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European countries are increasingly targeting migrant populations in latent TB programmes. Dr Zenner will describe recent initiatives to deliver these often complex screening programmes through primary care services, exploring lessons learned and best practice approaches.

BACKGROUND: An appropriate screening approach and quality care are crucial for TB programmes in prisons. This study assessed crude TB prevalence, accuracy of the screening methods and treatment outcomes in a Thai prison.METHOD: This was a retrospective analysis of findings from a mass CXR screening conducted among incarcerated people in July 2017. Digital radiographs were forwarded to a chest physician to read and classify in six categories using WHO categorisation. CXR with significant Categories 3 (no active TB), 4 (not TB), 5 (TB) and 6 (unclassified) abnormalities were eligible for sputum microscopy and Xpert testing. A screening questionnaire locally known as TB-P1 was used for case management. Patients with TB received care in the prison.RESULTS: Of 2,382 prisoners screened, 6.3% had CXR Categories 3–6. Crude prevalence of bacteriologically confirmed TB was 1,133/100,000 (95% CI 748.3–1644.9). The screening´s sensitivity was 96.3% based on CXR Category 5 and 22.2% using TB-P1. Treatment success rates in drug-susceptible and drug-resistant TB patients were respectively 66.7% and 33.3%.CONCLUSION: The WHO radiograph categorisation could be used to screen for TB in the field and may be applied in artificial intelligence for interpreting CXR; screening questionnaires are not effective in prison environments. Nonetheless, low treatment success rates remained a challenge.

Objectives: To examine the prevalence and characteristics of HIV-tuberculosis (TB) co-infected patients in Singapore, an intermediate TB-burden country. Methods: Retrospective data across 11 years was obtained from the National University Hospital (NUH), a quaternary hospital and the National Centre for Infectious Diseases (NCID), the national HIV center. Results: From December 2005 to December 2016, 4015 HIV-infected patients were managed at NUH and NCID, of whom, respectively, 48 and 272 were diagnosed with active TB disease. Only 2 patients (0.6%) were screened for latent TB infection on HIV diagnosis. Mean CD4 count at TB diagnosis was 125.0 +/- 153.9 cells/mm(3). More patients with HIV diagnosed >= 6 weeks before TB (41%) were associated with CD4 counts > 200 cells/mm(3) than patients with TB diagnosed > 6 weeks before HIV (2%). Of 124 (38.6%) HIV-TB patients with CD4 count

As the proportion of foreign-born persons among TB notifications continues to rise, Japan is preparing to introduce pre-migration TB screening for those coming from selected countries, who are intending to stay for more than 90 days. It has announced that the programme will commence in 2020. In this review, the authors examine the experiences from two countries which already have years of experience in operating pre-migration TB screening, namely the United Kingdom and Australia. The authors point out that both countries have developed strong health information system not only to collect and analyse screening results, but also to use the data to effectively monitor and evaluate the screening programme itself. The critical role which health information system plays within pre-migration screening is often overlooked. Here we argue that Japan, as with any other countries planning to introduce pre-migration screening for TB, must also plan for data management.

Background: Screening of high-risk groups for TB is considered as the cornerstone for TB elimination but the measure of cost-effectiveness is also crucial in deciding the strategy for TB screening. This study aims to measure the cost-effectiveness of TB screening between the various high-risk groups in Malaysia.Methods: A decision tree model was developed to assess the cost-effectiveness of TB screening among the high-risk group from provider perspective using a secondary data from year 2016 to 2018. The outcome is presented in term of cost per TB case detected and the ICER. Deterministic and Probabilistic Sensitivity Analysis were also performed to measure the robustness of the model.Results: The most cost-effective strategy was TB screening among PL HIV, with MYR 2,597.00 per one TB case detected. This is followed by elderly, prisoners and smokers with MYR 2,868.62, MYR 3,065.24 and MYR 4,327.76 per one TB case detected respectively. There was an incremental costs of MYR 2.49 per screening, and 3.4 TB case detection per 1000 screening for TB screening among PL HIV in relation to TB screening among prisoners. The probability of symptomatic cases diagnosed as TB was the key driver for increasing cost effectiveness efficacy among PL HIV.Conclusions: Results of the study suggest prioritization of high-risk group TB screening programme by focusing on the most cost-effective strategy such as screening among PL HIV, prisoners and elderly, which has lower cost per TB case detected.

Background Japan plans to introduce pre-entry tuberculosis (TB) screening for those traveling from the Philippines, China, Vietnam, Nepal, Indonesia, and Myanmar, who are intending to stay in Japan for more than 90 days, in 2020. According to its screening algorithm, migrants will be screened by chest X-ray and those with abnormal findings will be asked to undergo sputum testing. We analyzed the characteristics of foreign-born TB patients coming from the above six countries, to identify some potential issues. Methods Data on foreign-born patients who had been newly notified with active pulmonary TB (PTB) in 2018 and 2017, and who had entered Japan in the same year they were notified, was extracted from the Japan TB Surveillance system. We assumed that these patients approximated to those hypothetical migrants who would be detected by pre-entry TB screening, and analyzed them by basic socio-demographic characteristics, radiological findings, and bacteriological test results. Results In 2017 and 2018, a total of 1,915 foreign-born PTB patients were notified from the above six countries. Of them, 19.9% (n = 381) had entered Japan in the same year they were notified. Among the 381, 23.9% (n = 50) had cavitary lesion, 27.3% (n = 57) were smear positive, and 48.9% (n = 73) were culture positive. 34.4% (n = 72) were both smear and culture negative, and the diagnosis would have depended on radiographical presentation. However, among the 72, the majority i.e. 87.5%, presented with non-cavitary pulmonary involvement. Conclusions Considering that approximately a third of TB patients who would may detected by the pre-entry screening are likely to be bacteriologically negative, Japan must ensure that the clinics conducting the pre-entry TB screening have access to high-quality radiography with expert interpretations, such as teleradiology and computer-assisted reading. Key messages A third of TB patients who would may detected by the pre-entry screening are likely to be bacteriologically negative. It is critical that clinics conducting screening have access to high-quality radiography with expert interpretations, such as teleradiology and computer-assisted reading.

People undergoing chronic dialysis are at an increased risk of active tuberculosis (TB). In 2012, the Canadian province of British Columbia began systematically screening people initiating dialysis for latent TB using interferon-gamma release assay (IGRA), and treating when appropriate.The objective of this study was to compare active TB rate in people who initiated dialysis and were screened using an IGRA compared with those not screened during the same period.Retrospective cohort study.British Columbia (BC), a Canadian province of 5.0 million people with an active TB incidence of 5.1 per 100 000 population.All people in BC who initiated at least 90 days of dialysis between January 2012 and May 2017 were included in the study. People were excluded if they were18 years of age or had a prior history of active TB diagnosis or treatment for latent TB.A retrospective cohort was created of British Columbians who initiated dialysis between 2012 and 2017. Individuals were stratified into a screened and nonscreened group. Multivariable Cox regression was used to determine the association between latent TB screening and the development of active TB. The primary outcome was incident active TB, either microbiologically confirmed or clinically diagnosed.Of the 3190 people included in the study, 1790 (56.1%) were screened, of which 152 (8.5%) initiated latent TB treatment postscreening. During follow-up, incident active TB was diagnosed in 6 (0.3%) of the 1790 people screened, compared with 11 (0.8%) of the 1400 people who received no screening. In multivariable analysis, latent TB screening and treatment was associated with a significant reduction in the rate of active TB (adjusted hazard ratio = 0.3, 95% confidence interval = 0.1-0.8;This was an observational retrospective study and the potential for unmeasured confounding should be carefully assessed.These findings suggest that systematically screening and treating people initiating dialysis can significantly decrease the rate of active TB in this high-risk population. Given the importance of screening high-risk groups, the results from this analysis could inform scale-up of TB screening in dialysis programs in other low incidence regions. Trial registration is not applicable as this was a retrospective cohort analysis and not a randomized trial.Les patients sous dialyse chronique sont plus susceptibles de développer une tuberculose (TB) active. En 2012, la Colombie-Britannique (province canadienne) a entrepris de dépister systématiquement la TB latente chez les patients qui amorcent un traitement de dialyse. Le dépistage s’effectue à l’aide du test sanguin de libération d’interféron gamma (test IGRA—L’objectif de l’étude était de comparer le taux de TB active chez les patients dépistés par le test IGRA à celui des individus non testés au cours de la même période.Étude de cohorte rétrospective.L’étude s’est tenue en Colombie-Britannique, une province canadienne de cinq millions d’habitants dont l’incidence de TB active est de 5,1 cas pour 100 000 habitants.Ont été inclus tous les Britanno-Colombiens ayant amorcé une dialyse de plus de 90 jours entre janvier 2012 et mai 2017. Les mineurs et les individus avec des antécédents de TB active ou ayant déjà été traités pour une TB latente ont été exclus.Une étude de cohorte rétrospective a été menée auprès des Britanno-Colombiens ayant amorcé une dialyse entre 2012 et 2017. Les individus ont été divisés en deux groupes: un groupe dépisté et un groupe non dépisté. Une régression de Cox à variables multiples a servi à établir l’association entre une TB latente et le développement d’une TB active. Le principal résultat d’intérêt était une TB active confirmée par analyse microbiologique ou diagnostiquée cliniquement.Des 3 190 individus retenus pour l’étude, 1 790 (56,1 %) ont été testés et de ceux-ci, 152 (8,5 %) ont été traités pour une TB latente après l’examen. Pendant le suivi, parmi les 1 790 individus dépistés, 6 patients (0,3 %) ont reçu un diagnostic de TB active comparativement à onze (0,8 %) parmi les 1400 qui n’avaient pas été examinés. Dans l’analyse multivariée, le traitement et le dépistage de la TB latente ont été associés à une réduction significative du taux de TB active (aHR 0,3; IC 95%: 0,1 à 0,8;Il s’agit d’une étude observationnelle rétrospective et le risque de confusion devrait être rigoureusement évalué.Ces résultats suggèrent que le taux de TB active chez les patients dialysés pourrait être réduit significativement par le dépistage et le traitement systématique des individus qui entreprennent un traitement de dialyse. Vu l’importance du dépistage des populations à haut risque, les résultats de cette étude sont susceptibles d’éclairer l’augmentation du dépistage de la TB au sein des programmes de dialyse dans d’autres régions de faible incidence.

Background: Following the first wave of COVID-19 outbreak, Uganda experienced a 40% drop in Tuberculosis (TB) screening by June 2020. We sought to identify barriers to and facilitators of integrated COVID-19 and TB screening from the perspective of healthcare providers (HCP) at a National Referral Hospital in Kampala, Uganda. Design/Methods: We conducted a cross sectional study using in-depth interviews with 12 HCP involved in TB activities in the outpatient and emergency departments at Kiruddu National Referral hospital Kampala, Uganda. We explored the HCP experiences at work in the setting of COVID-19, HCP perceived effect of COVID-19 on TB screening activities at the Hospital, and perceptions about social and contextual factors that might influence the willingness of HCP to integrate screening of COVID-19 and TB. We analyzed the data using an inductive thematic approach and the emergent themes were denoted as barriers to and facilitators of COVID-19-TB integrated screening. We then mapped the themes to the Capability, Opportunity, Motivation and Behavior (COM-B) model. Results: The facilitators to integrated COVID-19 and TB screening included; HCP knowledge of how to separately screen for TB and COVID-19, availability of TB focal persons and interest in learning how to provide integrated screening for TB and COVID-19. The barriers included; HCP inadequate knowledge on how to integrate screening of TB and COVID-19, absence of simple standard operating procedures and data collection tools for integrated screening, inconsistent supply of personal protective equipment (PPE), under staffing, and fear of contracting COVID-19 infection. The identified intervention functions to address the facilitators or barriers included education, persuasion, enablement, and training. Conclusions: These findings provide a basis for designing contextually appropriate interventions targeting factors that are likely to influence HCP decisions and willingness to conduct TB screening in the context of COVID-19.

SETTING: In July 2019, the Anambra State (south-east Nigeria) TB Control Programme implemented the integration of TB case-finding with the polio vaccination campaign with the support of the WHO. OBJECTIVE: To improve TB case-finding from communities leveraging already existing polio structures. DESIGN: Vaccination teams were trained to ask for symptoms of TB in each household and to document details of people presumed to have TB. Community TB workers subsequently tracked those identified for subsequent sample collection. We report the numbers detected, and the proportion of wards that reported people with TB. Regression analyses were used to estimate the relationship between ward characteristics and reporting. Odds ratios (ORs) with associated 95% confidence intervals (CIs) are also reported. RESULTS: Of 281 people with presumptive TB, 32 were diagnosed with TB; 21% (70/330) of wards identified at least one presumptive, while 5% (18/330) of the people were identified with TB. Peri-urban slums were most likely to identify presumptives (adjusted OR [aOR] 11.52, 95% CI 1.62–81.79), while Riverine areas were most likely to identify a person with TB (aOR 3.59, 95% CI 1.16–11.01). CONCLUSION: Integrating community TB case-finding into house-to-house vaccination campaigns can boost case detection. This approach proved effective in areas perennially underserved by routine healthcare services.

Wellness on Wheels (WoW) provided mobile systematic TB screening of high-risk populations combining digital chest radiography with computer-aided automated interpretation and chronic cough screening to identify beneficiaries of GeneXpert MTB/RIF testing in communities and prisons. We piloted and refined approaches in phased evaluations, recalibrating CAD4TB thresholds adjusting to balance TB yield and feasibility. Iterative data monitoring of screening volumes, risk mix, number needed to screen (NNS), number needed to test (NNT), sample loss, TB treatment initiation and HIV testing are required. Given pre-selection of highest risk individuals via an accurate screening test, inability to collect or test samples impacts yield and cost-per-case. Linkage to care and treatment outcomes improved overtime. Short conclusion: Mobile computer-assisted digital chest x-ray and chronic cough screening with GeneXpert MTB/RIF testing is feasible, acceptable, efficient and high-yield when highest risk groups are engaged, and operations evolve in response to monitoring data.

Background The securitisation of borders against the threat of invading microbes, carried by immigrant bodies, is not a new phenomenon. Tuberculosis (TB), transmitted through coughing, has been a core member of the infectious diseases deemed important to control for more than a century. Following evidence suggesting airport screening for TB using chest x-rays was ad hoc, ineffective and costly, the UK - following in the footsteps of other high-income, low TB-burden countries - moved to pre-entry screening of migrants for TB. Thus the 'biosecuritisation' of immigrant bodies was shifted off-shore. Since 2014, pre-entry screening for TB has been a mandatory part of the visa application system for those moving to the UK for a period of 6 months or longer from high-incidence countries. This ethnographic study explores how pre-entry screening is experienced by migrants. Methods Data was drawn from a project exploring migrants' experiences of accessing healthcare. This involved a focused ethnography, comprising 180 hours of field work over four weeks including interviews with clients and staff, in a pre-entry TB screening centre in India in 2017. During this time over 1000 individuals were screened for active pulmonary TB as part of their visa application. In addition, 14 in-depth interviews were conducted with migrants diagnosed with TB in the UK. Foucault's concept 'governmentality' and sociological theories of bordering were used alongside thematic analysis to analyse the data. Results This study reveals the previously undocumented harms experienced by individuals who are required to undergo pre-entry screening for TB. Through the 'biosecuritisation' of some, but not all, off-shore bodies; some, but not all, off-shore TB; some, but not all, infectious diseases; pre-entry screening becomes a border force, reinforcing global inequities and racialised hierarchies. In this context, I argue pre-entry screening makes UK citizens live while letting 'others' die. Key messages Pre-entry screening marks migrants as ‘other’ in a global, racialised, hierarchy of TB risk that ignores intra-country heterogeneity, obfuscating solutions that might reduce inter-country inequities. The global health security agenda must consider the experiences of those caught up in its policies and practices in order to ensure disease control does not do more harm than good.

INTRODUCTION The WHO End TB Strategy emphasises early diagnosis and screening of TB in high-risk groups, including migrants. We analysed TB yield data from four large migrant TB screening programmes to inform TB policy.METHODS We pooled routinely collected individual TB screening episode data from Italy, the Netherlands, Sweden and the United Kingdom under the European Union Commission E-DETECT.TB grant, described characteristics of the screened population, and analysed TB case yield.RESULTS We collected data on 2,302,260 screening episodes among 2,107,016 migrants, mostly young adults aged 18-44 years (77.8%) from Asia (78%) and Africa (18%). There were 1,658 TB cases detected through screening, with substantial yield variation (per 100,000): 201.1 for Sweden (95% confidence intervals CI 111.4-362.7), 68.9 (95% CI 65.4-72.7) for the United Kingdom, 83.2 (95% CI 73.3-94.4) for the Netherlands and 653.6 (95% CI 445.4-958.2) in Italy. Most TB cases were notified among migrants from Asia (n = 1,206, 75/100,000) or Africa (n = 370, 76.4/100,000), and among asylum seekers (n = 174, 131.5/100,000), migrants to the Netherlands (n = 101, 61.9/100,000) and settlement visa migrants to the United Kingdom (n = 590, 120.3/100,000).CONCLUSIONS We found considerable variations in yield across programmes, types of migrants and country of origin. These variations may be partly explained by differences in migration patterns and programmatic characteristics.

INTRODUCTION The WHO End TB Strategy emphasises early diagnosis and screening of TB in high-risk groups, including migrants. We analysed TB yield data from four large migrant TB screening programmes to inform TB policy.METHODS We pooled routinely collected individual TB screening episode data from Italy, the Netherlands, Sweden and the United Kingdom under the European Union Commission E-DETECT.TB grant, described characteristics of the screened population, and analysed TB case yield.RESULTS We collected data on 2,302,260 screening episodes among 2,107,016 migrants, mostly young adults aged 18–44 years (77.8%) from Asia (78%) and Africa (18%). There were 1,658 TB cases detected through screening, with substantial yield variation (per 100,000): 201.1 for Sweden (95% confidence intervals CI 111.4–362.7), 68.9 (95% CI 65.4–72.7) for the United Kingdom, 83.2 (95% CI 73.3–94.4) for the Netherlands and 653.6 (95% CI 445.4–958.2) in Italy. Most TB cases were notified among migrants from Asia (n = 1,206, 75/100,000) or Africa (n = 370, 76.4/100,000), and among asylum seekers (n = 174, 131.5/100,000), migrants to the Netherlands (n = 101, 61.9/100,000) and settlement visa migrants to the United Kingdom (n = 590, 120.3/100,000).CONCLUSIONS We found considerable variations in yield across programmes, types of migrants and country of origin. These variations may be partly explained by differences in migration patterns and programmatic characteristics.

Additional file 1. Consolidated Criteria for Reporting Qualitative Research (COREQ): 32-item checklist.

BACKGROUND Incarcerated individuals, especially in high HIV and TB burden settings, are at increased risk of latent TB infection and/or TB disease. We implemented a comprehensive HIV-TB intervention in a Malawi prison and studied its feasibility.METHODS Between February and December 2019, consenting individuals underwent screening for HIV, TB infection and TB disease. HIV-positive individuals without TB disease were treated with a fixed-dose combination of isoniazid, cotrimoxazole and vitamin B6 (INH-CTX-B6). HIV-negative persons with TB infection received 12 weeks of isoniazid and rifapentine (3HP).RESULTS Of 1,546 consenting individuals, 1,498 (96.9%) were screened and 1,427 (92.3%) included in the analysis: 96.4% were male, the median age was 31 years (IQR 25–38). Twenty-nine (2.1%) participants were diagnosed with TB disease, of whom 89.7% started and 61.5% completed TB treatment. Of the 1,427 included, 341 (23.9%) were HIV-positive, of whom 98.5% on antiretroviral therapy and 95% were started on INH-CTX-B6. Among 1,086 HIV-negative participants, 1,015 (93.5%) underwent the tuberculin skin test (TST), 670 (65.9%) were TST-positive, 666 (99.4%) started 3HP and 570 (85.5%) completed 3HP treatment.CONCLUSION A comprehensive TB screening and treatment package among incarcerated individuals was acceptable and feasible, and showed high prevalence of HIV, TB disease and TB infection. Treatment uptake was excellent, but treatment completion needs to be improved. Greater investment in comprehensive HIV-TB services, including access to shorter TB regimens and follow-up upon release, is needed for incarcerated individuals.

Introduction: The Collaborative TB Strategy recommends latent TB (LTBI) screening in New Entrants who have entered the UK in the previous 5 years, are aged 16–35 and from countries with a TB incidence of ≥150 cases/100,000 population.1 This screening programme was started in Bolton in 2017 and in discussion with Local Commissioning Group all screening activity was carried out via secondary care. Aims and Objectives: We aimed to look at the effectiveness of our new entrant TB screening program. Methods: We collected data from consecutive new entrants referred for TB screening between April 2018 and December 2018. The data included the source of referral (asylum centres and primary care registration [Flag 4]), country of origin, and diagnosis of LTBI by interferon gamma release assay (IGRA) results. Patients from the asylum team are pre-screened using Mantoux test and are only referred if positive (>5mm). Results: 279 new entrants were referred to our service. 118 were from Africa, many of whom were referred by the asylum centre, 88 (74%) of those referred attended the TB clinic, and 34 (38%) were diagnosed with LTBI. 161 patients referred were from Asia (mostly GP registration data), 98 (60%) of those attended clinic and only 16 (16%) were diagnosed with LTBI. Conclusions: The majority of new entrants invited to our clinic attended (66%). A significant number (26%) of these patients are diagnosed with LTBI. The incidence of LBTI is greater in the patients referred by asylum team, noting that they were pre-screened with the Mantoux test. We aim to continue to monitor our new entrant screening service and clinic outcomes, and to compare with services in neighbouring regions. Reference: 1. Collaborative TB Strategy for England 2015–2020: PHE2015, January

Tuberculosis (TB) screening programs may apply computer-aided diagnostic (CAD) tools on chest radiographs to select people for microbiological sputum examination using a pre-selected triaging threshold. CAD software-updates are frequently introduced and it is unknown whether their use requires adjustment of triaging thresholds. In a community-based screening program in South Africa, we compared the scores between the three recent CAD4TB versions (v5, v6, and v7) and assessed their performance to identify microbiologically-confirmed TB. The performance of all versions was similar (v5: AUC 0.78, v6: AUC 0.79, v7: AUC 0.80; p-values>0.05), but along a 0-100 point scale, each had markedly different score distributions and optimal triaging thresholds (v5: 40, v6: 47, v7: 20). This has the potential to cause confusion within TB screening programs as these tools are increasingly adopted and new versions released. Independent guidance for adapting CAD triaging thresholds for frequently released software updates is needed.

BackgroundImplementation outcome assessment such as fidelity is essential in implementing health intervention. Limited studies that have been conducted have assessed fidelity separately at the healthcare provider level or facility level with managers. However, there might be variations in facility resources and their utilization, skewing such comparisons. We, therefore, would like to investigate whether a combined provider-facility level fidelity is a more effective assessment. We aim to describe the weighted fidelity of implementing the guidelines for TB screening among PLHIV and examine its effect on TB screening coverage at selected HIV clinics in Ghana.MethodsWe used cross-sectional study and collected data from 226 HIV care providers and 27 managers of district hospitals implementing the TB screening intervention at the HIV clinics. We also extracted information from TB registers monthly for 2018. Weighted fidelity was measured based on the extent to which the intervention was implemented, considering both the facility and the provider level assessments. Response scores and extracted data on fidelity were analyzed and summarized using the median and inter-quartile range for non-normal data such as fidelity scores and coverage and frequencies and percentages for categorical data such as resources availability. Linear regressions models were fitted for TB screening coverage using the fidelities separately.ResultsThe study revealed that the weighted fidelity median score was 67% (IQR: 59.9 – 74.9%), and the TB screening coverage was 71.3% (IQR: 56.9 – 96.7). Weighted fidelity of delivery was statistically associated with TB screening coverage (p0.05) except for IE&C. Facilities with TB IE&C materials available had a significantly (p=0.025) higher median fidelity score 75.4% (74.9 – 88.5) than their counterparts 65.7% (59.4 – 72.6).ConclusionsThe combined provider-facility level assessment of fidelity demonstrated that weighted fidelity of delivery is positively associated with TB screening coverage and provided a better platform for assessing implementation fidelity. It also showed that the availability of IE&C materials significantly moderates the weighted fidelity of delivery. Weighted fidelity is an efficient way of holistically assessing fidelity within health facilities.

This is the first multi-district Standardised Patient (SP) study in South Africa. It measures the quality of TB screening at primary healthcare (PHC) facilities. We hypothesise that TB screening protocols and best practices are poorly adhered to at the PHC level. The SP method allows researchers to observe how healthcare providers identify, test and advise presumptive TB patients, and whether this aligns with clinical protocols and best practice. The study was conducted at PHC facilities in two provinces and 143 interactions at 39 facilities were analysed. Only 43% of interactions resulted in SPs receiving a TB sputum test and being offered an HIV test. TB sputum tests were conducted routinely (84%) while HIV tests were offered less frequently (47%). Nurses frequently neglected to ask SPs whether their household contacts had confirmed TB (54%). Antibiotics were prescribed without taking temperatures in 8% of cases. The importance of returning to the facility to receive TB test results was only explained in 28%. The SP method has highlighted gaps in clinical practice, signalling missed opportunities. Early detection of sub-optimal TB care is instrumental in decreasing TB-related morbidity and mortality. The findings provide the rationale for further quality improvement work in TB management.