Settings and target population The use of respiratory hygiene measures applies to individuals with confirmed or presumed TB in all health care settings, as well as to such individuals in other settings with a high risk of M. tuberculosis transmission (including households and non-health care congregate settings such as correctional facilities, and refugee and asylum centres), independent of the burden of TB disease in the community and the level of care of the facility (i.e. primary, secondary or tertiary). Respiratory hygiene must be implemented at all times. The use of surgical masks, in particular, is of utmost importance in waiting rooms, during patient transport and in any situation which can lead to temporary exposure to M. tuberculosis (e.g. in physician offices). Resources TB continues to be highly stigmatized, with TB patients and their families experiencing considerable discrimination. In some settings, the use of surgical masks by patients may perpetuate social stigma and local misconceptions about TB (58). Thus, the Guideline Development Group emphasized the need to:

• consider health education to key stakeholders – including patients’ families, community members and health workers – to better understand the prevailing causes of discrimination and to implement targeted health education programmes;
• institute effective health counselling for patients as part of a comprehensive package of interventions within social protection systems;
• institute respiratory hygiene (including cough etiquette) as a standard practice for coughing patients; and
• provide “how to” information on wearing of surgical masks, during sensitization and educational activities with both patients and health workers. Surgical masks are part of the standard medical supplies procured by health care facilities. Hence, the provision of surgical masks to patients and a related education programme may incur minimal additional costs, in health care as well as in non-health care settings (e.g. correctional facilities, and refugee and asylum centres). National authorities will need to consider the additional costs of providing surgical masks to inpatients as well as to those eligible for home isolation, and those under palliative and end-of-life care. Subgroup considerations Childhood TB is often paucibacillary, and likely to contribute little to transmission (59–62). The Guideline Development Group acknowledged that use of surgical masks in paediatric TB patients can have a negative psychosocial impact on children and families (63); nevertheless, children should be provided with masks until they are initiated in effective treatment to ensure that they are non-infectious. The use of surgical masks may be poorly tolerated in severely ill patients. Therefore, health care authorities need to ensure the proper implementation of interventions within the hierarchy of controls for preventing M. tuberculosis transmission