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

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

Measurement of hearing protection devices performance in the workplace during full-shift working operations.

OBJECTIVES: The effectiveness of hearing protection devices (HPDs), when used in workplace conditions, has been shown over the years to be usually lower than the labeled values obtained under well-controlled laboratory conditions. Causes for such discrepancies have been listed and discussed by many authors. This study is an attempt to understand the issues in greater details and quantify some of these factors by looking at the performance of hearing protectors as a function of time during full work shift conditions. METHODS: A non-invasive field microphone in the real ear (F-MIRE)-based method has been developed for measuring the effectiveness of different HPDs as a function of time in the workplace. Details of the test procedures, the equipment used, and the post-processing operations are presented and discussed. The methodology was developed in such a way that a complete time and frequency representation are possible. The system was used on a total of 24 workers in eight different companies. Work shifts of up to 9-h long were recorded. Various types of earmuffs and one type of molded earplugs were tested. RESULTS: Attenuation data reported as a function of time showed, for most workers tested, considerable fluctuations over entire work shift periods. Parts of these fluctuations are attributed to variations in the low-frequency content in the noise (in particular for earmuffs) as well as poor insertion and/or fitting of earplugs. Lower performances than laboratory-based ones were once again observed for most cases tested but also, important left and right ear differences were obtained for many individuals. When reported as a function of frequency, the attenuation results suggested that the few approximations used to relate the measurements to subjective real-ear-attenuation-at-threshold (REAT) data were realistic. CONCLUSIONS: The use of individualized attenuation data and performance ratings for HPDs as well as a good knowledge of the ambient noise in the workplace are key ingredients when evaluating the performance of hearing protectors in field conditions.