful? Results of a comparative study from Tiruvallur District, South India. International Journal of Tuberculosis and Lung Disease, 2003. 7: p. 258-265. 13. Kranzer, K., et al., Yield of HIV-associated tuberculosis during intensified case finding in resource- limited settings: a systematic review and meta-analysis. Lancet Infectious Diseases, 2010. 10(2): p. 93-102. 14. Kucherov, A.L., Tuberculosis among socially predisposed groups of the population. [Russian]. Problemy tuberkuleza, (of Publication: 1990): p. (6) (pp 20-23), 1990. 15. Storla, D.G., S. Yimer, and G.A. Bjune, A systematic review of delay in the diagnosis and treatment of tuberculosis. Bmc Public Health, 2008. 8. 16. McClaren, B.J., et al., 'It is not in my world': an exploration of attitudes and influences associated with cystic fibrosis carrier screening. European Journal of Human Genetics, 2008. 16(4): p. 435- 444. 17. Marrazzo, J.M. and D. Scholes, Acceptability of Urine-Based Screening for Chlamydia trachomatis in Asymptomatic Young Men: A Systematic Review. Sexually Transmitted Diseases, 2008. 35(11): p. S28-S33. 18. O'Sullivan, I. and S. Orbell, Self-sampling in screening to reduce mortality from colorectal cancer: a qualitative exploration of the decision to complete a faecal occult blood test (FOBT). Journal of Medical Screening, 2004. 11(1): p. 16-22. 19. Rosen, A., et al., Mass screening for celiac disease from the perspective of newly diagnosed adolescents and their parents: A mixed-method study. Bmc Public Health, 2011. 11. 20. Szarewski, A., et al., Exploring the acceptability of two self-sampling devices for human papillomavirus testing in the cervical screening context: a qualitative study of Muslim women in London. Journal of Medical Screening, 2009. 16(4): p. 193-198. 21. Balfe, M., et al., Young women's decisions to accept chlamydia screening: influences of stigma and doctor-patient interactions. Bmc Public Health, 2010. 10. 22. Chaudhary, R., et al., Opportunistic screening for Chlamydia: a pilot study into male perspectives on provision of Chlamydia screening in a UK university. Journal of Public Health, 2008. 30(4): p. 466- 471. 23. Matthews, A.K., et al., A qualitative evaluation of a faith-based breast and cervical cancer screening intervention for African American women. Health Education & Behavior, 2006. 33(5): p. 643-663. 24. Mills, N., et al., Population screening for Chlamydia trachomatis infection in the UK: a qualitative study of the experiences of those screened. Family Practice, 2006. 23(5): p. 550-557. 25. Pavlin, N.L., et al., Implementing chlamydia screening: what do women think? A systematic review of the literature. Bmc Public Health, 2006. 6. 26. Brealey, S.D., et al., Screening for postnatal depression - is it acceptable to women and healthcare professionals? A systematic review and meta-synthesis. Journal of Reproductive and Infant Psychology, 2010. 28(4): p. 328-344. 27. Downe, S.M., E. Butler, and S. Hinder, Screening tools for depressed mood after childbirth in UK- based South Asian women: a systematic review. Journal of Advanced Nursing, 2007. 57(6): p. 565- 583. 28. Christofides, N. and R. Jewkes, Acceptability of universal screening for intimate partner violence in voluntary HIV testing and counseling services in South Africa and service implications. Aids Care- Psychological and Socio-Medical Aspects of Aids/Hiv, 2010. 22(3): p. 279-285. 29. Koziol-McLain, J., et al., Intimate Partner Violence Screening and Brief Intervention: Experiences of Women in Two New Zealand Health Care Settings. Journal of Midwifery & Womens Health, 2008. 53(6): p. 504-510. 30. Dodge, B., et al., Field collection of rectal samples for sexually transmitted infection diagnostics among men who have sex with men. International Journal of Std & Aids, 2010. 21(4): p. 260-264. 31. Lorimer, K., M.E. Reid, and G.J. Hart, "It has to speak to people's everyday life...": qualitative study of men and women's willingness to participate in a non-medical approach to Chlamydia trachomatis screening. Sexually Transmitted Infections, 2009. 85(3): p. 201-205. 32. Ansink, A.C., et al., Cervical cancer in Bangladesh: community perceptions of cervical cancer and cervical cancer screening. Transactions of the Royal Society of Tropical Medicine and Hygiene,

DRAFT-NOT FOR DISTRIBUTION

2008. 102(5): p. 499-505. 33. Bacchus, L., G. Mezey, and S. Bewley, Women's perceptions and experiences of routine enquiry for domestic violence in a maternity service. Bjog-an International Journal of Obstetrics and Gynaecology, 2002. 109(1): p. 9-16. 34. Taylor, T., et al., Acceptability of flexible sigmoidoscopy screening in older adults in the United Kingdom. Journal of Medical Screening, 2000. 7(1): p. 38-45. 35. Cowley, S. and A.M. Houston, A structured health needs assessment tool: acceptability and effectiveness for health visiting. Journal of Advanced Nursing, 2003. 43(1): p. 82-92. 36. Feinberg, E., M.V. Smith, and R. Naik, Ethnically Diverse Mothers' Views on the Acceptability of Screening for Maternal Depressive Symptoms during Pediatric Well-Child Visits. Journal of Health Care for the Poor and Underserved, 2009. 20(3): p. 780-797. 37. Chan, C.W.H., et al., Piloting electronic self report symptom assessment - Cancer (ESRA-C) in Hong Kong: A mixed method approach. European Journal of Oncology Nursing, 2011. 15(4): p. 325-334. 38. Cleland, J., J. Caldow, and D. Ryan, A qualitative study of the attitudes of patients and staff to the use of mobile phone technology for recording and gathering asthma data. Journal of Telemedicine and Telecare, 2007. 13(2): p. 85-89. 39. Fenton, K.A., et al., The acceptability of urinary LCR testing for Chlamydia trachomatis among participants in a probability sample survey of sexual attitudes and lifestyles. Sexually Transmitted Infections, 2001. 77(3): p. 194-198. 40. Hewitt, C.E., et al., Methods to identify postnatal depression in primary care: an integrated evidence synthesis and value of information analysis. Health Technology Assessment, 2009. 13(36): p. 1-+. 41. Chang, Y., et al., Transforming Verbal Counts in Reports of Qualitative Descriptive Studies Into Numbers. Western Journal of Nursing Research, 2009. 31(7): p. 837-852. 42. Woeltje, K.F., et al., Tuberculin skin testing of hospitalized patients. Infection Control and Hospital Epidemiology, 1997. 18(8): p. 561-565. 43. Babikako, H.M., et al., Patient satisfaction, feasibility and reliability of satisfaction questionnaire among patients with pulmonary tuberculosis in urban Uganda: a cross-sectional study. Health Research Policy and Systems, 2011. 9. 44. Fox, W., Tuberculosis case-finding and treatment programmes in the developing countries. British Medical Bulletin, (of Publication: 1988): p. 44 (3) (pp 717-737), 1988. 45. Whoolery, M., Survivalising among homeless people with tuberculosis: a grounded theory study., in Faculty of Society and Health Bucks New University, Brunel University, UK. 2008, Bucks New University, Brunel University, UK. 46. Swigart V, K.R., Homeless persons‘ decisions to accept or reject public health disease-detection services. . Public Health Nursing 2004. 21(2): p. 162-170. 47. Rodger, A.J., et al., HIV prevalence and testing practices among tuberculosis cases in London: A missed opportunity for HIV diagnosis? Thorax, (of Publication: January 2010): p. 65 (1) (pp 63-69), 2010. 48. Van't Hoog, A.H., et al., High prevalence of pulmonary tuberculosis and inadequate case finding in rural Western Kenya. American Journal of Respiratory and Critical Care Medicine, 2011. 183(9): p. 1245-1253. 49. Waako; J.; Suzanne Verver; Anne Wajja; Willy Ssengooba; Moses L Joloba; Robert Colebunders;Philippa Musoke; Harriet, M.-K., Burden of tuberculosis disease among adolescents in a rural cohort in Eastern Uganda. under submission. 50. Geldenhuys H, S.K., Kafaar F, Stein D, M Hatherill, WA Hanekom, Mahomed H. , Risky Behaviour and Psychosocial Correlates in Adolescents – is there a link with Tuberculosis? Afr J of Psych. , 2011. 51. Kline, S.E., L.L. Hedemark, and S.F. Davies, OUTBREAK OF TUBERCULOSIS AMONG REGULAR PATRONS OF A NEIGHBORHOOD BAR. New England Journal of Medicine, 1995. 333(4): p. 222-227. 52. Jackson, A.D., et al., Characterising transmission of a tuberculosis genotype in Scotland: A qualitative approach to social network enquiry. International Journal of Tuberculosis and Lung Disease, (of Publication: April 2009): p. 13 (4) (pp 486-493), 2009. 53. Yamazaki, S., et al., A study on drinking and problem drinking in tuberculosis patients. [Japanese]. [Nippon koshu eisei zasshi] Japanese journal of public health, (of Publication: Feb 1993): p. 40 (2) (pp 123-127), 1993. 54. Murhekar, M.V., et al., Tuberculosis situation among tribal population of Car Nicobar, India, 15 years after intensive tuberculosis control project and implementation of a national tuberculosis programme. Bulletin of the World Health Organization, 2004. 82(11): p. 836-843. 55. Doering, D., R. Kocuipchyk, and S. Lester, A tuberculosis screening and chemoprophylaxis project in children from a high risk population in Edmonton, Alberta. Canadian Journal of Public Health, (of

DRAFT-NOT FOR DISTRIBUTION

Publication: May 1999): p. 90 (3) (pp 152-155), 1999. 56. Minodier, P., et al., Evaluation of a school-based program for diagnosis and treatment of latent tuberculosis infection in immigrant children. Journal of Infection and Public Health, (of Publication: 2010): p. 3 (2) (pp 67-75), 2010. 57. Okelloh, D.M., W;Odid,i B; Nduba, V; Kiringa, G; Van't Hoog, A; Laserson, K; Mitchell, E.M.H., Perception of communities in Siaya district, Western Kenya on tuberculosis diagnostic procedures involving children: Implications for future TB vaccine trials in communities in Siaya district, Western Kenya in 41st World Lung Health Conference. 2010: , Berlin

58. Risser, N.L., et al., The accuracy of tuberculin skin tests: Self-assessment by adult outpatients. Public Health Reports, (of Publication: 1985): p. 100 (4) (pp 439-445), 1985. 59. Salomon, N., et al., Knowledge of tuberculosis among drug users: Relationship to return rates for tuberculosis screening at a syringe exchange. Journal of Substance Abuse Treatment, (of Publication: Apr 1999): p. 16 (3) (pp 229-235), 1999. 60. Factor, S.H., et al., Street-outreach Improves Detection but not Referral for Drug Users with Latent Tuberculosis, New York City. Substance Use & Misuse, 2011. 46(14): p. 1711-1715. 61. O'Connor, P.G., et al., Human immunodeficiency virus infection in intravenous drug users: A model for primary care. American Journal of Medicine, (of Publication: 1992): p. 93 (4) (pp 382-386), 1992. 62. Dewan, P.K., et al., Feasibility, acceptability, and cost of tuberculosis testing by whole-blood interferon-gamma assay. Bmc Infectious Diseases, 2006. 6. 63. Horsburgh Jr, C.R., et al., Latent TB infection treatment acceptance and completion in the United States and Canada. Chest, (of Publication: 01 Feb 2010): p. 137 (2) (pp 401-409), 2010. 64. Marchand, R., P. Tousignant, and H. Chang, Cost-effectiveness of screening compared to case-finding approaches to tuberculosis in long term care facilities for the elderly. International Journal of Epidemiology, (of Publication: 1999): p. 28 (3) (pp 563-570), 1999. 65. Hutton, M.D., G.M. Cauthen, and A.B. Bloch, Results of a 29-state survey of tuberculosis in nursing homes and correctional facilities. Public Health Reports, (of Publication: 1993): p. 108 (3) (pp 305- 313), 1993. 66. Taiwo, H., et al., Long stay patients in a psychiatric hospital in Lagos, Nigeria. African Journal of Psychiatry (South Africa), (of Publication: May 2008): p. 11 (2) (pp 128-132), 2008. 67. De Lima, M.L.L.T., et al., Hearing impairment in patients with tuberculosis from Northeast Brazil. Revista do Instituto de Medicina Tropical de Sao Paulo, (of Publication: Mar 2006): p. 48 (2) (pp 99-102), 2006. 68. Sonnenberg, P., et al., HIV-1 and recurrence, relapse, and reinfection of tuberculosis after cure: a cohort study in South African mineworkers. Lancet, 2001. 358(9294): p. 1687-1693. 69. Rose, N., et al., Tuberculosis therapy in the Canton of Zurich 1991-1993 - What are the causes of relapse and treatment failure. Schweizerische Medizinische Wochenschrift, 1996. 126(48): p. 2059-2067. 70. de Oliveira, H.B. and D.D. Moreira, Retreatment of tuberculosis: aspects of previous episodes, Brazil, 1993-1994. Revista De Saude Publica, 2000. 34(5): p. 437-443. 71. Harries, A.D., et al., Relapse and recurrent tuberculosis in the context of a National Tuberculosis Control Programme. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2000. 94(3): p. 247-249. 72. Hiransuthikul, N., et al., Factors associated with tuberculin skin test reactivity among HIV-infected people in Bangkok. Southeast Asian Journal of Tropical Medicine and Public Health, (of Publication: December 2003): p. 34 (4) (pp 804-809), 2003. 73. Simon, S., et al., An integrated approach of community health worker support for HIV/AIDS and TB care in Angonia district, Mozambique. BMC International Health and Human Rights. 9 (1) , 2009. Article Number(of Publication: 2009): p. 13. 74. Lester, R., et al., Barriers to implementation of isoniazid preventive therapy in HIV clinics: A qualitative study. Aids, ((pp S45-S48), 2010): p. 24 (SUPPL. 75. Sangala, W.T., et al., Screening for pulmonary tuberculosis: an acceptable intervention for antenatal care clients and providers? International Journal of Tuberculosis and Lung Disease, 2006. 10(7): p. 789-794. 76. Gupta, A., et al., Symptom Screening Among HIV-Infected Pregnant Women Is Acceptable and Has High Negative Predictive Value for Active Tuberculosis. Clinical Infectious Diseases, 2011. 53(10). 77. Uwimana, J., et al., Health system barriers to implementation of collaborative TB and HIV activities including prevention of mother to child transmission in South Africa. Tropical Medicine &

DRAFT-NOT FOR DISTRIBUTION

International Health, 2012. 17(5): p. 658-665. 78. Ahsan, G., et al., Gender difference in treatment seeking behaviors of tuberculosis cases in rural communities of Bangladesh. Southeast Asian Journal of Tropical Medicine and Public Health, (of Publication: March 2004): p. 35 (1) (pp 126-135), 2004. 79. Zenner, D., et al., Risk of Tuberculosis in Pregnancy A National, Primary Care-based Cohort and Self- controlled Case Series Study. American Journal of Respiratory and Critical Care Medicine, 2012. 185(7): p. 779-784. 80. Worjoloh, A., et al., Interferon Gamma Release Assay Compared With the Tuberculin Skin Test for Latent Tuberculosis Detection in Pregnancy. Obstetrics and Gynecology, 2011. 118(6): p. 1363- 1370. 81. Francis, D., "They should know where they stand": attitudes to HIV Voluntary Counselling and Testing amongst a group of out-of-school youth. South African Journal of Education, 2010. 30(3): p. 327-342. 82. Francis, D. and N. Rimmensberger, Between the cracks: out-of-school youth and discourses of HIV/AIDS. South African Journal of Psychology, 2008. 38(4): p. 603-613. 83. COCHRAN, J.B., C. CLAYSON, and W.B. FLETCHER, Pulmonary tuberculosis in a rural area in South Scotland the Annandale survey. British Medical Journal, 1957. 2: p. 185-7. 84. Aghilinejad, M., M.R. Jamamati, and A.A. Farshad, Prevalence of silicosis among workers in stone- cutter and silica powder production factories. Tanaffos, (of Publication: 2006): p. 5 (3) (pp 31-36), 2006. 85. Al-Khal, A.L., A. Bener, and D.A. Enarson, Tuberculosis among garment workers in an Arabian developing country: State of Qatar. Archives of Environmental and Occupational Health, (of Publication: Nov 2005): p. 60 (6) (pp 295-298), 2005. 86. Murlidhar, V. and V. Kanhere, Asbestosis in an asbestos composite mill at Mumbai: A prevalence study. Environmental Health: A Global Access Science Source. 4 , 2005. Article Number(of Publication: 31 Oct 2005): p. 24. 87. Clarke, M., J. Dick, and L. Bogg, Cost-effectiveness analysis of an alternative tuberculosis management strategy for permanent farm dwellers in South Africa amidst health service contraction. Scandinavian Journal of Public Health, (of Publication: 01 Feb 2006): p. 34 (1) (pp 83- 91), 2006. 88. Clarke, M., et al., Lay health worker intervention with choice of DOT superior to standard TB care for farm dwellers in South Africa: A cluster randomised control trial. International Journal of Tuberculosis and Lung Disease, (of Publication: Jun 2005): p. 9 (6) (pp 673-679), 2005. 89. MacIntyre, C.R., et al., High rate of transmission of tuberculosis in an office: Impact of delayed diagnosis. Clinical Infectious Diseases, (of Publication: Nov 1995): p. 21 (5) (pp 1170-1174), 1995. 90. Placidi, D., et al., Tuberculin Skin Test (TST) survey among Healthcare Workers (HCWs) in hospital: A systematic review of the literature. [Italian]. Giornale Italiano di Medicina del Lavoro ed Ergonomia, (of Publication: July/September 2007): p. 29 (3) (pp 409-411), 2007. 91. Plitt, S.S., et al., Prevalence and determinants of tuberculin reactivity among physicians in Edmonton, Canada: 1996-1997. International Journal of Epidemiology, (of Publication: 2001): p. 30 (5) (pp 1022-1028), 2001. 92. Prezant, D.J., et al., Tuberculin skin test conversion rates in New York City emergency medical service health care workers. Annals of Emergency Medicine, (of Publication: 1998): p. 32 (2) (pp 208- 213), 1998. 93. Roy, M.C., et al., Correlation between frequency of tuberculosis and compliance with control strategies. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America, (of Publication: Jan 1997): p. 18 (1) (pp 28-31), 1997. 94. Stone, D.S., Health surveillance for health care workers. A vital role for the occupational and environmental health nurse. AAOHN journal : official journal of the American Association of Occupational Health Nurses, (of Publication: Feb 2000): p. 48 (2) (pp 73-79), 2000. 95. Torda, A.J., Vaccination and screening of medical students: Results of a student health initiative. Medical Journal of Australia, (of Publication: 03 Nov 2008): p. 189 (9) (pp 484-486), 2008. 96. Ohmori, M., et al., Trends of delays in tuberculosis case finding in Japan and associated factors. International Journal of Tuberculosis and Lung Disease, (of Publication: Sep 2005): p. 9 (9) (pp 999-1005), 2005. 97. Joseph, H., Shrestha-Kuwahara, R.,Lowry, D., Lambert, L., Panlilio, A., Racher, B., Holcombe, J., Poujade, J., Rasmussen, D., Wilce, M., Factors influencing health care workers‘ adherence to work site tuberculosis screening and treatment policies. . American Journal of Infection Control., 2004. 32 (8):: p. 456 – 461.

DRAFT-NOT FOR DISTRIBUTION

98. Buregyeya E., N., N., Wanyenze, R., Mitchell, E.M.H, Criel, B., Verver, S. Kasasa, S., Colebunders, R. , Utilization of HIV and Tuberculosis Services by Health Care Workers in Uganda: Implications for Occupational Health Policies and Implementation. PLOS One. , 2012. 99. Steen, T.W., et al., Prevalence of occupational lung disease among Botswana men formerly employed in the South African mining industry. Occupational and Environmental Medicine, (of Publication: 1997): p. 54 (1) (pp 19-26), 1997. 100. White, N.W., et al., Occupational lung diseases among former goldminers in two labour sending areas. South African Medical Journal, (of Publication: 2001): p. 91 (7) (pp 599-604), 2001. 101. Shah, S.A., et al., Prevalence of pulmonary tuberculosis in Karachi juvenile jail, Pakistan. Eastern Mediterranean health journal = La revue de sante de la Mediterranee orientale = al-Majallah al- ihhiyah li-sharq al-mutawassi, (of Publication: Jul 2003): p. 9 (4) (pp 667-674), 2003. 102. Valleroy, L.A., et al., HIV infection in disadvantaged out-of-school youth: Prevalence for U.S. Job Corps entrants, 1990 through 1996. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 1998. 19(1): p. 67-73. 103. Yuan, L., E. Richardson, and P.R.W. Kendall, Evaluation of a tuberculosis screening program for high-risk students in Toronto schools. Canadian Medical Association Journal, (of Publication: 1995): p. 153 (7) (pp 925-932), 1995. 104. Kazi, A.M., et al., Risk factors and prevalence of tuberculosis, human immunodeficiency virus, syphilis, hepatitis B virus, and hepatitis C virus among prisoners in Pakistan. International Journal of Infectious Diseases, ((pp e60-e66), 2010): p. 14 (SUPPL. 105. Laraqui, C.H., et al., Perception of occupational hazards among health care workers in prison in Morocco. [French]. Archives des Maladies Professionnelles et de Medecine du Travail, (of Publication: Sep 2002): p. 63 (5) (pp 374-381), 2002. 106. Binswanger, I.A., et al., Tuberculosis testing in correctional officers: A national random survey of jails in the United States. International Journal of Tuberculosis and Lung Disease, (of Publication: April 2010): p. 14 (4) (pp 464-470), 2010. 107. Cooper-Arnold, K., et al., Occupational tuberculosis among deputy sheriffs in Connecticut: A risk model of transmission. Applied Occupational and Environmental Hygiene, (of Publication: Nov 1999): p. 14 (11) (pp 768-776), 1999. 108. Kimerling, M.E. and H. Kluge, The need for longitudinal screening studies in prison TB control. International Journal of Tuberculosis and Lung Disease, (of Publication: Jun 2005): p. 9 (6) (pp 589), 2005. 109. Nolan, C.M., et al., Directly observed isoniazid preventive therapy for released jail inmates. American Journal of Respiratory and Critical Care Medicine, (of Publication: 1997): p. 155 (2) (pp 583-586), 1997. 110. Gray, N.J., M. Hansen-Knarhoi, and V.L. Krause, Tuberculosis in illegal foreign fishermen: Whose public health are we protecting? Medical Journal of Australia, (of Publication: 04 Feb 2008): p. 188 (3) (pp 144-147), 2008. 111. Mangan, J.M., et al., Evaluating the strengths and weaknesses of tuberculosis educational activities for prisoners in Honduras. International Journal of Tuberculosis and Lung Disease, (of Publication: Oct 2006): p. 10 (10) (pp 1152-1158), 2006. 112. Rutz, H.J., et al., Tuberculosis control in a large urban jail: discordance between policy and reality. Journal of public health management and practice : JPHMP, (of Publication: 2008 Sep-Oct): p. 14 (5) (pp 442-447), 2008. 113. Levesque, J.F., et al., Acceptance of screening and completion of treatment for latent tuberculosis infection among refugee claimants in Canada. International Journal of Tuberculosis and Lung Disease, 2004. 8(6): p. 711-717. 114. Tiwari, S.K., E.J. Love, and C. Sitthi-Amorn, Tuberculosis treatment services in armed conflict areas: Does access matter? International Medical Journal, (of Publication: Sep 2006): p. 13 (3) (pp 163- 169), 2006. 115. Tupasi, T.E., et al., Bacillary disease and health seeking behavior among Filipinos with symptoms of tuberculosis: Implications for control. International Journal of Tuberculosis and Lung Disease, (of Publication: 2000): p. 4 (12) (pp 1126-1132), 2000. 116. Walton, D.A., et al., Integrated HIV prevention and care strengthens primary health care: Lessons from rural Haiti. Journal of Public Health Policy, (of Publication: 2004): p. 25 (2) (pp 137-158), 2004. 117. Edelson, P.J. and M. Phypers, TB transmission on public transportation: A review of published studies and recommendations for contact tracing. Travel Medicine and Infectious Disease, 2011. 9(1): p. 27-31.

DRAFT-NOT FOR DISTRIBUTION

118. Feske, M.L., et al., Giving TB wheels: Public transportation as a risk factor for tuberculosis transmission. Tuberculosis, 2011. 91: p. S16-S23. 119. Horna-Campos, O.J., et al., Risk of tuberculosis in public transport sector workers, Lima, Peru. International Journal of Tuberculosis and Lung Disease, 2010. 14(6): p. 714-719. 120. Powell, K., et al., Passenger Contact Investigation Associated with a Transport Driver with Pulmonary Tuberculosis. Public Health Reports, 2012. 127(2): p. 202-207. 121. Patel, K.R., Pulmonary tuberculosis in residents of lodging houses, night shelters and common hostels in Glasgow: A 5-year prospective survey. British Journal of Diseases of the Chest, (of Publication: 1985): p. 79 (1) (pp 60-66), 1985. 122. de Vries, G., R.A.H. van Hest, and A.H. Richardus, Impact of mobile radiographic screening on tuberculosis among drug users and homeless persons. American Journal of Respiratory and Critical Care Medicine, 2007. 176(2): p. 201-207. 123. De Vries, G. and R.A. Van Hest, From contact investigation to tuberculosis screening of drug addicts and homeless persons in Rotterdam. European Journal of Public Health, (of Publication: Apr 2006): p. 16 (2) (pp 133-136), 2006. 124. Southern, A., et al., Tuberculosis among homeless people in London: an effective model of screening and treatment. International Journal of Tuberculosis and Lung Disease, 1999. 3(11): p. 1001- 1008. 125. Swigart, V. and R. Kolb, Homeless persons' decisions to accept or reject public health disease- detection services. Public Health Nursing, (of Publication: March/April 2004): p. 21 (2) (pp 162- 170), 2004. 126. Nyamathi, A., J.A. Stein, and A. Schumann, Latent variable assessment of outcomes in a nurse- managed intervention to increase latent tuberculosis treatment completion in homeless adults. Health Psychology, 2007. 26(1): p. 68-76. 127. Falchook, G., et al., Tuberculosis screening, referral, and treatment in an inner city homeless shelter in Orleans parish. The Journal of the Louisiana State Medical Society : official organ of the Louisiana State Medical Society, (of Publication: Aug 2000): p. 152 (8) (pp 398-404), 2000. 128. Laurenti, P., et al., Tuberculosis in Sheltered Homeless Population of Rome: An Integrated Model of Recruitment for Risk Management. Scientific World Journal, 2012. 129. Johnson De Rosa, C., et al., HIV risk behavior and HIV testing: A comparison of rates and associated factors among homeless and runaway adolescents in two cities. AIDS Education and Prevention, 2001. 13(2): p. 131-148. 130. Podschun, G.D., Teen Peer Outreach-Street Work Project: HIV prevention education for runaway and homeless youth. Public Health Reports, 1993. 108(2): p. 150-155. 131. Walters, A.S., HIV prevention in street youth. Journal of Adolescent Health, 1999. 25(3): p. 187-198. 132. Smeja, C. and P. Brassard, Tuberculosis infection in an Aboriginal (First Nations) population of Canada. International Journal of Tuberculosis and Lung Disease, 2000. 4(10): p. 925-930. 133. McGillivray, J., et al., Tuberculosis: finding a community solution. International journal of circumpolar health, (of Publication: 1998): p. 57 Suppl 1 (pp 242-246), 1998. 134. Gibson, N., et al., Socio-cultural factors influencing prevention and treatment of tuberculosis in immigrant in and Aboriginal communities Canada. Social Science & Medicine, 2005. 61(5): p. 931- 942. 135. Macdonald, M.E., N. Rigillo, and P. Brassard, Urban Aboriginal Understandings and Experiences of Tuberculosis in Montreal, Quebec, Canada. Qualitative Health Research, 2010. 20(4): p. 506-523. 136. Grace, J. and R. Chenhall, A rapid anthropological assessment of tuberculosis in a remote aboriginal community in northern Australia. Human Organization, 2006. 65(4): p. 387-399. 137. Hurtado, A.M., et al., Longitudinal study of tuberculosis outcomes among immunologically naive Ache natives of Paraguay. American Journal of Physical Anthropology, 2003. 121(2): p. 134-150. 138. Nobrega, R.G., et al., The Active Search for Respiratory Symptomatics for the Control of Tuberculosis in the Potiguara Indigenous Scenario, Paraiba, Brazil. Revista Latino-Americana De Enfermagem, 2010. 18(6): p. 1169-1176. 139. Romero-Sandoval, N.C., et al., Pulmonary tuberculosis in an indigenous community in the mountains of Ecuador. International Journal of Tuberculosis and Lung Disease, 2007. 11(5): p. 550-555. 140. Balasubramanian, R., et al., Feasibility of involving liberate tribal youths in tuberculosis case-finding in a tribal area in Tamil Nadu. Tubercle and Lung Disease, 1995(of Publication: 1995): p. 76 (4) (pp 355-359), 1995. 141. Mihas, C., et al., Is screening for tuberculosis acceptable to immigrants? A qualitative study. Journal of Public Health, 2007. 29(1): p. 98-98. 142. Kulane, A., B.M. Ahlberg, and I. Berggren, "It is more than the issue of taking tablets": The interplay

DRAFT-NOT FOR DISTRIBUTION

between migration policies and TB control in Sweden. Health Policy, (of Publication: Septemper 2010): p. 97 (1) (pp 26-31), 2010. 143. Carvalho, A.C.C., et al., Completion of screening for latent tuberculosis infection among immigrants. Epidemiology and Infection, (of Publication: Feb 2005): p. 133 (1) (pp 179-185), 2005. 144. Tardin, A., et al., Tuberculosis cluster in an immigrant community: Case identification issues and a transcultural perspective. Tropical Medicine and International Health, (of Publication: September 2009): p. 14 (9) (pp 995-1002), 2009. 145. Leone, N., et al., The effect of a strategy to improve adherence of irregular non UE citizens to tuberculosis screening in a clinic of Reggio Emilia. [Italian]. Assistenza infermieristica e ricerca : AIR, (of Publication: 2008 Jan-Mar): p. 27 (1) (pp 13-17), 2008. 146. Shetty, N., M. Shemko, and A. Abbas, Knowledge, attitudes and practices regarding tuberculosis among immigrants of Somalian ethnic origin in London: a cross-sectional study. Communicable disease and public health / PHLS, 2004(of Publication: Mar 2004): p. 7 (1) (pp 77-82), 2004. 147. Mulder, C., van Deutekom, H., Huisman, E.M., Toumanian, S.,, B. Koster, Meijer-Veldman, W., van Loenhout-Rooyackers, J.,Appel,M.,, and S. Arend, Borgdorff,M.W., van Leth,F., Role of Quantiferon- TB Gold In-Tube in screening new immigrants for tuberculosis infection. European Respiratory Journal, 2012. 148. Zolopa, A.R., et al., HIV AND TUBERCULOSIS INFECTION IN SAN-FRANCISCOS HOMELESS ADULTS - PREVALENCE AND RISK-FACTORS IN A REPRESENTATIVE SAMPLE. Jama-Journal of the American Medical Association, 1994. 272(6): p. 455-461. 149. Fischl, M.A., et al., An outbreak of tuberculosis caused by multiple-drug-resistant tubercle bacilli among patients with HIV infection. Annals of Internal Medicine, (of Publication: 1992): p. 117 (3) (pp 177-183), 1992. 150. Sterling, T.R., et al., A multi-state outbreak of tuberculosis among members of a highly mobile social network: Implications for tuberculosis elimination. International Journal of Tuberculosis and Lung Disease, (of Publication: 2000): p. 4 (11) (pp 1066-1073), 2000. 151. Khanani, M.A., I.; Ansari, A., , Tuberculosis and HIV Infection among Drug Users and Males having Sex with Males in Karachi, Pakistan,, in in International Union of Tuberculosis and Lung Disease. 2008: Paris. p. S61. 152. McDowell, M.H., N Rahman. FHI 360, Dhaka, Bangladesh World Lung Conference, Lille,2011 http://uwclh.conference2web.com/. TB/HIV Among Marginalized Populations : Peer-to-peer TB health services: Reaching populations engaged in commercial sex work and drug abuse in World Lung Conference 2011: Lille. 153. Legesse, M., et al., Knowledge and perception of pulmonary tuberculosis in pastoral communities in the middle and Lower Awash Valley of Afar region, Ethiopia. Bmc Public Health, 2010. 10. 154. Legesse, M., et al., Knowledge of cervical tuberculosis lymphadenitis and its treatment in pastoral communities of the Afar region, Ethiopia. Bmc Public Health, 2011. 11. 155. Gele, A.A., G. Bjune, and F. Abebe, Pastoralism and delay in diagnosis of TB in Ethiopia. Bmc Public Health, 2009. 9: p. 5. 156. Gele, A.A., et al., Barriers to tuberculosis care: a qualitative study among Somali pastoralists in Ethiopia. BMC research notes, 2010. 3: p. 86. 157. Girma, A., H.M. D, and K. Deribe, Quality of tuberculosis care in six health facilities of Afar Region, Ethiopia. Ethiop Med J, 2010. 48(3): p. 195-202. 158. Hussen, A., et al., Treatment delay among pulmonary tuberculosis patients in pastoralist communities in Bale Zone, Southeast Ethiopia. BMC research notes, 2012. 5(1): p. 320. 159. Bloss, E., et al., GENDER DIFFERENCES AMONG TB PATIENTS IN HARD-TO-REACH PASTORALIST REGIONS IN NORTHERN KENYA. American Journal of Epidemiology, 2010. 171: p. S42-S42. 160. Tayler-Smith, K., et al., The experience of implementing a 'TB village' for a pastoralist population in Cherrati, Ethiopia. Int J Tuberc Lung Dis, 2011. 15(10): p. 1367-72. 161. Gilks, C.F., et al., Recent transmission of tuberculosis in a cohort of HIV-1-infected female sex workers in Nairobi, Kenya. Aids., 1997. 11(7): p. 911-8. 162. English, A., Runaway and street youth at risk for HIV infection: Legal and ethical issues in access to care. Journal of Adolescent Health, 1991. 12(7): p. 504-510. 163. Snell, C.L., Help-seeking and risk-taking behavior among black street youth: Implications for HIV/AIDS prevention and social policy. Journal of Health and Social Policy, 2002. 16(1-2): p. 21-32. 164. Roy, E., et al., HIV incidence among street youth in Montreal, Canada. Aids, 2003. 17(7): p. 1071- 1075. 165. Dematteo, D., et al., Toronto street youth and HIV/AIDS: Prevalence, demographics, and risks. Journal of Adolescent Health, 1999. 25(5): p. 358-366.

DRAFT-NOT FOR DISTRIBUTION

166. Mulder, C., et al., Coverage and yield of tuberculosis contact investigations in the Netherlands. Int J Tuberc Lung Dis, 2011. 15(12): p. 1630-7. 167. Mulder, C., et al., Missed opportunities in tuberculosis control in The Netherlands due to prioritization of contact investigations. Eur J Public Health, 2012. 22(2): p. 177-82. 168. Garcia-Garcia Ma, D.L., et al., The role of core groups in transmitting Mycobacterium tuberculosis in a high prevalence community in Southern Mexico. International Journal of Tuberculosis and Lung Disease, 2000. 4(1): p. 12-17. 169. Macintyre, K. and E. Bloss, Alcohol Brewing and the African Tuberculosis Epidemic. Medical Anthropology, 2011. 30(2): p. 126-135. 170. Moller, V., I. Erstad, and D. Zani, Drinking, Smoking, and Morality: Do 'Drinkers and Smokers' Constitute a Stigmatised Stereotype or a Real TB Risk Factor in the Time of HIV/AIDS? Social Indicators Research, 2010. 98(2): p. 217-238. 171. Bond, V., et al., Children's role in enhanced case finding in Zambia. International Journal of Tuberculosis and Lung Disease, 2010(of Publication: October 2010): p. 14 (10) (pp 1280-1287), 2010. 172. Sandelowski, M., "Meta-jeopardy": The crisis of representation in qualitative metasynthesis. Nursing Outlook, 2006. 54(1): p. 10-16. 173. Corbett, E.L., et al., Provider-initiated symptom screening for tuberculosis in Zimbabwe: diagnostic value and the effect of HIV status. Bulletin of the World Health Organization, 2010. 88(1): p. 13-21. 174. Sandelowski, M., Reading, writing and systematic review. Journal of Advanced Nursing, 2008. 64(1): p. 104-110. 175. Sandelowski, M., et al., "Distorted into clarity": A methodological case study illustrating the paradox of systematic review. Research in Nursing & Health, 2008. 31(5): p. 454-465. 176. Crandell, J.L., et al., Bayesian data augmentation methods for the synthesis of qualitative and quantitative research findings. Quality & Quantity, 2011. 45(3): p. 653-669. 177. Voils, C.I., et al., Combining adjusted and unadjusted findings in mixed research synthesis. Journal of Evaluation in Clinical Practice, 2011. 17(3): p. 429-434. 178. Carbonne, A., et al., Investigation of patient contacts of heath care workers with infectious tuberculosis: 6 cases in the Paris area. The International Journal of Tuberculosis and Lung Disease, 2005. 9: p. 848-52.