Health care systems must implement available patient care and support measures (including decentralized models of care,a,b,c if applicable) before resorting to isolation of any person. a WHO treatment guidelines for drug-resistant tuberculosis, 2016 update. October 2016 revision (WHO/HTM/TB/2016.04). Geneva: World Health Organization; 2016 (http://apps.who.int/iris/bitstream/10665/250125/1/9789241549639-eng.pdf, accessed 18 December 2018). b Guidelines for treatment of drug-susceptible tuberculosis and patient care, 2017 update (WHO/HTM/TB/2017.05). Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/10665/255052/1/9789241550000-eng.pdf?ua=1, accessed 18 December 2018). c Ethics guidance for the implementation of the End TB strategy (WHO/HTM/TB/2017.07). Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/handle/10665/254820/9789241512114-eng.pdf?sequence=1, accessed 18 December 2018). It is critical that national health authorities and public health policy-makers consider these recommendations in the context of the burden of disease; the strengths and weaknesses of health systems; and the availability of financial, human and other essential resources. Additionally, they should be aware that the data assessment and conclusions reached by the Guideline Development Group supported the implementation of respiratory separation in certain circumstances (provided that rapid initiation of effective anti-TB treatment is in place), and other measures to prevent or reduce M. tuberculosis transmission. Current recommendations on models of care for all TB patients – including the management of cases with DR-TB, and recommendations on patient care and support – have been described elsewhere (45–47). A decentralized27 model of care is recommended over a centralized model for TB patients (including those on DR-TB treatment). However, this model of patient care may not be appropriate for patients for whom treatment adherence is of concern, severely ill patients with extremely infectious forms of the disease or serious comorbidities, or cases where there are important barriers to accessing other forms of ambulatory care (e.g. outpatient or community-based care). In such situations, an individual risk assessment should be considered; this assessment should follow a human rightsbased approach to TB, balancing the potential risks and benefits of the proposed interventions (i.e. respiratory separation or isolation) to the patient with the potential risks and benefits to health workers and the community in general. Health care systems must implement available patient care and support measures before resorting to isolation of any person. In situations where isolation is required, this should be decided in consultation with the patient, and carried out in medically appropriate settings. The Guideline Development Group did not address the use of involuntary hospitalization and incarceration of TB cases. For the adequate implementation of isolation, it is important that health care authorities and those implementing the interventions consider the rights and freedoms of TB patients, balancing such individual liberties with the advancement of the common good (47). The use of respiratory isolation or separation measures for TB patients can present several challenges, especially if:

• such measures are not implemented through clear protocols;
• facilities do not meet minimal standards for implementation;
• staff are not trained; and
• the undesirable effects (e.g. perception of alienation) for those affected are not considered. Appropriate financial resources would be required to provide proper respiratory separation or isolation measures in such a way that the intervention protects the rights of the patient, and does not increase the risk for health workers or other persons attending health care or settings with a high risk of M. tuberculosis transmission. In situations where respiratory isolation is not feasible, health care facilities should consider the use of referral systems, in consultation with the patient. Patients admitted to isolation have higher rates of anxiety and depression than other hospitalized subjects (48, 49). Therefore, it is essential that patients are informed of the rationale for respiratory separation or isolation measures, and that psychological support is provided to patients who are isolated. In addition, health care staff should be trained in the identification of anxiety and depression in TB patients, and the provision of the necessary support. Mental health risk assessments can be conducted to inform isolation decisions, to discuss supportive measures with the patient and their families, and to provide opportunities for the patient to participate in decision-making, as appropriate. Although evidence on physical separation at home, including specifications of such, was not evaluated in this systematic review, it is important to emphasize current recommendations on decentralized models of care (46). In situations in which patients are considered to be infectious and care is being provided at decentralized facilities (e.g. patient’s home), patients and family members providing care should receive clear guidance and indications on IPC, particularly if the TB patient is receiving palliative and end-of-life care. Decentralized care” was defined as care provided in the local community where the patient lives, by non-specialized or peripheral health centres, by community health workers or nurses, non-specialized doctors, community volunteers or treatment supporters. Care could occur at local venues or at the patient’s home or workplace. “Centralized care” was defined as inpatient treatment and care provided solely by specialized DR-TB centres or teams for the duration of the intensive phase of therapy, or until culture or smear conversion. Settings and target population The use of respiratory isolation or separation measures applies to health care settings, as well as other settings with a high risk of M. tuberculosis transmission (congregate settings where health care services, including hospitalization is provided, such as correctional facilities), regardless of the burden of TB disease in the community. Initiation and duration of isolation The systematic review28 attempted to estimate the effect of effective treatment on the infectiousness of TB cases, to guide the duration of isolation (see Web Annex B). However, the temporal dynamics indicating when effective treatment renders the patient non-infectious could not be ascertained in the present review. Where management policies differ across settings, in some settings individuals with infectious TB are separated at the outset of treatment. However, elsewhere, priority areas of patient care (e.g. treatment supervision, treatment adherence interventions and decentralized models of care) have been recommended. If these measures fail and there is an increased risk of transmission of M. tuberculosis to the community, health care authorities can resort to isolating a patient. In situations in which patients are isolated, de-isolation should be based on the likely infectivity of the individual case and the availability of other supportive systems (in particular, decentralised models of care). Patients who are isolated for extended periods of time, regardless of disease, have been shown to experience greater levels of anxiety, depression, anger and feelings of imprisonment; this is difficult for patients and their families. Resources Health care authorities need to allocate enough resources, based on a needs assessment, to strengthen the implementation of IPC interventions. Data on the cost of the intervention were not extracted or captured in this systematic review; however, members of the Guideline Development Group discussed the allocation of resources, and noted that this would vary, depending on factors such as existing structures, burden of disease, and respiratory separation or isolation measures (e.g. open-wall concept versus closed-wall isolation rooms). Subgroup considerations The Guideline Development Group did not assess any evidence on the implementation of respiratory separation or isolation measures in children