The International Standards for Tuberculosis Care define the essential level of care for managing patients who have or are presumed to have tuberculosis, or are at increased risk of developing the disease. The resources and capacity in the European Union (EU) and the European Economic Area permit higher standards of care to secure quality and timely TB diagnosis, prevention and treatment. On this basis, the European Union Standards for Tuberculosis Care (ESTC) were published in 2012 as standards specifically tailored to the EU setting. Since the publication of the ESTC, new scientific evidence has become available and, therefore, the standards were reviewed and updated.
A panel of international experts, led by a writing group from the European Respiratory Society (ERS) and the European Centre for Disease Prevention and Control (ECDC), updated the ESTC on the basis of new published evidence. The underlying principles of these patient-centred standards remain unchanged. The second edition of the ESTC includes 21 standards in the areas of diagnosis, treatment, HIV and comorbidities, and public health and prevention.
The ESTC target clinicians and public health workers, provide an easy-to-use resource and act as a guide through all the required activities to ensure optimal diagnosis, treatment and prevention of TB.
With 58 994 tuberculosis (TB) cases notified in the European Union and European Economic Area (EU/EEA; refers to Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Republic of Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, The Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and the UK) member states in 2016 , TB continues to be a priority public health challenge in this setting. Although several EU/EEA countries are progressing towards sustained low levels of TB incidence and some towards the pre-elimination phase (defined as less than 10 cases per million population [1–3]), great diversity in TB disease burden remains within the sub-region . Drug-resistant TB, multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) pose a specific public health threat in many countries . Furthermore, documenting the prevalence of HIV co-infection among TB cases is still compromised by sub-optimal reporting in several countries [5, 6].
While EU/EEA countries adopted the key principles of TB control and elimination through the Europe-specific, consensus-based documents born within the Wolfheze initiative  and subsequent documents , a uniform set of guidelines summarising essential standards to guide European clinicians and healthcare workers was developed only in 2012 . These European Union Standards for Tuberculosis Care (ESTC) were based on the second version of the International Standards for Tuberculosis Care (ISTC) issued in 2009 . The documents were developed by experts selected to include the perspectives of several countries, organisations, national TB programmes, and scientific and civil societies, as well as representatives of the affected communities, which endorsed them for universal (ISTC) or EU/EAA countries’ use (ESTC).
Both ISTC and ESTC [8–11] prescribe a widely accepted level of TB care, to guide all healthcare providers and clinicians, both public and private, in achieving optimal standards in managing individuals who have active TB, latent TB infection (LTBI) or signs and symptoms compatible with the disease. The standards are designed to complement existing national or international guidelines and are consistent with World Health Organization (WHO) definitions and recommendations .
The original ESTC include 21 standards organised into four sections: 1) standards for diagnosis, 2) standards for treatment, 3) standards for addressing HIV co-infection and other comorbidities and 4) standards for public health . The standards are a living document, and will thus be revised as technology and circumstances change. In 2014, the third edition of the ISTC was published . An assessment and a survey among European Respiratory Society (ERS) members and European Centre for Disease Prevention and Control (ECDC) contacts concluded that a revision of the ESTC would be appropriate [13, 14].
The specific mix of characteristics among the EU/EEA member states which justified the development of standards specifically tailored to the EU context are still valid, and are summarised below [8, 11, 15]:
1) Although the majority of EU/EEA countries have a low incidence of TB, a number of member states have intermediate TB levels, with varying incidence of MDR-TB and TB-HIV co-infection. Furthermore, several countries located at the eastern border of the EU are neighbours to non-EU countries with a high TB and MDR-TB burden.
2) TB services are fully integrated and merged within the health system in the majority of EU/EEA countries. This leads to individual country peculiarities in allocating responsibilities for the optimal delivery of TB care.
3) The EU/EEA countries have a long-established tradition of TB control that has evolved over past decades. New tools and high standards of diagnosis and care are often implemented in EU/EEA countries.
4) The EU/EEA is committed to pursuing the elimination of TB, sharing a common platform based on the Wolfheze documents and subsequent documents; the Global End TB Strategy and its related action plan specific to the European region; as well as the surveillance system driven by ECDC and WHO Regional Office for Europe [2, 16–22].
The purpose of this document is to incorporate the new scientific evidence that has become available after the publication of the ESTC in 2012.