Who Consolidated Guidelines

WHO
consolidated
guidelines on
tuberculosis
Module 2: Screening
Systematic screening for
tuberculosis disease
WHO
consolidated
guidelines on
tuberculosis
Module 2: Screening
Systematic screening for
tuberculosis disease
WHO consolidated guidelines on tuberculosis. Module 2: screening – systematic screening for tuberculosis disease
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Contents
Acknowledgements v
Abbreviations and acronyms viii
Definitions ix
Executive summary 1
1. Introduction 5
1.1 Background 5
1.2 Definition and objectives of systematic screening for TB disease 5
1.3 Scope of the 2021 update 6
1.4 Rationale for the guideline update 8
1.5 Objectives of the guideline update 8
1.6 Target audience 9
2. Recommendations for systematic screening for TB disease in targeted

populations 11
2.1 Systematic screening for TB disease in the general population 13
2.2 Systematic screening for TB disease among people with structural risk factors for TB 15
2.3 Systematic screening for TB disease among people living with HIV 16
2.4 Systematic screening for TB disease among household and other close contacts of
individuals with TB disease 16
2.5 Systematic screening for TB disease in prisons and other penitentiary institutions 18
2.6 Systematic screening for TB disease among miners and others exposed to silica dust 19
2.7 Systematic screening for TB disease among people attending health care services who
have clinical risk factors for TB 19
3. Recommendations for tools for systematic screening for TB disease 23

3.1 Tools for screening for TB disease among the general population and high-risk groups 23
iii
3.2 Use of computer-aided detection software for automated reading of digital chest
radiographs 25
3.3 Tools for screening for TB disease among people living with HIV 28
3.4 Tools for systematic screening for TB disease among children and adolescents 35
4. Monitoring and evaluation 37

4.1 Indicators 37
4.2 Routines for recording and reporting 38
4.3 Programmatic evaluations 38
4.4 Initial calibration for computer-aided detection technologies 39
5. Research gaps 41
5.1 Screening for TB in targeted populations 41
5.2 Tools for screening for TB 42
5.3 Operational research 43
6. References 45
Supplementary Table 51
Web annexes
Web Annex A. Methods and Expert Panels
https://apps.who.int/iris/bitstream/handle/10665/340241/9789240022690-eng.pdf
Web Annex B. GRADE Summary of Findings Tables

Web Annex C. GRADE Evidence to Decision Tables

iv
Acknowledgements
The production of the WHO consolidated guidelines on tuberculosis. Module 2: screening was coordinated
and written by Cecily Miller, with support from Annabel Baddeley, Dennis Falzon and Matteo Zignol,
under the overall direction of Tereza Kasaeva, Director of the World Health Organization (WHO)
Global Tuberculosis Programme. The WHO Global Tuberculosis Programme gratefully acknowledges
the contribution of all experts involved in producing these guidelines1. This update was funded
by grants provided to WHO by the United States Agency for International Development and the
Russian Federation.
Guideline Development Group

The Guideline Development Group (GDG) was composed of Denise Arakaki-Sanchez (Ministry of
Health, Brazil), Omolola Atalabi (University College Hospital, Ibadan, Nigeria), Helen Ayles (London
School of Hygiene and Tropical Medicine, United Kingdom of Great Britain and Northern Ireland,
and Zambart, Zambia), David Branigan (Treatment Action Group, United States of America), Jeremiah
Chakaya (The UNION [the International Union Against Tuberculosis and Lung Disease], Kenya),
Gavin Churchyard (The Aurum Institute, South Africa), Elizabeth Corbett (London School of Hygiene
and Tropical Medicine, United Kingdom, and Malawi-Liverpool-Wellcome Trust Clinical Research
Programme, Malawi), Anand Date (Centers for Disease Control and Prevention, USA), Esty Febriani
(Civil Society Task Force, Indonesia), Celine Garfin (National TB Programme, Philippines), Amir M
Khan (Association for Social Development, Pakistan), Katharina Kranzer (London School of Hygiene
and Tropical Medicine, United Kingdom), Tamara Kredo (University of Cape Town, South Africa),
Knut Lönnroth (Karolinska Institute, Sweden), Guy Marks (University of Sydney, Australia), Andrey
Maryandyshev (Northern State Medical University, Russian Federation), David Mungai (Civil Society
Task Force, Kenya), Iveta Ozere (Centre of Tuberculosis and Lung Diseases, Latvia), Alena Skrahina
(National TB Programme, Belarus) and Marieke J van der Werf (European Centre for Disease Prevention
and Control, Sweden). Jeremiah Chakaya and Tamara Kredo co-chaired the GDG meetings.
External Reviewer Group

The external reviewers were Grania Brigden (The UNION, France), Connie Erkens (Tuberculosis
Foundation [KNCV], Netherlands), Andrew Kerkhoff (University of California, San Francisco, USA),
Giovanni B Migliori (Maugeri Care and Research Institute, Italy), Ikushi Onozaki (Japan Anti-TB
Association, Japan), Srinath Satyanarayana (The UNION, India), James Seddon (Imperial College
London, United Kingdom), Ivan Solovic (National TB Programme, Slovakia) and Sabira Tahseen
(National TB Reference Laboratory, Pakistan).
Evidence reviewers
The following persons contributed to the reviews and summarized evidence for the guidelines using
the Population, Intervention, Comparator and Outcomes (PICO) framework (see Section 1.3 for more
information about the PICO questions).
1
More information about the areas of expertise, and the gender and geographical distribution of participants as well as declarations of
interests and the management of potential conflicts for members of the GDG and External Review Group are summarized in Web Annex A.
Acknowledgements v
PICO questions 1–4 (individual effects of screening): Lily Telisinghe, Maria Ruperez, Tila Mainga,
Modope Amofa-Seki, Lawrence Mwenge, Virginia Bond, Ramya Kumar, Cyrus Daneshvar and
Maged Hassan (London School of Hygiene and Tropical Medicine, United Kingdom and Zambart,
Zambia); and Eveline Klinkenberg (independent consultant, Netherlands).
PICO questions 5–7 (community effects of screening): Peter MacPherson, Marriott Nliwasa, Rachael
Burke and Helene Feasy (Liverpool School of Tropical Medicine, United Kingdom and Malawi-Liverpool-
Wellcome Trust Clinical Research Programme, Malawi).
PICO question 8 (accuracy of screening approaches in people living with HIV): Gary Maartens and
Ashar Dhana (University of Cape Town, South Africa).
PICO question 9 (accuracy of screening approaches in the general population): Anja Van’t Hoog
(Amsterdam Institute for Global Health and Development, Netherlands), Miranda Langendam and Ba
Da Yang (Amsterdam University Medical Centre), and Olivia Biermann (Karolinska Institute, Sweden).
PICO question 10 (accuracy of screening approaches in children and adolescents): Anna Mandalakas,
Tara Ness and Bryan Vonasek (Baylor College of Medicine, USA); Karen Steingart (Cochrane Infectious
Diseases Group, Liverpool School of Tropical Medicine, United Kingdom); and Yemisi Takwoingi
(University of Brimingham, United Kingdom).
PICO question 11 (accuracy of computer-aided detection software): Sandra Kik, Morten Ruhwald,
Claudia Denkinger, Stefano Ongarello and Samuel Schumacher (Foundation for Innovative New
Diagnostics, Switzerland); Faiz Ahmad Khan, Mikashmi Kohli and Gamuchirai Tavaziva (McGill University,
Canada); Sifrash Gelaw (International Organization for Migration, Philippines); and Jacob Creswell and
Zhi Zhen Qin (Stop TB Partnership, Switzerland).
PICO question 12 (accuracy of molecular WHO-recommended rapid diagnostic tests for screening):
Adrienne Shapiro (University of Washington, USA) and Karen Steingart (Cochrane Infectious Diseases
Group, Liverpool School of Tropical Medicine, United Kingdom).
PICO question 13 (number needed to screen in general and high-risk groups): Lelia Chaisson University
of Illinois at Chicago, USA); Jonathan Golub, Fahd Naufal, Katherine Robsky, Hector Manzo and Pamela
Delgado (Johns Hopkins University, USA); and Adrienne Shapiro (University of Washington, USA)
PICO question 14 (number needed to screen and effectiveness of screening in contacts): Gregory
Fox and Kavindhran Velen (University of Sydney, Australia), Mariana Velleca (University of California
San Francisco, USA).
PICO question 15 (risk factors for TB): Rafia Bosan (Harvard University, USA) and Lelia Chaisson
(University of Illinois at Chicago, USA).
PICO question 16 (costs and cost–effectiveness of TB screening): Hannah Alsdurf, Brianna Empringham
and Alice Zwerling (University of Ottawa, Canada).
PICO question 17 (community perceptions of TB screening): Paul Garner and Nancy Medley (Liverpool
School of Tropical Medicine, United Kingdom).
WHO Guideline Steering Group

The WHO Guideline Steering Group was composed of Annabel Baddeley, Dennis Falzon, Avinash
Kanchar, Alexei Korobitsyn, Cecily Miller, Nobu Nishikiori, Linh N Nguyen, Sabine Verkuijl and Matteo
Zignol (WHO Global Tuberculosis Programme); Satvinder Singh and Lara Vojnov (WHO Global HIV,
Hepatitis and Sexually Transmitted Infections Programme); Andreas Reis (Department of Health Ethics
and Governance); Maria del Rosario Perez (Department of Radiation and Health); Farai Mavhunga
(WHO Regional Office for Africa); Muhammad Akhtar (WHO Regional Office for the Eastern
Mediterranean); Mukta Sharma (WHO Regional Office for South-East Asia); Tauhidul Islam (WHO
Regional Office for the Western Pacific); and Askar Yedilbayev (WHO Regional Office for Europe).
WHO consolidated guidelines on tuberculosis:

vi
systematic screening for tuberculosis disease
Others
Holger Schünemann (McMaster University, Canada) served as the technical resource person on GRADE
(Grading of Recommendations Assessment, Development and Evaluation) methodology. The following
persons participated as observers at the GDG meetings: Sevim Ahmedov and Charlotte Colvin
(United States Agency for International Development, USA), Draurio Barreira Cravo Neto (Unitaid,
Switzerland), Olivia Bierman (Karolinska Institute, Sweden), Michael Campbell (Clinton Health Access
Initiative, USA), Jacob Creswell (Stop TB Partnership, Switzerland), Pierre-Marie David (Université
de Montréal, Canada), Christopher Gilpin (International Organization for Migration, Switzerland),
Brian Kaiser (Global Drug Facility, Switzerland) and Mohammed Yassin (Global Fund to Fight AIDS,
Tuberculosis and Malaria, Switzerland). Kerri Viney (WHO Global Tuberculosis Programme) contributed
to the reviews on the accuracy of screening approaches in the general population. The document
was edited by Miriam Pinchuk. The Global Tuberculosis Programme also thanks the Guideline Review
Committee and its WHO secretariat for their review and approval of the guidelines.
Acknowledgements vii
Abbreviations and acronyms
ART antiretroviral treatment
CAD computer-aided detection of TB-related abnormalities on chest radiography
CI confidence interval
CRP C-reactive protein
CXR chest radiograph (chest X-ray)
ERG External Review Group
GDG Guideline Development Group
GRADE Grading of Recommendations Assessment, Development and Evaluation
IPD individual patient data
LF-LAM lateral flow urine lipoarabinomannan assay
mWRD molecular WHO-recommended rapid diagnostic test
NNS number needed to screen (to detect one person with tuberculosis disease)
PICO population, intervention, comparator and outcomes (framework)
RR relative risk
TB tuberculosis
TPT TB preventive treatment
W4SS WHO-recommended four-symptom screen
WHO World Health Organization

viii
Definitions
The definitions below apply to terms as used in these guidelines, and they may have different
meanings elsewhere.
Active (tuberculosis) case-finding (ACF): Provider-initiated screening and testing in communities
by mobile teams, often using mobile X-ray and rapid molecular tests. The term is sometimes used
synonymously with “systematic screening”.
Computer-aided detection (CAD): The use of specialized software to interpret abnormalities on
chest radiographs that are suggestive of TB. The results are expressed as abnormality scores. CAD
may be used for screening or triage.
Enhanced (tuberculosis) case-finding: Health information or education, or awareness campaigns
to provide information about what type of health-seeking behaviour is appropriate when people
experience symptoms of TB; this type of case-finding may be combined with improving access to
diagnostic services. Enhanced case-finding may or may not be combined with screening.
Initial screening: The first screening test, examination or other procedure applied in the population
eligible for screening.
Number needed to screen (NNS): The number of persons that need to undergo screening in
order to diagnose one person with TB disease.
Passive case-finding: A patient-initiated pathway to TB diagnosis involving: (1) a person with TB
disease who experiences symptoms that he or she recognizes as serious; (2) the person having access
to and seeking care, and presenting spontaneously at an appropriate health facility; (3) a health worker
correctly assessing that the person fulfils the criteria for presumptive TB; and (4) successful use of a
diagnostic algorithm with sufficient sensitivity and specificity to diagnose TB.
Repeat screening: This refers to rescreening the same population at a given interval.
Risk groups: Any group of people in which the prevalence or incidence of TB is significantly higher
than in the general population.
Screening test, examination or procedure for tuberculosis disease: A test, examination, or
other procedure used to distinguish people with a high likelihood of having TB disease from people
who are highly unlikely to have TB. A screening test is not intended to be diagnostic. People with
positive results on a screening test should undergo further evaluation, depending on the screening
algorithm used.
Second screening: A second screening test, examination or other procedure undergone by persons
whose results were positive during the initial screen.
Systematic screening for TB disease: The systematic identification of people at risk for TB
disease, in a predetermined target group, by assessing symptoms and using tests, examinations or
other procedures that can be applied rapidly. For those who screen positive, the diagnosis needs
to be established by one or several diagnostic tests and additional clinical assessments. This term is
sometimes used interchangeably with “active tuberculosis case-finding”. It should be distinguished
from testing for TB infection (with a TB skin test or interferon-g release assay).
Definitions ix
Triage: The process of deciding the diagnostic and care pathways for people based on their symptoms,
signs, risk markers and test results. Triaging involves assessing the likelihood of various differential
diagnoses as a basis for making clinical decisions. It can follow more- or less-standardized protocols
and algorithms, and it may be done in multiple steps.
Triage test for TB: A test that can be rapidly conducted among people presenting to a health facility
to differentiate those who should have further diagnostic evaluation for TB from those who should
undergo further investigation for non-TB diagnoses.
Tuberculosis disease: The disease state caused by Mycobacterium tuberculosis. It is usually
characterized by clinical manifestations, which distinguish it from TB infection without signs or
symptoms (previously referred to as latent TB infection). Also referred to as active tuberculosis.

x
Executive summary
Tuberculosis (TB) is a leading cause of death from a single infectious agent, despite being largely
curable and preventable. In 2019 an estimated 2.9 million of the 10 million people who fell ill with TB
were not diagnosed or reported to the World Health Organization (WHO). The Political Declaration
adopted by the United Nations General Assembly in September 2018 at the High-Level Meeting on
the Fight Against Tuberculosis commits to, among other goals, diagnosing and treating 40 million
people with TB by 2022. In order to achieve this ambitious target, there is an urgent need to deploy
strategies to improve the diagnosis and initiation of care for people with TB. One of these strategies is
systematic screening for TB disease, which is included in the End TB Strategy as a central component
of its first pillar aimed at ensuring early diagnosis for all with TB.
To facilitate the implementation of TB screening at the country level, WHO published guidelines on
Systematic screening for active tuberculosis: principles and recommendations in 2013. Since then,
there have been important new studies evaluating the impact of screening interventions on both
individual-level and community-level outcomes related to TB, as well as new research evaluating
innovative tools for screening for TB – including the use of computer-aided detection of TB on digital
radiographs, C-reactive protein and molecular WHO-recommended rapid diagnostic tests for TB –
among important populations at high risk for TB disease.
In view of these new developments and due to requests by countries for more guidance, WHO
convened a Guideline Development Group (GDG) in 2020 to examine the evidence and update the
2013 guidelines. The GDG met in virtual sessions between June and October 2020 and proposed
several new and updated recommendations related to TB screening. WHO gratefully acknowledges
the work of the GDG members, the evidence reviewers, representatives of national TB and HIV
programmes, WHO colleagues, technical and funding partners, civil society representatives, patients
and all others who contributed to the data used to inform this guideline update.
The evidence reviewed to address the guideline questions was derived from several trials and other
studies, programmatic data, surveys and modelling work. The certainty of the evidence and the
strength of the recommendations were assessed using the GRADE (Grading of Recommendations
Assessment, Development and Evaluation) method. Decisions about the strength of a recommendation
and the evidence depend on the level of confidence in the estimates, as well as on other critical
considerations, such as acceptability, feasibility, resource use and impact on health equity.
The use of chest radiography (chest X-ray, or CXR) as a screening tool for detecting TB disease
in several populations was reviewed, including in the general public, people living with HIV, people
younger than 15 years who are contacts of TB patients and other high-risk groups. Across all
populations considered, CXR was found to be a sensitive screening tool that, while lacking sufficient
specificity to confirm a TB diagnosis, has an important role in the early detection of TB in children
and adults who are at higher risk of TB, as well as the potential to reduce the population burden of
TB disease when combined with early treatment.
In recent years computer-aided detection (CAD) software packages have been developed and
introduced to automate the interpretation of digital CXR images and produce a numerical score
indicating the likelihood of TB. Three independent evaluations of CAD were reviewed to develop
recommendations for both screening and triage for TB. The diagnostic accuracy and the overall
performance of CAD software were similar to the interpretation of digital CXR by a human reader, in
Executive summary 1
both the screening and triage contexts. Evaluations showed substantial variation in diagnostic accuracy
across different contexts, implying that the use of CAD will require calibration for the purpose and
setting in which it will be implemented.
C-reactive protein (CRP) is an indicator of inflammation that can be measured using point-of-
care tests performed on capillary blood collected via finger prick. The accuracy of CRP to detect
bacteriologically confirmed TB in people living with HIV was assessed with a meta-analysis of individual
patient data of people screened in high- and medium-burden settings. CRP was found to have similar
sensitivity and higher or similar specificity to symptom screening in all subpopulations tested. CRP
offers a clinically significant improvement in accuracy over the WHO-recommended four-symptom
screen among ambulant people living with HIV who are newly in care and not yet on antiretroviral
treatment, a subpopulation for whom the accuracy of the four-symptom screen is low.
Molecular WHO-recommended rapid diagnostic tests for TB (mWRDs; eg Xpert MTB/RIF) were
reviewed for use as TB screening tools among different populations at high risk of TB. Evidence shows
improved accuracy and effectiveness in people living with HIV and in other high-risk populations. The
evidence is strongest for hospitalized patients with HIV in settings with a high burden of TB, given
the limited value of symptom screening and the grave consequences of missing the opportunity to
initiate TB treatment promptly in this patient group.
Based on these updates, a set of 17 new and revised recommendations for screening for TB
disease have been developed (Table 1). The main changes from the previous WHO guidance are
summarized in Box 1. The new guidelines replace all previous WHO guidance on TB screening.
The recommendations are accompanied by updated operational guidance, the WHO operational
handbook on tuberculosis. Module 2: screening – systematic screening for tuberculosis disease, that
includes further details on target populations and tools to use for systematic screening, including
revised algorithms and modelled estimates of their performance.
Table 1. Recommendations in the WHO consolidated guidelines on tuberculosis.

Module 2: screening – systematic screening for tuberculosis disease, 2021
Screening for TB in targeted populations
1 Systematic screening for TB disease may be conducted among the general population in
areas with an estimated TB prevalence of 0.5% or higher
(updated recommendation: conditional recommendation, low certainty of evidence).
2 Systematic screening for TB disease may be conducted among subpopulations
with structural risk factors for TB. These include urban poor communities, homeless
communities, communities in remote or isolated areas, indigenous populations, migrants,
refugees, internally displaced persons and other vulnerable or marginalized groups with
limited access to health care
(existing recommendation: conditional recommendation, very low certainty of evidence).
3 People living with HIV should be systematically screened for TB disease at each visit to a
health facility
(existing recommendation: strong recommendation, very low certainty of evidence).
4 Household contacts and other close contacts of individuals with TB disease should be
systematically screened for TB disease
(updated recommendation: strong recommendation, moderate certainty of evidence).
5 Systematic screening for TB disease should be conducted in prisons and penitentiary
institutions
(updated recommendation: strong recommendation, very low certainty of evidence).

2
Screening for TB in targeted populations
6 Current and former workers in workplaces with silica exposure should be systematically
screened for TB disease
(existing recommendation: strong recommendation, low certainty of evidence).
7 In settings where the TB prevalence in the general population is 100/100 000 population
or higher, systematic screening for TB disease may be conducted among people with a
risk factor for TB who are either seeking health care or who are already in care
8 People with an untreated fibrotic lesion seen on chest X-ray may be systematically
Tools for screening for TB
9 Among individuals aged 15 years and older in populations in which TB screening is

recommended, systematic screening for TB disease may be conducted using a symptom
screen, chest X-ray or molecular WHO-recommended rapid diagnostic tests, alone or in
combination
(new recommendation: conditional recommendation, very low certainty of evidence for
test accuracy).
10 Among individuals aged 15 years and older in populations in which TB screening is
recommended, computer-aided detection software programmes may be used in place of
human readers for interpreting digital chest X-rays for screening and triage for TB disease
(new recommendation: conditional recommendation, low certainty of evidence).
11 Among adults and adolescents living with HIV, systematic screening for TB disease should
be conducted using the WHO-recommended four symptom screen and those who report
any one of the symptoms of current cough, fever, weight loss or night sweats may have
TB and should be evaluated for TB and other diseases
(existing recommendation: strong recommendation, moderate certainty of evidence).
12 Among adults and adolescents living with HIV, C-reactive protein using a cut-off of
>5mg/L may be used to screen for TB disease
(new recommendation: conditional recommendation, low certainty of evidence for
test accuracy).
13 Among adults and adolescents living with HIV, chest X-ray may be used to screen for TB
disease
(new recommendation: conditional recommendation, moderate certainty of evidence for
test accuracy).
14 Among adults and adolescents living with HIV, molecular WHO-recommended rapid
diagnostic tests may be used to screen for TB disease
test accuracy).
15 Adult and adolescent inpatients with HIV in medical wards where the TB prevalence
is > 10% should be tested systematically for TB disease with a molecular WHO-
recommended rapid diagnostic test
(new recommendation: strong recommendation, moderate certainty of evidence for
test accuracy).
Executive summary 3
16 Among individuals younger than 15 years who are close contacts of someone with
TB, systematic screening for TB disease should be conducted using a symptom screen
including any one of cough, fever or poor weight gain; or chest radiography; or both
(new recommendation: strong recommendation, moderate to low certainty of evidence for
test accuracy).
17 Among children younger than 10 years who are living with HIV, systematic screening for
TB disease should be conducted using a symptom screen including any one of current
cough, fever, poor weight gain or close contact with a TB patient
(new recommendation: strong recommendation, low certainty of evidence for
test accuracy).
TB: tuberculosis.
Box 1. Main changes to the guidance in the current update
Î Community-wide systematic screening using an accurate screening and diagnostic

algorithm may be used in settings with a TB prevalence of 0.5% and higher, based on
new evidence of public health benefit.
Î Computer-aided detection (CAD) is being recommended for the first time as an alternative
to human interpretation of digital chest X-ray (CXR) for screening and triage for TB. Its
use should be limited to the interpretation of plain CXRs for pulmonary TB in individuals
aged 15 years or older.
Î Molecular WHO-recommended rapid diagnostic tests (mWRDs) may be used to improve
the accuracy of symptom screening in populations at high risk of TB.
Î When scaling up CXR and innovations such as CAD, C-reactive protein and mWRDs
for screening, due consideration should be given to avoid creating inequities. The use
of mWRDs needs to be prioritized for diagnostic testing for people with presumptive
TB. Implementation of CAD will require thorough consideration of its infrastructure
requirements, including the availability of digital radiography equipment, computers and
internet access, as well as the costs to licence and use different CAD products.
Î In adults and adolescents living with HIV:
y screening with CXR improves the sensitivity of the WHO-recommended four-symptom
screen (cough, fever, weight loss or night sweats) for detecting TB, including in people
who attend HIV care services for antiretroviral treatment;
y C-reactive protein may be used for TB screening in addition to the WHO-recommended
four-symptom screen in all people living with HIV in settings with a high TB burden;
y mWRDs may be used to screen for TB in all people living with HIV as well as in other
high-risk populations in settings with a high TB burden. They offer a distinct opportunity
to improve timely diagnosis and treatment in hospitalized patients with HIV in medical
wards in settings with a high TB burden.

4
1. Introduction
1.1 Background
Tuberculosis (TB) is a leading cause of death from a single infectious agent, despite being largely
curable and preventable. In 2019, an estimated 2.9 million of the 10 million people who fell ill with TB
were not diagnosed or reported to the World Health Organization (WHO) (1). WHO’s End TB Strategy
envisions a 90% reduction in TB incidence and a 95% reduction in TB deaths by 2035 (2, 3), and the
Declaration adopted by the United Nations General Assembly in September 2018 at the High-Level
Meeting on the Fight Against Tuberculosis commits to diagnosing and treating 40 million people
with TB by 2022 (4). In order to achieve these ambitious targets, there is an urgent need to deploy
strategies to improve the diagnosis and initiation of care for people with TB. One key strategy is
systematic screening for TB disease, which is included in the End TB Strategy as a central component
of its first pillar, aimed at ensuring early diagnosis for all with TB.
To help facilitate the implementation of TB screening at the country level, WHO published guidelines on
systematic screening for TB in 2013 (5). Since then, there have been important new studies evaluating
the impact of screening interventions on both individual-level and community-level outcomes related
to TB, as well as new research evaluating innovative tools for screening for TB among important
populations at high risk for TB disease. In light of these new developments and continual requests by
Member States for guidance on how to conduct effective TB screening, in 2020 WHO convened a
Guideline Development Group (GDG) to examine the evidence in order to update WHO’s guidelines
and recommendations for screening for TB disease.
1.2 Definition and objectives of systematic screening

for TB disease
For the purpose of this guideline, systematic screening for TB disease is defined as the systematic
identification of people at risk for TB disease, in a predetermined target group, by assessing
symptoms and using tests, examinations or other procedures that can be applied rapidly.
The screening tests, examinations and other procedures should efficiently distinguish people with a
high probability of having TB disease from those who are unlikely to have TB disease. Among those
whose screening is positive, the diagnosis needs to be established by diagnostic evaluation, consisting
of one or more diagnostic tests, and clinical assessment, which together have high accuracy.
Systematic screening for TB disease is predominantly provider initiated. It may be conducted among
people who do not seek health care because they do not have or recognize symptoms, they do
not perceive that they have a health problem that warrants medical attention, there are barriers to
accessing care, or for other reasons. It may also target people seeking health care who do or do not
have symptoms or signs compatible with TB and who may not be identified by passive case-finding
as possibly having TB. People seeking care who may be eligible for TB screening include people
with medical conditions that constitute risk factors for TB (such as people living with HIV or diabetes
mellitus) who may be seeking care for reasons other than symptoms compatible with TB.
1. Introduction 5
There are two primary objectives of screening for TB disease: the first objective is to ensure that TB
disease is detected early and treatment is initiated promptly, with the ultimate aim of reducing the risk
of poor treatment outcomes, health sequelae and the adverse social and economic consequences of
TB; the second objective is to reduce the community-level prevalence of TB disease, thus reducing
transmission of Mycobacterium tuberculosis and averting future incident TB. Beyond TB disease,
screening can also identify individuals who are eligible for and would benefit from TB preventive
treatment (TPT) once TB disease is ruled out, thus further averting future incident TB.
Arising from these two primary objectives, there are two primary levels at which screening can
augment standard TB care practices: that of the individual and the community. For individuals with TB
disease, screening interventions can speed up and improve the probability of receiving a diagnosis
and initiating treatment by bypassing many of the barriers to diagnosis and care that people suffering
from TB disease can face, including (6):
• lacking knowledge about the signs and symptoms of TB;
• not recognizing symptoms;
• being unable to seek care or lacking sufficient resources for care-seeking;
• lacking access to TB diagnostic and treatment services;
• seeking care from providers who lack sufficient knowledge of TB or in facilities where TB diagnosis
and treatment services are not available or of sufficient quality.
Beyond improving individual health and welfare, screening interventions for infectious diseases such
as TB also address the epidemiology of the disease at the community level. By identifying and treating
a proportion of the pool of individuals with TB disease in a given community, screening for TB seeks
to reduce the prevalence, transmission and future incidence of the disease, with the long-term goal
of eliminating the disease from the population.
The recommendations in this document apply to screening interventions that are conducted for the
purpose of directly benefitting the individuals being screened by improving TB case detection and
care and, thereby, benefitting the larger community by reducing the population burden of TB.
1.3 Scope of the 2021 update

Fig. 1 summarizes the potential contribution of TB screening to standard TB care practices based on
the above frameworks for TB screening and shows the conceptual framework that guided the 2021
update to the TB screening guidelines.

6
Fig. 1. Conceptual framework for the 2021 WHO update to guidelines for systematic
screening for TB. Numbers in parentheses refer to the PICO (population, intervention,
comparator and outcome) questions that guided the evidence gathering
INDIVIDUAL-LEVEL POPULATION-LEVEL
INPUTS ACTIVITIES
OUTCOMES OUTCOMES
Increased TB knowledge, awareness, care-seeking (5)
Increased TB diagnosis and treatment initiation (4, 6)

Political and
stakeholder
engagement Screening
interventions Reduced diagnostic Reduced time of
and activities delay and earlier infectiousness and
Financial (including a range diagnosis of TB (1) reduced prevalence
resources of health centre-, of infectious cases in
community- and community
household-based Improved treatment
Human activities designed outcomes (2)
resources to systematically Reduced transmission
screen people of TB (7)
Equipment and for TB) Reduced costs of
supplies treatment and financial
loss, reduced risk Reduced incidence and
of adverse social prevalence of TB (7)
consequences of
disease (3)
A series of PICO (population, intervention, comparator and outcome) questions was established and
systematic reviews were sought or commissioned for each of the PICO questions and the priority
background questions.
The first PICO questions aimed at summarizing the evidence on the effectiveness of systematic
screening interventions for TB disease to address individual and community outcomes.
1. Among people with TB disease, does TB screening identify people at an earlier stage of disease
compared with passive case-finding?
2. Is there a difference in TB treatment outcomes between people with TB identified through
screening interventions compared with people with TB identified through passive case-finding?
3. For people with TB disease and their families, does receiving a diagnosis and undergoing a course
of treatment after case detection through screening have a different cost of illness and risk of
adverse social consequences compared with receiving a diagnosis and undergoing a course of
treatment after diagnosis through passive case-finding?
4. For people being screened who do not have TB disease, what are the consequences of TB
screening?
5. Does TB screening used in addition to passive case-finding affect subsequent health-seeking
behaviour compared with passive case-finding alone?
1. Introduction 7
6. Does TB screening initially increase the number of people with TB detected compared with passive
case-finding alone?
7. Does TB screening affect the epidemiology of TB in a community, including the prevalence,
incidence and transmission, compared with passive case-finding alone?
A series of questions focusing on the diagnostic accuracy and performance of screening tools was
also prioritized.
8. Among people living with HIV, what is the performance of a range of screening tools compared
with a microbiological reference standard?
9. Among the general population and high-risk groups eligible for TB screening, what is the
performance of a range of screening tools compared with a microbiological reference standard?
10. Among children and adolescents eligible for TB screening, what is the performance of a range of
screening tools compared with a composite or microbiological reference standard?
11. What is the performance of computer-aided detection (CAD) software for automated reading of
digital chest radiographs (CXRs) for the detection of TB disease in the screening- and the triage-
use cases?
12. Among the general population and high-risk groups eligible for TB screening, what is the
performance of molecular WHO-recommended rapid diagnostic tests (mWRDs) for screening
for TB disease compared with a microbiological reference standard?
Lastly, in addition to the PICO questions assessing the accuracy and effectiveness of screening
interventions, there was a series of background questions prioritized to inform the implementation
of TB screening interventions.
13. Among the general public and high-risk populations, what is the number needed to screen (NNS)
to detect one person with TB disease?
14. Among contacts of people with TB disease, what is the NNS to detect one person with TB disease?
15. What are the estimated relative risks of TB associated with a range of risk factors?
16. What are the costs and cost–effectiveness of implementing TB screening interventions?
17. What are the perceptions and attitudes of communities towards TB screening programmes?
1.4 Rationale for the guideline update

Since the publication of the first WHO guidelines on systematic screening for TB in 2013 (5), there
have been numerous studies, including reviews, randomized controlled trials, observational studies,
modelling and cost–effectiveness research, evaluating the real or potential impacts of screening
interventions on both individual-level and community-level outcomes related to TB. There have also
been numerous prevalence surveys since 2013, which have shed new light on the magnitude of the
burden of TB in several key countries. The majority of prevalence surveys have shown that the burden
of TB is greater than previously thought.
1.5 Objectives of the guideline update

The specific objectives of the guideline update are:
1. to support Member States in implementing effective TB screening interventions by providing
updated information about the expected impact of TB screening on patient-important outcomes
and the epidemiology of TB, the expected yield of screening interventions and the expected
performance of different screening tools and algorithms;

8
2. to contribute to finding more people with TB and finding them earlier in the course of disease
in order to reduce disease burden, morbidity and mortality, and costs and financial hardship for
people suffering from TB.
This update will allow policymakers in ministries of health to choose the best approach to planning
and implementing screening and active case-finding activities, depending on the context. It will also
provide a sound basis for developing or updating national guidelines for TB screening based on the
epidemiology of TB and the health care delivery system in the country.
1.6 Target audience

This guideline is intended for personnel working in national TB programmes, national HIV/AIDS
programmes or their equivalents, and other relevant national health programmes in ministries
of health; other relevant ministries working in public health and screening; and for other health
policymakers, clinicians and public health practitioners working on TB, HIV and infectious diseases in
the public and private sectors. The recommendations provided here must be adapted to local settings.
An accompanying operational handbook, WHO operational handbook on tuberculosis. Module 2:
screening – systematic screening for tuberculosis disease (7) provides more detail and discussion of
how screening recommendations can be adapted to address the conditions for and objectives of
screening in specific contexts. National and subnational recommendations must be developed by
national TB programmes and other national and subnational public health agencies and partners;
recommendations developed by national and subnational agencies should guide health care staff
working in specific settings.
1. Introduction 9
10
2. Recommendations for
systematic screening for TB
disease in targeted populations
In this guideline, recommendations about systematic screening for TB disease are made for distinct
populations for whom it is judged that the benefits and desirable effects of screening outweigh the
potential harms.
Systematic screening for TB disease can be done for an entire population (community-wide screening)
or it can be targeted at selected risk groups or subpopulations of people who may be at higher risk of
being exposed to TB, developing TB disease or suffering poor outcomes from the disease, or some
combination of these. It can target people who seek health care (with or without symptoms or signs
compatible with TB) and people who do not seek care (because they do not perceive that they have
a health problem that warrants medical attention, barriers make it difficult to access health care, or
for other reasons). Furthermore, screening can help identify people who are at particularly high risk of
developing TB disease and thus may require repeat screening, for example, people with an abnormal
CXR compatible with TB but who are not diagnosed with TB disease at the time of screening or people
for whom TPT is recommended. Combining screening for TB with screening for TB risk factors can also
help map individual- or community-level risk factors, comorbidities and socioeconomic determinants
that need to be addressed to more effectively prevent the disease.
Strong recommendations are made for those risk groups or subpopulations for which the desirable
effects of adhering to the recommendation are judged to clearly outweigh the undesirable effects: for
these recommendations, screening is judged to be feasible, acceptable and affordable in all settings.
Conditional recommendations are made for those risk groups for which the desirable effects of TB
screening probably outweigh the undesirable effects, but the trade-offs, cost–effectiveness, feasibility
or affordability, or a combination of these, are uncertain. Reasons for uncertainty may include a lack of
high-quality evidence to support the recommendation; limited evidence of benefit from implementing
the recommendation; high costs or low feasibility or acceptability, or a combination of these.
It is important that TB is diagnosed promptly in groups that have a particularly high likelihood of
undetected TB or a high risk of poor health outcomes, or both, in the absence of early diagnosis
and treatment, even if direct evidence of benefit from screening is lacking. This is the rationale for
making strong recommendations despite a lack of high-quality direct evidence for some risk groups.
However, prioritization should also consider the risks associated with screening, including false-positive
diagnoses, overtreatment and the opportunity costs of screening in terms of the resources required,
both across risk groups and in relation to other interventions aimed at improving early diagnosis,
treatment and prevention. Therefore, owing to the lack of high-quality direct evidence comparing
benefits with harms and on the cost–effectiveness of screening in many of the populations considered,
many of the recommendations made for screening in specific populations are conditional.
The degree of uncertainty about the trade-offs between the desirable effects and undesirable effects
varies across settings, and it depends on the epidemiological situation and the health system. Therefore,
a conditional recommendation in this guideline implies that the appropriateness of adhering to the
2. Recommendations for systematic screening for TB disease in targeted populations 11

recommendation needs to be assessed in each setting, and there is a need to prioritize screening
across risk groups in each setting.
For TB screening recommendations across all populations and in all settings, all people identified
with presumptive TB disease should be offered HIV counselling and testing. In settings with a high
prevalence of HIV, counselling and testing for HIV may be offered to all people screened for TB (8).
People identified through screening who have symptoms or abnormalities suggestive of TB but who
are not diagnosed with TB disease should be counselled and supported to seek medical care if their
symptoms continue, emerge, re-emerge or worsen. If possible, repeat testing for TB should be offered
to these individuals.
People who are diagnosed with TB disease through screening should have nutrition screening and
assessment. If malnutrition is identified, it should be managed according to WHO’s recommendations
on nutritional care and support for people with TB. Concerns about weight loss or failure to gain
weight should trigger further clinical assessment (e.g. to determine whether there is resistance to TB
drugs, poor adherence, comorbid conditions) and nutrition assessment in order to determine the
most appropriate interventions (9).
Screening population groups at higher risk for TB is ethically sound as long as it designed and
conducted to improve individual and public health and wellbeing; in this way screening contributes
to the common good and upholds the ethical principle of accountability. As such, screening should
always be done with the intent to provide care to those who need it, and never to exclude entry or
employment or discriminate against individuals (10).
Nevertheless, screening population groups primarily based on risk raises a range of ethical issues (10).
First, most of the individuals offered screening will not have TB disease and are not contagious. This
makes the ethical obligations different from those associated with testing people who seek care
because they are ill. For example, the absence of an immediate risk of transmission makes it unethical
to restrict the movements of someone who has been offered screening. Refusal of screening should
be respected and should not introduce discrimination of any sort. A screening programme should
not create inequities in access to care for TB disease or any other reason.
Second, a positive screening test carries uncertainties, and confirmatory tests should be available
to ensure an effective diagnostic pathway. Informed consent requires effective communication with
each person about these uncertainties (e.g. false-positive results, risk of overtreatment). Appropriate
mechanisms to obtain informed consent should comply with international human rights standards
and account for different languages, literacy skills and legal status. Risk and uncertainty must be
communicated in a way that is culturally and linguistically appropriate, including to those whose first
language is foreign to the local setting, children, as well as to people in prison.
Third, TB disproportionately affects individuals and groups that are already disadvantaged due to
disease, their socioeconomic situation or legal status, among other disadvantages. Therefore, efforts
must be made to address existing inequities in access to services and to uphold human rights, so that
the vulnerability of targeted groups does not impede their access to screening and treatment or violate
their rights. Any intervention for vulnerable groups – including migrants, prisoners and children –
should include measures to minimize the risk of stigmatization. Testing positive on a screening test
– as with a confirmed diagnosis of TB – should not influence an immigration procedure or be used
to force migration or deny entry to a country. Screening done for migration or employment reasons
must uphold ethical principles; this should be reflected in laws or other policy regulations (10).
People should be offered screening in strict adherence to human rights and ethical considerations (11).
Policies should be evaluated from an ethical perspective by those who use the guidelines, and the
views and experiences of affected populations should be gathered after implementation, both to
consider possible unexpected effects and to ensure that the evidence on which they are based
remains current and relevant (12). Person-centred care entails, among other considerations, that it

12
is provided in an equitable fashion without placing marginalized and vulnerable populations at an
added disadvantage; it focuses on the human rights aspects of screening so that there are appropriate
safeguards in law, policy and practice to minimize any additional stigma, discrimination, violation of
bodily integrity or restrictions on freedom of movement; and people who are offered testing and
treatment should understand the associated uncertainties, which will help them make decisions about
care options. Established human rights principles, such as consent, noncoercion, and confidentiality,
should be respected.
2.1 Systematic screening for TB disease among the

general population
1. Systematic screening for TB disease may be conducted among the general population in
areas with an estimated TB prevalence of 0.5% or higher
(updated recommendation: conditional recommendation, low certainty of evidence).
2.1.1 Summary of the evidence and rationale

Systematic screening in the general population is conducted on the premise that it bears dual benefit:
to the persons diagnosed with TB and to the community in which screening is conducted. Individuals
found to have TB may benefit from less diagnostic delay, improved treatment outcomes, and lower
costs and financial losses associated with the disease. It also benefits public health by reducing the
population prevalence of TB, thereby reducing further transmission of TB.
There is limited direct evidence of individual benefit from improved treatment success or reduced
mortality when TB screening is performed in the general population. There is some evidence that
systematic screening helps reduce delay in TB diagnosis and that it detects patients at an earlier
stage of their disease. Data also show that screening interventions result in a reduction in costs for
patients who are detected through screening and, most critically, a reduction in the risk of catastrophic
costs for patients detected through screening and their families. However, some data show that the
proportion of people who do not start treatment is higher among those identified through screening
than among those who present with illness.
With respect to the benefits of screening for the community, there is inconsistent evidence that
systematic screening for TB improves detection and notification in the general population, with
none coming from randomized trials. There is, however, evidence of an effect on TB prevalence and
transmission. A trial in Viet Nam in a population with an estimated prevalence of 0.35% that used 3
years of annual door-to-door sputum collection and testing using the Xpert MTB/RIF assay showed
that systematic screening reduced adult TB disease prevalence (13). An observational study in China
conducted between 2013 and 2015 reported that three rounds of door-to-door symptom screening
followed by CXR were associated with serial reductions in the absolute number of people with TB
detected (14). In addition, two trials showed lower frequencies of TB infection among children in
clusters where TB screening was done compared with others without the intervention (13, 15).
This is an updated recommendation: previously, systematic screening for TB disease in the general
population was recommended in defined populations with extremely high levels of undetected TB,
defined as a 1% prevalence or higher. Based on the updated evidence reviewed, the GDG concluded
that the threshold of 1% recommended in the 2013 guidelines could be lowered, but considered
that screening under programmatic conditions would not perform as well as was observed in the
trial in Viet Nam and, therefore, proposed a 0.5% threshold to guide country implementation. Thus,
the GDG recommended that general population screening may be considered in defined areas
with a prevalence of undetected TB of 0.5% or more (see Web Annex B, Tables 1 and 2, and Web
Annex C, Table 1).

2.1.2 Implementation considerations
The magnitude and balance of desirable and undesirable effects vary according the epidemiological
conditions (the prevalence of TB and of risk factors) and the intensity of the screening intervention
being implemented (the coverage of the population and the sensitivity of the screening test and
algorithm). There is currently no evidence that population-wide screening using less sensitive screening
algorithms that begin with symptom screening are effective at reducing the population prevalence
or transmission of TB. However, there is limited evidence that screening utilizing symptom-based
screening tools may benefit individuals who are diagnosed with TB by leading to earlier diagnosis with
less severe TB disease, lower costs to the patient and lower risk of catastrophic costs associated with
the course of disease. The balance of potential benefits and harms of screening may tip in favour of
the intervention depending on factors such as the prevalence of TB in the population to be screened
(particularly undetected TB), the accuracy of the screening and diagnostic tests used, the degree of
current TB case detection and the vulnerability of the population being screened.
Screening should be conducted using the most sensitive and specific screening algorithm possible,
with a screening test that identifies those with a higher likelihood of having TB and a diagnostic test to
confirm the diagnosis. Highly accurate screening tests such as CXR and mWRDs have high sensitivity,
specificity, or both; however, the feasibility of their use is affected by resource and implementation
requirements. Symptom screening is less accurate (reduced sensitivity, specificity, or both), but is
generally considered much more feasible to implement. Recent evidence suggests that reductions in
the population prevalence of TB can be achieved with repeated annual screenings using a sensitive
screening algorithm (mWRD followed by clinical evaluation) (13). See Section 3 for recommendations
on tools for screening for more discussion on this topic.
While the implementation of a population-wide screening programme inevitably requires a significant
investment of resources, overall there may be potential long-term savings to be made for health
services through reduced future incidence. The costs of conducting community-wide screening will
vary greatly, depending on the screening and diagnostic tests used and the population prevalence of
TB. The cost–effectiveness of population-wide screening using a highly accurate algorithm is unknown,
but the higher the prevalence, the more cost–effective the intervention will be. Using a highly accurate
screening and diagnostic algorithm will inevitably require more resources than using symptom-based
screening approaches, but it has a greater potential to reduce the population burden of TB.
The optimal frequency of screening in a general population to achieve individual- or community-level
benefits remains unclear. There is also uncertainty about how people value the benefits expected from
being screened. A review of qualitative studies of community perceptions of TB screening showed
that, in general, screening was acceptable. However, resistance to screening was common, resulting
from a combination of disparate factors, such as having a perception of being at low risk for TB
among healthy participants, having little conviction in the effectiveness of screening, holding in poor
regard TB services offered in the community, having concerns about confidentiality and the possible
disclosure of diagnosis, and being anxious about the need to take TB medication.
Separate recommendations are made for select high-risk groups in the following sections. See the
operational handbook for more details on the practicalities of implementing TB screening interventions
using different tools and algorithms (7).

14
2.2 Systematic screening for TB disease among
people with structural risk factors for TB
2. Systematic screening for TB disease may be conducted among subpopulations with structural
risk factors for TB. These include urban poor communities, homeless communities, communities
in remote or isolated areas, indigenous populations, migrants, refugees, internally displaced
persons and other vulnerable or marginalized groups with limited access to health care
2.2.1 Summary of evidence and rationale

Populations with structural risk factors for TB are those that are at increased risks of TB and of
poor health outcomes from TB due to structural determinants in their environment, defined as the
conditions that generate or reinforce social stratification (e.g. socioeconomic inequalities, population
growth, urbanization), and therefore give rise to an unequal distribution of key social determinants of
TB epidemiology, such as poor housing, poverty and malnutrition, which in turn influence exposure
to risk, vulnerability and ability to recover after developing the disease (16,17). Structural risk factors
for TB include poverty; malnutrition; overcrowded and poorly ventilated living, working and gathering
conditions; and limited or no access to health care. These risk factors are not mutually exclusive nor do
they exclude the clinical risk factors described in other recommendations, and they often compound
one another.
This recommendation has not been changed from the 2013 guidelines as, since the last GDG meeting,
no new evidence was found to inform the question of the impact of systematic screening for TB
disease compared with passive case-finding practices in these risk groups. Observational studies
during 2013–2020 suggest that TB screening conducted among populations affected by structural
risk factors may initially increase TB case notifications and decrease TB prevalence; however, all studies
had a major risk of bias.

Due to the inherent lack of access to health care that defines the risk groups described in this
recommendation, screening interventions would need to be conducted in and extended into the
communities where members of these populations live and work in order to achieve effective reach
and coverage.
The list of potential populations affected by structural risk factors included in this recommendation is
not exhaustive, and this recommendation may apply to other groups with a high risk of TB and who
have poor access to health care, including poor access to high-quality TB services.
There is no evidence about the effectiveness of different screening intervals; in the absence of such
evidence, the choice of screening interval should be guided by feasibility. To the extent possible,
community screening should be combined with screening for other diseases or risk factors and with
health-promotion or social support activities. When screening is done in refugee camps and among
displaced populations, consult Tuberculosis care and control in refugee and displaced populations (18)
for recommendations on TB management and operational considerations.

people living with HIV
3. People living with HIV should be systematically screened for TB disease at each visit to a
health facility
(existing recommendation: strong recommendation, very low certainty of evidence).

People living with HIV are approximately 19 times more likely to develop TB disease than those without
HIV; in 2019, an estimated 44% of people living with HIV who also had TB disease did not reach care,
and 30% of all HIV-related deaths were due to TB (1). Thus, ensuring early detection and treatment
for TB among all people living with HIV is crucial for reducing morbidity and mortality in this group.
This recommendation, which applies to people of all ages, was first published in 2011 in WHO’s
Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living
with HIV in resource-constrained settings (19), and it remains in place. The GDG placed high value on
ensuring that TB is diagnosed early in this risk group, which has a high likelihood of having undetected
TB and a high risk of poor health outcomes in the absence of early diagnosis and treatment.

Recommendations on specific tools to be used for screening people living with HIV are described in
detail in Section 3. Persons living with HIV who have a positive or abnormal screening test should
go on to have primary diagnostic tests to confirm or rule out TB disease including an mWRD and
lateral flow urine lipoarabinomannan assay (LF-LAM), if eligible (8). Once TB disease is ruled out,
either through a normal screening test or after a negative diagnostic evaluation, people living with
HIV should be evaluated for TPT as part of offering a comprehensive package of HIV care (20).

household and other close contacts of individuals
with TB disease
4. Household contacts and other close contacts of individuals with TB disease should be
systematically screened for TB disease
(updated recommendation: strong recommendation, moderate certainty of evidence).

Household and close contacts of individuals with TB disease are at high risk of TB infection and
developing TB disease. A systematic review conducted for the guideline update found the weighted
pooled prevalence of TB disease among all close contacts of TB patients was 3.6% (95% confidence
interval [CI]: 3.3–4.0), with a median NNS of 35 (95% CI: 17–65). Systematic screening has been
strongly recommended since 2012 for contacts of individuals with TB disease {21}, given the high
prevalence of disease in this population. At the GDG meeting, evidence was also presented on the
individual- and community-level effects of screening of close contacts of TB patients. One trial of
screening household contacts in Viet Nam showed a 2.5-fold increase in notification of contacts

16
diagnosed with TB resulting from the intervention (relative risk [RR]: 2.5; 95% CI: 2.0–3.2), along with
a 40% reduction in all-cause mortality among household contacts (RR: 0.6; 95% CI: 0.4–0.8) (22).
Another trial of contact screening in South Africa and Zambia showed evidence that screening
household contacts may reduce TB prevalence in the larger community after 4 years during which
contact investigation is conducted, although this did not reach statistical significance (prevalence ratio:
0.82; 95% CI: 0.64–1.04); there was also a suggestion that the intervention reduced the transmission
of TB, measured through the incidence of TB infection in schoolchildren (RR: 0.45; 95% CI: 0.20–1.05)
(see Web Annex B, Table 3, and Web Annex C, Table 2) (15).
Eligibility for TPT should be assessed among all TB contacts who are screened and found not to have
indications of TB disease (20). Children aged < 5 years who are household and close contacts of
people with bacteriologically confirmed pulmonary TB and who are found not to have TB disease after
appropriate clinical evaluation or according to national guidelines should be given TPT even if testing
for TB infection is unavailable. Children aged ≥ 5 years, adolescents and adults who are household
and close contacts of people with bacteriologically confirmed pulmonary TB who are found not to
have TB disease after appropriate clinical evaluation or according to national guidelines may also
be given TPT. Contacts of TB patients who are living with HIV, no matter what their age, in whom TB
disease has been ruled out, should receive TPT as part of a comprehensive package of HIV care (20).

Contact screening should always be done when a person with TB has any of the following characteristics:
bacteriologically confirmed pulmonary TB, proven or presumed multidrug-resistant TB or extensively
drug-resistant TB, is a person living with HIV or is a child younger than 5 years. Among contacts of
patients with bacteriologically confirmed TB, the weighted pooled prevalence of TB was 3.4% (95%
CI: 2.9–3.8). Among contacts of patients with multidrug-resistant or extensively drug-resistant TB
the weighted pooled prevalence of TB was 3.7% (95% CI: 2.4–5.3). The weighted pooled prevalence
of TB among HIV-positive contacts was 11.6% (95% CI: 8.2–15.4), with a median NNS of 9 (95% CI:
5–13). The weighted pooled prevalence among contacts younger than 5 years was 3.9% (95% CI:
2.5–5.4), with a median NNS of 30 (95% CI: 12–62), while the prevalence among contacts aged 5–14
years was 2.4% (95% CI: 1.6–3.4), with a median NNS of 36 (95% CI: 17–61). Contact investigation
may also be performed for TB patients with all other forms of disease.
The definition of a household or close contact can vary greatly across settings, and in some contexts
there is no clear distinction between households; therefore, decisions about screening household and
close contacts should be based on local definitions and policies, prioritizing contacts for screening
based on an assessment of their level of exposure.
2.4.3 Subgroup considerations

Children and adolescents are of particular importance in contact screening, given the high prevalence
found in the youngest age groups and the importance of rapid diagnosis and treatment owing to
the risk of rapid disease progression in children younger than 5 years (23), as well as the importance
of initiating preventive treatment if TB disease has been ruled out (see Section 2.4.2).
Contacts who are persons living with HIV are also of particular importance in contact screening, given
their extremely high prevalence of TB disease. Contacts living with HIV are also at increased risk for
rapid progression to TB disease, and if they develop it, an increased risk of mortality. Contacts of TB
patients who are also living with HIV are at a higher probability of themselves being HIV-positive,
even they are unaware of their status. Thus, in settings with a high prevalence of HIV or when the
index case is a person living with HIV, or both, all household contacts and close contacts should be
offered counselling and testing for HIV. People living with HIV who are household contacts or close
contacts of someone with TB disease and who, after an appropriate clinical evaluation, are found not
to have TB disease should be evaluated for TPT.

2.5 Systematic screening for TB disease in prisons
and other penitentiary institutions
5. Systematic screening for TB disease should be conducted in prisons and penitentiary
institutions
(updated recommendation: strong recommendation, very low certainty of evidence).

People in prisons and other penitentiary institutions are at an increased risk for TB compared with
the general population, and they often have limited access to health care services. The estimated
incidence of TB among people residing in prisons is 23 times higher than that among the general
population (24). Data reviewed for the GDG meeting suggest that screening in prisons may improve
early case detection, increase overall case detection and reduce TB prevalence. One observational
study showed that a smaller proportion of TB patients in prisons whose disease was detected through
screening were at an advanced stage of disease compared with those diagnosed through passive
case-finding services (25). Two observational studies showed that TB screening in prisons may reduce
TB prevalence in the facilities (26, 27). One trial showed that screening in prisons may increase case
detection by more than 50% (28).
Based on this new evidence and the high risk of TB in this population, the GDG felt that this risk
group now merited a strong recommendation for TB screening (see Web Annex B, Table 4, and
Web Annex C, Table 3). The GDG felt that implementing TB screening in prisons has the potential
to increase equity in access to health care, particularly in settings where health services in prisons
are suboptimal.

A prisoner is anyone held in a criminal justice facility or correctional facility during the investigation
of a crime, anyone awaiting trial and anyone who has been sentenced. In addition, people residing
in a correctional facility are almost always in close contact with several other inmates; thus, whenever
a person residing in a prison is diagnosed with TB, prisoners who have been in close contact with
that person should be investigated (see Recommendation 4). People who work in prisons and other
penitentiary institutions are also at high risk of exposure to TB and should also be eligible for screening.
At a minimum, screening in prisons and other penitentiary institutions should always include screening
when a person enters a detention facility, annual screening and screening upon release to prevent
the reintroduction of TB into the broader community. Treatment and follow up after release should
also be ensured.
Screening in prisons should be combined with efforts to improve living conditions and provide
infection control measures. If possible, TB screening in prisons and other penitentiary institutions
should be combined with screening for other diseases, including HIV, and health-promotion activities
targeted towards people in these institutions. When starting screening, it is important to ensure that
high-quality treatment and effective case management are in place, as well as effective mechanisms
for continuing treatment after transfer or release. For recommendations on and operational aspects
associated with TB care and prevention in prisons and other penitentiary institutions, see WHO’s
Guidelines for the control of tuberculosis in prisons (29). However, even if TB management practices
are suboptimal, screening may be initiated to assess the burden of undetected TB among inmates
to provide a rationale for strengthening general diagnostic and treatment services for TB, as well as
implementing measures to improve infection control and living conditions. In addition to systematic
screening, any inmate who develops symptoms suggestive of TB should have easy access to diagnostic

18
testing. People identified through screening and presumed to have TB disease but in whom active
TB has not been diagnosed, should be informed about the importance of seeking medical care if TB
symptoms continue, emerge, re-emerge or worsen.

miners and others exposed to silica dust
6. Current and former workers in workplaces with silica exposure should be systematically
(existing recommendation: strong recommendation, low certainty of evidence).

Exposure to silica dust and silicosis are among the strongest risk factors for TB, with a relative risk of
2.8–39 for silicosis, depending on the severity of the disease (30). Silicosis is common in miners (31, 32),
which is a primary reason for the high incidence of TB among them, and this is often compounded
by a high prevalence of HIV. TB patients with silicosis have an increased risk of death (RR: 3.0; 95% CI:
1.4–6.3) (33). Thus, while the quality of the direct evidence is low for the benefit of TB screening in
employees in workplaces where they are exposed to silica, the GDG placed high value on ensuring
that TB is diagnosed early in this risk group, which has a high likelihood of having undetected TB as
well as other pulmonary diseases that may be detected through screening. This recommendation
has not been changed from the 2013 guidelines as no new robust evidence was found to inform the
subject since the last guideline meeting.

There is limited evidence on the effectiveness of different screening intervals. The GDG suggests
that the screening interval should be no longer than 12 months if possible, while an interval shorter
than 12 months may be more beneficial. To the extent possible, TB screening should be combined
with screening for other diseases and with health-promotion activities, as well as with efforts to
improve working conditions (especially by reducing exposure to silica) and living conditions. During
employment, screening should be considered to be the responsibility of the employer, and countries
may have occupational health and safety legislation that addresses this.

people attending health care services who have
clinical risk factors for TB
7. In settings where the TB prevalence in the general population is 100/100 000 population or
higher, systematic screening for TB disease may be conducted among people with a risk factor
for TB who are either seeking health care or who are already in care
8. People with an untreated fibrotic lesion seen on chest X-ray may be systematically screened
for TB disease

Several clinical characteristics, conditions and comorbidities can indicate an increased risk for
developing TB disease or suffering worse outcomes from the disease, or both. Individuals identified
as having untreated fibrotic lesions on CXR and who are not diagnosed with TB disease are at
increased risk of developing TB disease (34–37). These individuals are often identified through TB
screening or clinical evaluation or during a clinical evaluation done for other reasons. Individuals
with other risk factors for TB or risk factors for poor outcomes from TB often can be identified most
easily in health care settings (38–66). Table 2 summarizes the evidence about the primary risk factors
for TB and for poor health outcomes related to TB. Groups with other risk factors – such as people
with malignancies and other disorders that compromise their immune system and people receiving
immunomodulatory therapies – may also be prioritized, depending on the local epidemiology and
capacity of the health system.
This recommendation has not been changed from the 2013 guidelines because since the last GDG
meeting, no new, robust evidence was found about the impact of systematic screening for TB disease
compared with passive case-finding for screening of individuals with risk factors.
Table 2. Risk factors for tuberculosis (TB) to be considered when prioritizing TB

screening among people attending for health care
Risk factor Risk of TB or of poor outcomes

Fibrotic lesions on Studies have shown an increased risk of developing TB disease among
chest X-ray individuals with fibrotic lesions identified on chest X-ray but who are not
diagnosed with TB disease.a
Diabetes mellitus Systematic reviews have found that the risk of TB for patients with DM
(DM) ranges from 1.5 to 2.0 to 3.1, with a decreasing risk in patients with well-
controlled DM. Patients with DM were also at an increased risk of relapse,
treatment failure and death.b
Previous TB Patients with a history of TB are at increased risk of subsequent TB episodes,
poor outcomes and developing drug-resistant TB.c
Chronic lung disease Studies have found hazard ratios for developing TB among individuals with
COPD ranging from 2.5 in China to 3.0 in Sweden.d
Smoking Systematic reviews have found that people who smoke or who have a
history of smoking have an increased risk of TB, with the RR ranging from
1.5 to 2.0 to 3.3; smokers are also at an increased risk of drug-resistant TB
and poor outcomes from TB, including relapse and death.e
Alcohol use disorder Systematic reviews have found a 1.35 to 1.9 RR associated with alcohol use
and a 3 to 3.33 RR associated with alcohol use disorder, as well as increased
risks of treatment failure and development of drug-resistant TB. An
exposure–response analysis showed that for every 10–20 g of daily alcohol
intake, there was a 12% increase in TB risk.f
Substance use People with substance use disorder are at increased risks of treatment
disorder failure, development of drug resistance, and mortality from TB due to low
adherence and coincident clinical, socioeconomic and structural risk factors.g
Malnourishment A systematic review found that lower BMI is associated with an increased risk
of TB, with a reduction in TB incidence of 13.8% (95% confidence interval:
13.4–14.2) per unit increase in BMI within the range 18.5–30 kg/m2. There
are multiple pathways by which undernourishment can increase the risk
of TB, including cell-mediated immunity and micronutrient deficiency, and
other conditions can increase the risk of malnourishment and TB, including
mental health and substance use disorders.h

20
Risk factor Risk of TB or of poor outcomes
Pregnancy A national registry study found IRRs for TB in pregnant women of 1.4 and
of 1.9 for postpartum women compared with non-pregnant women. TB in
pregnancy is associated with adverse outcomes and complications during
birth. These outcomes include a roughly 2-fold increased risk of premature
birth, low birthweight and intrauterine growth retardation, and a 6-fold
increased risk of perinatal death.i
Immunocompromising Systematic reviews have found that patients with immunosuppression for
conditions (organ reasons other than HIV, including those undergoing organ transplantation
transplant, renal failure, or haemodialysis and those with renal failure, have a greatly increased risk
dialysis) of TB: one study found that the incidence of TB is 20–74 times higher in
organ transplant patients compared with the general population; one study
found that the incidence of TB is 10–25 times higher in dialyzed individuals
compared with the general population; and one cohort study found that
the incidence of TB is 100 times greater in persons undergoing dialysis
compared with general population.j
Health care workers A systematic review found the IRR of TB disease for health care workers was
2.94 compared with the general population.k
BMI: body mass index; COPD: chronic obstructive pulmonary disease; DM: diabetes mellitus; IRR: incidence rate ratio; RR: relative risk.
a
Ferebee SH. Controlled chemoprophylaxis trials in tuberculosis. A general review. Bibl Tuberc. 1970;26:28–106. Meijer J, Barnett GD, Kubík
A, Stýblo K. Identification des sources d’infection [Identification of sources of infection]. Bull Int Union Tuberc. 1971;45:5–54. Okada K,
Onozaki I, Yamada N, Yoshiyama T, Miura T, Saint S, et al. Epidemiological impact of mass tuberculosis screening: a 2-year follow-up after
a national prevalence survey. Int J Tuberc Lung Dis. 2012;16:1619–24. doi:10.5588/ijtld.12.0201. Gao L, Li X, Liu J, Wang X, Lu W, Bai L, et
al. Incidence of active tuberculosis in individuals with latent tuberculosis infection in rural China: follow-up results of a population-based,
multicentre, prospective cohort study. Lancet Infect Dis. 2017;17:1053–61. doi:10.1016/s1473–3099(17)30402–4.
b
Hayashi S, Chandramohan D. Risk of active tuberculosis among people with diabetes mellitus: systematic review and meta-analysis. Trop
Med Int Health. 2018;23:1058–70. doi:10.1111/tmi.13133. Al-Rifai RH, Pearson F, Critchley JA, Abu-Raddad LJ. Association between diabetes
mellitus and active tuberculosis: a systematic review and meta-analysis. PLOS ONE. 2017;12:e0187967. doi:10.1371/journal.pone.0187967.
Harries AD, Kumar AM, Satyanarayana S, Lin Y, Zachariah R, Lönnroth K, et al. Addressing diabetes mellitus as part of the strategy for ending
TB. Trans R Soc Trop Med Hyg. 2016;110:173–9. doi:10.1093/trstmh/trv111. Baker MA, Harries AD, Jeon CY, Hart JE, Kapur A, Lönnroth K,
et al. The impact of diabetes on tuberculosis treatment outcomes: a systematic review. BMC Med. 2011;9:81. doi:10.1186/1741–7015–9-81.
c
Zignol M, Wright A, Jaramillo E, Nunn P, Raviglione MC. Patients with previously treated tuberculosis no longer neglected. Clin Infect
Dis. 2007;44:61–4. doi:10.1086/509328. Lambert ML, Hasker E, Van Deun A, Roberfroid D, Boelaert M, Van der Stuyft P. Recurrence in
tuberculosis: relapse or reinfection? Lancet Infect Dis. 2003;3:282–7. doi:10.1016/s1473–3099(03)00607–8. Verver S, Warren RM, Beyers
N, Richardson M, van der Spuy GD, Borgdorff MW, et al. Rate of reinfection tuberculosis after successful treatment is higher than rate of
new tuberculosis. Am J Respir Crit Care Med. 2005;171:1430–5. doi:10.1164/rccm.200409–1200OC. Osman M, Welte A, Dunbar R, Brown
R, Hoddinott G, Hesseling AC, et al. Morbidity and mortality up to 5 years post tuberculosis treatment in South Africa: a pilot study. Int J
Infect Dis. 2019;85:57–63. doi:10.1016/j.ijid.2019.05.024.
d
Inghammar M, Ekbom A, Engström G, Ljungberg B, Romanus V, Löfdahl CG, et al. COPD and the risk of tuberculosis–a population-based
cohort study. PLOS ONE. 2010;5:e10138. doi:10.1371/journal.pone.0010138. Lee CH, Lee MC, Shu CC, Lim CS, Wang JY, Lee LN et al. Risk
factors for pulmonary tuberculosis in patients with chronic obstructive airway disease in Taiwan: a nationwide cohort study. BMC Infect Dis.
2013;13:194. doi: 10.1186/1471-2334-13-194.
e
Jayes L, Haslam PL, Gratziou CG, Powell P, Britton J, Vardavas C, et al. SmokeHaz: systematic reviews and meta-analyses of the effects of
smoking on respiratory health. Chest. 2016;150:164–79. doi:10.1016/j.chest.2016.03.060. Lin HH, Ezzati M, Murray M. Tobacco smoke,
indoor air pollution and tuberculosis: a systematic review and meta-analysis. PLOS Med. 2007;4:e20. doi:10.1371/journal.pmed.0040020.
Wang MG, Huang WW, Wang Y, Zhang YX, Zhang MM, Wu SQ, et al. Association between tobacco smoking and drug-resistant tuberculosis.
Infect Drug Resist. 2018;11:873–87. doi:10.2147/idr.s164596. Alavi-Naini R, Sharifi-Mood B, Metanat M. Association between tuberculosis
and smoking. Int J High Risk Behav Addict. 2012;1:71–4. doi:10.5812/ijhrba.5215.
f
Imtiaz S, Shield KD, Roerecke M, Samokhvalov AV, Lönnroth K, Rehm J. Alcohol consumption as a risk factor for tuberculosis: meta-
analyses and burden of disease. Eur Respir J. 2017;50:1700216. doi:10.1183/13993003.00216–2017. Simou E, Britton J, Leonardi-Bee J.
Alcohol consumption and risk of tuberculosis: a systematic review and meta-analysis. Int J Tuberc Lung Dis. 2018;22:1277–85. doi:10.5588/
ijtld.18.0092. Rehm J, Samokhvalov AV, Neuman MG, Room R, Parry C, Lönnroth K, et al. The association between alcohol use, alcohol use
disorders and tuberculosis (TB). A systematic review. BMC Public Health. 2009;9:450. doi:10.1186/1471–2458–9-450.

g
Deiss RG, Rodwell TC, Garfein RS. Tuberculosis and illicit drug use: review and update. Clin Infect Dis. 2009;48:72–82. doi:10.1086/594126.
Getahun H, Gunneberg C, Sculier D, Verster A, Raviglione M. Tuberculosis and HIV in people who inject drugs: evidence for action for
tuberculosis, HIV, prison and harm reduction services. Curr Opin HIV AIDS. 2012;7:345–53. doi:10.1097/COH.0b013e328354bd44. Silva
DR, Muñoz-Torrico M, Duarte R, Galvão T, Bonini EH, Arbex FF, et al. Risk factors for tuberculosis: diabetes, smoking, alcohol use, and the
use of other drugs. J Bras Pneumol. 2018;44:145–52. doi:10.1590/s1806–37562017000000443.
h
Lönnroth K, Williams BG, Cegielski P, Dye C. A consistent log-linear relationship between tuberculosis incidence and body mass index. Int
J Epidemiol. 2010;39:149–55. doi:10.1093/ije/dyp308. Cegielski JP, McMurray DN. The relationship between malnutrition and tuberculosis:
evidence from studies in humans and experimental animals. Int J Tuberc Lung Dis. 2004;8:286–98.
i
Jonsson J, Kühlmann-Berenzon S, Berggren I, Bruchfeld J. Increased risk of active tuberculosis during pregnancy and postpartum: a
register-based cohort study in Sweden. Eur Respir J. 2020;55:1901886. doi:10.1183/13993003.01886–2019. Sugarman J, Colvin C, Moran
AC, Oxlade O. Tuberculosis in pregnancy: an estimate of the global burden of disease. Lancet Glob Health. 2014;2:e710–6. doi:10.1016/
s2214–109x(14)70330–4. doi:10.1016/S2214–109X(14)70330–4. Loto OM, Awowole I. Tuberculosis in pregnancy: a review. J Pregnancy.
2012;2012:379271. doi:10.1155/2012/379271.
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Muñoz P, Rodríguez C, Bouza E. Mycobacterium tuberculosis infection in recipients of solid organ transplants. Clin Infect Dis. 2005;40:581–
7. doi:10.1086/427692. Moore DA, Lightstone L, Javid B, Friedland JS. High rates of tuberculosis in end-stage renal failure: the impact of
international migration. Emerg Infect Dis. 2002;8:77–8. doi:10.3201/eid0801.010017. Moran E, Baharani J, Dedicoat M, Robinson E, Smith G,
Bhomra P, et al. Risk factors associated with the development of active tuberculosis among patients with advanced chronic kidney disease.
J Infect. 2018;77:291–5. doi:10.1016/j.jinf.2018.06.003.
k
Uden L, Barber E, Ford N, Cooke GS. Risk of tuberculosis infection and disease for health care workers: an updated meta-analysis. Open
Forum Infect Dis. 2017;4:ofx137. doi:10.1093/ofid/ofx137.

This recommendation concerns interventions that should be undertaken in addition to passive case-
finding practices, namely properly triaging and evaluating people seeking care who report signs or
symptoms of TB, which should be done in all settings and is particularly important to implement
rigorously among people who have risk factors for TB.
Groups should be prioritized based on their risk of TB, the risk of poor treatment outcomes if diagnosis
is delayed and the size of the risk group in a given setting. People who are living with HIV, people
who have had recent close contact with a person who has TB and people who have silicosis should
always be screened for TB as described above (Recommendations 3, 4 and 6). Other risk factors
that indicate an individual should be considered for screening are listed in Table 2.
For several of the clinical risk factors indicated above, TPT may be beneficial for the patient, subject
to their exposure and eligibility (20).
Health care workers are a specific group that merits consideration for screening in health facilities,
given the potentially high level of occupational exposure and the risk of further transmission to
patients.

22
3. Recommendations for tools
for systematic screening for TB
disease
TB screening tools are designed to distinguish people with a higher probability of having TB disease
from those with a low probability and can be assumed to be free of TB disease. They are not intended
to provide a definitive diagnosis. In general, they need to be able to be implemented easily and relay
results rapidly in order to be informative in a screening context. Screening tests need to be followed
by a diagnostic test, offered as part of a comprehensive clinical evaluation, to confirm or rule out TB
disease in individuals who screen positive.
The most desirable screening strategy would be one with a high total yield of true-positive cases of
TB, few false positives, low NNS, low cost, a rapid and simple algorithm and high client acceptability.
In practice, many of these factors tend to run in opposite directions, so a multifactorial analysis is
needed to decide which screening tools and algorithms to use.
In 2014, WHO released a report summarizing the desirable characteristics, or target product profiles,
of screening tests for detecting TB disease (67). The report highlighted that the minimal requirements
for a target screening test would be an overall sensitivity of 90% and a specificity of 70% to detect
pulmonary TB disease or rule it out in individuals being screened. Based on these benchmarks, an array
of potential tools for screening for TB disease in different populations was considered by the GDG.
3.1 Tools for screening for TB disease among the

general population and high-risk groups
9. Among individuals aged 15 years and older in populations in which TB screening is
recommended, systematic screening for TB disease may be conducted using a symptom screen,
chest X-ray or molecular WHO-recommended rapid diagnostic tests, alone or in combination
(new recommendation: conditional recommendation, very low certainty of evidence for
test accuracy).

The data used to inform this recommendation came from a systematic review of the diagnostic
accuracy of using symptoms and chest radiography to detect TB disease among individuals aged
15 years and older with negative or unknown HIV status. The review included studies of screening
conducted in the general population (including several prevalence surveys conducted in African and
Asian countries), as well as screening conducted in high-risk groups (including contacts of TB patients,
prisoners and others). Data from a separate review of the diagnostic accuracy of mWRDs used as a
screening tool in individuals from high-risk groups aged 15 years and older (including contacts of TB

patients, prisoners and miners, all with negative or unknown HIV status) were also used to inform this
recommendation. All data were pooled to estimate the sensitivity and specificity of each screening
tool, as there was insufficient evidence to make estimates of accuracy for the screening tools in
each high-risk group (the performance of tools among people living with HIV is presented later, in
Recommendations 11–15). The reference standard used throughout was bacteriologically confirmed
pulmonary TB. Table 3 summarizes the diagnostic accuracy of the screening tools considered (see
Web Annex B, Tables 5–10 for more details).
Table 3. Diagnostic accuracy of symptoms, chest radiography, and molecular WHO-

recommended rapid diagnostic tests for screening for TB disease
No. of No. of
Screening test studies (no. Sensitivity studies (no. Specificity
of participants) of participants)
WHO target product NA > 0.90 NA > 0.70
profile
Prolonged cough 40 (6 737) 0.42 40 (1 284 181) 0.94
(≥ 2 weeks)
Any cough 21 (2 734) 0.51 21 (768 291) 0.88
Any TB symptom (cough, 28 (3 915) 0.71 28 (460 878) 0.64
haemoptysis, fever, night
sweats, weight loss)
Chest radiography 22 (4 243) 0.94 22 (1 012 752) 0.89
(any abnormality)
Chest radiography 19 (2 152) 0.85 19 (464 818) 0.96
(suggestive abnormality)
Molecular WHO- 5 (337) 0.69 5 (8 619) 0.99
recommended rapid
diagnostic test
NA: not applicable.
3.1.2 Implementation considerations for all tools

The GDG considered that all three approaches – symptom screening, CXR and mWRD – may have
roles in screening for TB disease in the general population. The ranking of the tools according to
accuracy proposed by the GDG is: first, CXR; second, mWRDs; third, screening for any TB symptom
(higher sensitivity and lower specificity); and fourth, screening for any cough or cough lasting 2 weeks
or longer (lower sensitivity and higher specificity). However, ease of implementation is highest by far for
symptom screening, and less so for CXR and mWRDs with the requirement of additional equipment
and resources. The GDG noted that factors related to patient selection, flow and timing may affect
the measures of accuracy observed for CXR to detect TB. The inferences made about using mWRDs
for screening in the general population relate primarily to pooled studies in high-risk populations and,
therefore, there is uncertainty about whether the findings are directly applicable to a general population
with a comparable burden of TB. See Web Annex C, Table 1, for more details of the recommendation.
The GDG noted that different symptom screening approaches have varying trade-offs in sensitivity
and specificity. The feasibility of implementing symptom screening makes it a much more accessible
option programmatically. Symptom screening is a standard part of a clinical workup and can be
repeated as often as it is needed.

24
In contrast, additional resources are needed to undertake chest radiography and mWRDs. Radiography
involves exposure to some ionizing radiation, which may increase the long-term risks of cancer.
Innovations in radiography in recent years have substantially reduced radiation exposure levels.
CXR is largely considered safe, with a radiation dose of 0.1 mSv, which corresponds to 1/30 of the
average annual radiation dose from the environment (3 mSv) and 1/10 of the annual accepted dose
of ionizing radiation for the general public (1 mSv). Pregnant women are especially vulnerable to
ionizing radiation from radiography, and children have a longer life expectancy and, therefore, more
time to develop radiation-induced health effects. However, for a pregnant woman and her fetus and
for children, CXR has been deemed to not pose a significant risk, provided that good practices are
observed, as the primary beam is targeted away from the pelvis (68).
When used for screening, mWRDs have different accuracy than when they are used for diagnosis (69),
and different predictive values are associated with a positive test and a negative test due to differences
in prevalence of TB in the populations being tested. Therefore, results should be interpreted
appropriately, and those who screen positive for TB using an mWRD should receive a thorough
clinical evaluation that may include further tests and procedures – such as CXR, repeat mWRD on
additional sputum samples and other examinations – to establish a diagnosis of TB definitively prior
to initiating treatment. These tests can be used on sputum only when a person can expectorate.
Scaling up mWRDs for diagnosis should be prioritized (if full access has not yet been achieved) prior
to scaling up mWRDs for screening. Using an mWRD as a screening tool requires significant resources,
including increased capacity in and expansion of diagnostic and sample transportation networks.
Depending on the feasibility and resources available, countries may choose to prioritize TB screening
using mWRDs among certain subpopulations with a higher risk of TB.
Countries should position symptom screening, CXR and mWRDs within national TB screening and
diagnostic algorithms, according to the goals and objectives of the screening, the populations being
screened, the feasibility, resources available, and equity. A range of possible screening algorithms
is presented in the operational handbook, including modelled performance of the expected yield.
3.2 Use of computer-aided detection software for

automated reading of digital chest radiographs
10. Among individuals aged 15 years and older in populations in which TB screening is
recommended, computer-aided detection software programmes may be used in place of
human readers for interpreting digital chest X-rays for screening and triage for TB disease
(new recommendation: conditional recommendation, low certainty of evidence).

The use of CXR to screen for TB is a practice that goes back several decades. CXRs are also routinely
used for triage of patients presenting to care who are displaying signs, symptoms or risk factors for
TB to determine the most appropriate clinical pathway for proper evaluation. However, in many
settings, the use of CXR for TB screening and triage for TB disease is limited by the unavailability of
trained health personnel to interpret radiography images and by substantial intra- and inter-reader
variability in its accuracy to detect abnormalities associated with TB (70–72).
Numerous specific software packages that provide CAD, or automated interpretation of digital CXR
images for the express purpose of determining the likelihood of TB disease, have been developed
and offer a potential technological answer to the numerous implementation challenges inherent in
human interpretation of CXRs.

The GDG considered the performance of CAD software separately for the screening- and triage-
use cases. For this guideline, triaging is defined as the process of deciding the diagnostic and care
pathways for people based on their symptoms, signs, risk markers and test results. Triaging involves
assessing the likelihood of various differential diagnoses as a basis for making clinical decisions (73).
It can follow more- or less-standardized protocols and algorithms, and it may be done in multiple
steps (68). A triage test for TB is one that can be rapidly conducted among people presenting to
a health facility to differentiate those who should have further diagnostic evaluation for TB (those
whose TB triage test is positive or abnormal) from those who should undergo further investigation
for non-TB diagnoses (for those whose TB triage test is negative or normal) (74). While there may
be overlap between triaging and screening, there are several reasons to distinguish screening from
triage when evaluating the performance of CAD software:
• The disease presentation may be different in screening populations in which one is more likely to
encounter CXR findings of earlier TB than when compared with triage populations. Therefore, the
same sensitivity and specificity point may not be achieved or may be achieved but with a different
threshold score.
• TB prevalence will typically be much lower in screening populations (< 5%) than in triage populations
(10–20%), which will impact a test’s predictive values and the numbers of individuals correctly and
incorrectly diagnosed.
• The ethical consequences of not detecting TB or other non-TB-related CXR findings (but clinically
relevant abnormalities) that require follow-up examination are different for populations that do
not seek care than for those that do (11).
A previous assessment of using CAD for automated interpretation of digital CXRs for TB by WHO
determined that in order to adequately assess diagnostic accuracy, it was necessary to evaluate
CAD software using a standard panel of CXR files with associated demographic and clinical data,
including TB diagnosis, drawn from a representative population for the corresponding use case for
the technology. It was deemed essential that such evaluations ensure that CXR libraries used in an
evaluation not be made available for CAD software development, training or evaluation (68). For this
GDG meeting, a scoping review for independent evaluations that met these criteria was conducted.
Three independent evaluations for both the screening use case and the triage use case that assessed
the performance of three distinct CAD programmes were identified and presented to the GDG, and
they included all products that had received a CE mark (for Conformité Européenne, indicating a
product’s conformity with the European Economic Area’s directives or standards) by January 2020.2
The GDG was blinded to the brand names of the software programmes. A separate quality assessment
of the evaluations was conducted and results presented to the GDG.
CAD programmes produce a numerical abnormality score for each digital image read that can then
be compared to a threshold defined by the user to indicate if the patient is to be referred for further
TB diagnostic evaluation. Because the abnormality scores produced are continuous, the sensitivity
and specificity can vary from 0 to 100%, depending on where the threshold is set. For evaluation
for the GDG, each software programme was set to a threshold that corresponded to 90% sensitivity
for detecting pulmonary TB disease based on a microbiological reference standard. The resulting
accompanying specificity for the software at that threshold was then reported and compared with
the diagnostic accuracy of human readers interpreting CXRs in the same studies.
Due to specific methodological challenges, the estimates of CAD diagnostic accuracy were not
able to be pooled across software programmes or across evaluations. Thus, the performances of
CAD programmes and human readers from the included evaluations were presented as ranges
(see Table 4). The three included evaluations assessed each programme’s performance in different
populations and in different settings (see Web Annex B, Tables 11 and 12, and Web Annex C, Tables
4 and 5).
2
The three technologies that had received a CE mark by January 2020 and were included in all the evaluations are CAD4TB v6, Delft
Imaging; Lunit Insight CXR, Lunit Insight; and qXR v2, Qure.ai.

26
Table 4. Sensitivity and specificity ranges of computer-aided detection software
and human readers interpreting digital chest radiographs for detection of
bacteriologically confirmed TB across three software programmes, from three
independent evaluations of the software in a range of populations and settings
Accuracy estimate range

Type of case and type of reader Sensitivity Specificity
WHO target product profile > 0.90 > 0.70
Screening use case
CAD software 0.90–0.92 0.23–0.66
CXR with human reader 0.82–0.93 0.14–0.63
Triage use case
CAD software 0.90–0.91 0.25–0.79
CXR with human reader 0.89–0.96 0.36–0.63
CAD: computer-aided detection; CXR: chest X-ray.
The results showed the variability of both human readers and CAD software programmes across
different settings and populations. In comparing the range of accuracy of CAD to that of human readers
interpreting CXRs and noting the variability of readers and the substantial overlap between the two
ranges, the data suggested there is little difference between the two. Therefore, the GDG considered
that CAD software programmes can be considered accurate when compared with human readers.
Other desirable effects beyond the accuracy of the technologies would likely include the possibility
to scale up and thus increase the access to chest radiography, given the scarcity of radiologists in
many settings. In addition, GDG members noted that in many settings, general practitioners or other
providers without specific training in radiology are often tasked with interpreting chest radiographs,
and they may not be as highly skilled as the readers used for comparison in the evaluations considered,
thus indicating that the comparisons presented here may represent an underestimate of the true
comparative accuracy of CAD software for detecting TB.
The drawback of using CAD interpretation in place of human readers for chest radiographs included
the fact that it cannot detect other lung pathologies beyond TB. The capacity of CAD technologies
to simultaneously screen for multiple pulmonary or thoracic conditions could be attractive for
programmes, but no data on the performance of CAD for differential diagnosis were available to be
assessed by the GDG.
CAD technologies have the potential to increase equity in the reach of TB screening interventions
and in access to TB care if they facilitate the scale up of radiography for TB screening and triage and
improve the interpretation of images.
The recommendation applies to software brands that upon external validation demonstrate a
performance that is not inferior to the products reviewed by the GDG in 2020. The analysis for this
recommendation was restricted to bacteriologically confirmed TB and, thus, the recommendation
may not necessarily apply to other forms of TB (e.g. exclusively extrapulmonary TB, clinically
diagnosed TB). This recommendation is specific to adults and adolescents aged 15 years and older.
The recommendation applies only to the interpretation of anteroposterior or posteroanterior views
of digital plain CXRs for pulmonary TB: it does not apply to the interpretation of lateral or oblique
views, and its applicability to the interpretation of analogue CXRs is unknown.

The evaluations reviewed by the GDG demonstrated substantial variation in the diagnostic accuracy
(sensitivity and specificity) of CAD programmes across settings, even when using the same technology
set to the same threshold. Thus, it will be essential to calibrate the threshold to be used for any given
software for each setting and population in which it will be used in order to ensure that the accuracy,
predictive values, overall yield and requirements for further diagnostic testing are as expected. Further
guidance on calibrating CAD in a new setting is provided in the operational handbook accompanying
the guidelines, which links to a protocol for collecting the requisite data and a web-based tool to assist
with the analysis of data and calculation of receiver operating characteristic curves and sensitivity and
specificity values across a range of thresholds (7).
The feasibility of implementing CAD depends heavily on the setting, including ensuring access to the
required equipment for conducting digital radiography, a stable internet connection and required
maintenance for the hardware and software. The required resources and the cost–effectiveness will
depend on the setting, including the availability and salaries of human readers.
3.3 Tools for screening for TB disease among people

living with HIV
11. Among adults and adolescents living with HIV, systematic screening for TB disease should
be conducted using the WHO-recommended four symptom screen and those who report any
one of the symptoms of current cough, fever, weight loss or night sweats may have TB and
should be evaluated for TB and other diseases
(existing recommendation: strong recommendation, moderate certainty of evidence).
12. Among adults and adolescents living with HIV, C-reactive protein with a cut-off of > 5 mg/L
may be used to screen for TB disease
(new recommendation: conditional recommendation, low certainty of evidence for
test accuracy).
13. Among adults and adolescents living with HIV, chest X-ray may be used to screen for TB
disease
test accuracy).
14. Among adults and adolescents living with HIV, molecular WHO-recommended rapid
diagnostic tests may be used to screen for TB disease
test accuracy).
15. Adult and adolescent inpatients with HIV in medical wards where the TB prevalence is
> 10% should be tested systematically for TB disease with a molecular WHO-recommended
rapid diagnostic test
(new recommendation: strong recommendation, moderate certainty of evidence for
test accuracy).

TB remains the primary cause of AIDS-related morbidity and mortality worldwide, despite impressive
scale up of antiretroviral treatment (ART). In 2019, TB was associated with an estimated 208 000 (30%)
AIDS-related deaths (1). Global estimates show a 44% gap in case detection among people with HIV-
associated TB (1). A systematic review of postmortem studies of global AIDS-related deaths in adults
found TB to be the primary cause of death in 37.2% of cases (95% CI: 25.7–48.7). TB was undiagnosed

28
prior to death in 45.8% of cases (95% CI: 32.6–59.1) (75). Ensuring early detection and timely treatment
of TB among people living with HIV is of paramount importance for reducing mortality.
A key component of the HIV care cascade is the WHO-recommended four-symptom screen (W4SS)
for adults and adolescents living with HIV, comprising screening for a current cough, fever, night sweats
or weight loss. This has been the only WHO-recommended TB screening strategy for people living
with HIV since its introduction in 2011, and it is recommended for use at every patient encounter with
a health care worker (19). Designed primarily for ruling out active TB prior to the initiation of TPT, due
to its high negative predictive value, the development of the W4SS was informed by a meta-analysis
of individual patient data (IPD) from in observational studies conducted prior to 2010 and prior to
the scale up of ART (76). However, a more recent systematic review found that the pooled sensitivity
of the W4SS among people living with HIV who were on ART was 51% (95% CI: 28.4–73.2) and the
specificity was 70.7% (95% CI: 47.7–86.4) (77). For people living with HIV who were not on ART, the
sensitivity was 89.3% (95% CI: 82.6–93.9), and the specificity was 27.2% (95% CI: 17.3–40). In another
study, the W4SS was found to have 42.9% sensitivity among pregnant women in Kenya attending
services for prevention of mother to child transmission (78).
Therefore, a systematic literature review and meta-analysis of IPD was undertaken to assess further
the accuracy of the W4SS among people living with HIV overall and within important subgroups
and to identify other screening tools and strategies that would enhance TB detection among people
living with HIV. Screening tools and strategies reviewed by the GDG included the use of C-reactive
protein (CRP), CXR and mWRDs as stand-alone tests, as well as in combination with the W4SS.
Culture was the reference standard for assessing the accuracy of the different screening strategies.
These recommendations apply to adults and adolescents aged 10 years and older living with HIV;
for recommendation on children under 10 years living with HIV see section 3.4.
3.3.1.1 WHO-recommended four-symptom screen

The 2020 meta-analysis of IPD included 23 studies of 16 269 participants living with HIV, all of which
reviewed the accuracy of the W4SS. The studies primarily focused on pulmonary TB disease. The
unweighted average TB prevalence among participants within these studies was 9.2%, ranging from 1%
to 26%; and 52% of people living with HIV screened positive on the W4SS. The sensitivity of the W4SS
among all people living with HIV was 83% (95% CI: 74–89) and specificity was 38% (95% CI: 25–53).
Estimates of the accuracy of the W4SS in different subgroups of people living with HIV are shown in
Table 5. When used alone, the W4SS was found to have its lowest sensitivity among outpatients on
ART and among pregnant women, and it had markedly low specificity among medical inpatients.

Table 5. Diagnostic accuracy of the WHO-recommended four-symptom screen among
different subpopulations of people living with HIV compared with culture as a
reference standard
No. of studies Sensitivity Specificity

Population
(no. of participants) (95% CI) (95% CI)
WHO target product profile NA > 0.90 > 0.70
All people living with HIV 23 (16 269) 0.83 (0.74–0.89) 0.38 (0.25–0.53)
Inpatients 4 (672) 0.96 (0.92–0.98) 0.11 (0.08–0.14)
Outpatients on ART 9 (4 309) 0.53 (0.36–0.69) 0.70 (0.50–0.85)
Outpatients not on ART 19 (11 159) 0.84 (0.75–0.90) 0.37 (0.25–0.50)
CD4 ≤ 200 cells/µL 22 (5 956) 0.86 (0.77–0.92) 0.30 (0.18–0.45)
Pregnant women living with HIV 8 (1 937) 0.61 (0.39–0.79) 0.58 (0.39–0.75)
ART: antiretroviral treatment; CI: confidence interval; NA: not applicable.
While there may be real-life limitations to the W4SS in terms of consistency and quality of delivery
that might not be reflected in studies, it remains the simplest non-invasive tool to implement in any
setting, requiring no infrastructure. However, the high proportion of W4SS positivity (94%) and very
low specificity in medical inpatients living with HIV in settings where TB prevalence among study
participants was > 10% gives it limited utility as a screen to rule in TB prior to diagnostic confirmation
by mWRD in this very ill population.
The meta-analysis of IPD found no alternative screening tools or strategies that were significantly
higher in both sensitivity and specificity than the W4SS or that met the WHO target product profile
for a screening test on both parameters. In all cases, when sensitivity was higher and met the minimal
requirements of the target product profile, specificity was compromised, and vice versa. Depending on
a programme’s decision to prioritize higher sensitivity or higher specificity, other tools or combinations
of tools may be used to complement the W4SS.
3.3.1.2 C-reactive protein

CRP is an indicator of general inflammation that can be measured using point-of-care tests performed
on capillary blood collected via finger prick. The evidence reviewed for the performance of CRP
included 6 studies from Kenya, South Africa and Uganda with a total of 3 971 participants (see Web
Annex B, Table 13, and Web Annex C, Table 6). The average unweighted prevalence of TB among
participants in the studies was 14%, ranging from 1% to 26%.
Data on the accuracy of CRP using a cut-off value of > 5 mg/L and of > 10 mg/L as indicators of
TB disease were reviewed and both cut-offs were considered to have similar or superior accuracy
when compared with the W4SS. The cut-off of > 5 mg/L was recommended because it is the lowest
threshold indicating abnormality in many clinical settings, and it has higher sensitivity than the cut-
off of > 10 mg/L. The choice of cut-off will depend on the availability of CRP technology in a given
setting, the prevalence of TB and of other conditions that may increase CRP and the preference for
increased sensitivity or increased specificity.
The IPD meta-analysis on CRP using a cut-off of > 5 mg/L reported similar sensitivity to and higher
or similar specificity to the W4SS in all subpopulations assessed (see Table 6). When combined with
the W4SS and used in parallel, whereby a positive screen for either tool led to a diagnostic test, it was
found to have similar or higher sensitivity and specificity to the W4SS for all populations, depending

30
on the cut-off threshold used and the subpopulation assessed. CRP was found to be most accurate
among outpatients who were not on ART, compared with the W4SS alone, which had a sensitivity
of 0.84 (95% CI: 0.75–0.90) and specificity of 0.37 (95% CI: 0.25–0.50) in this subpopulation. When
performed sequentially after a positive W4SS among people living with HIV not on ART, CRP with a
cut-off of > 5 mg/L was found to be as sensitive (0.84; 95% CI: 0.73-0.90) as the W4SS alone but to
have significantly higher specificity (0.64; 95% CI: 0.55-0.72). Similar to the W4SS, the specificity of
CRP for TB screening among inpatients living with HIV was found to be extremely low, likely due to
competing comorbidities that would also result in raised CRP levels and the presence of symptoms
(see Web Annex C, Table 6).
Table 6. Diagnostic accuracy of C-reactive protein using a cut-off > 5 mg/L among

different subpopulations of people living with HIV compared with culture as a
reference standard
No. of studies (no. Sensitivity Specificity

Population
of participants) (95% CI) (95% CI)
Inpatients 1 (400) 0.98 (0.93–1.00) 0.12 (0.09–0.17)
Outpatients on ART 1 (381) 0.40 (0.10–0.80) 0.80 (0.75–0.84)
CD4 ≤ 200 cells/µL 6 (1 829) 0.93 (0.87–0.97) 0.40 (0.22–0.62)
Pregnant women living with HIV 2 (62) 0.70 (0.12–0.97) 0.41 (0.12–0.78)
As a point-of-care biomedical test, CRP represents an opportunity for enhancing TB screening among
people living with HIV. Health staff and patients might be more motivated to pursue a confirmatory
diagnostic test following a positive screen for CRP. The specificity and predictive value of the test for
detecting TB, however, will likely be reduced in settings with a lower TB prevalence than in those
included in the meta-analysis.
3.3.1.3 Chest radiography

CXR is recommended by WHO to be used in parallel with the W4SS where CXR is available to assist
in ruling out active TB prior to initiating TPT among people living with HIV who are on ART. The
GDG agreed that, due to the increased sensitivity, the evidence supported using CXR in addition
to the W4SS as a parallel screening strategy in which a positive or abnormal result on either screen
would indicate a referral for diagnostic evaluation. Data on “any abnormality” and an “abnormality
suggestive of TB” detected by CXR were reviewed and either approach is recommended, depending
on the context, the availability of radiological expertise, resources and preference towards higher
sensitivity or higher specificity.
The evidence reviewed for the performance of CXR and the W4SS for all people living with HIV came
from 8 studies conducted in Benin, Botswana, Brazil, Guinea, India, Kenya, Malawi, Myanmar, Peru,
South Africa and Zimbabwe, with a total of 6 238 participants (see Web Annex B, Table 14, and Web
Annex C, Table 7). The average prevalence of TB in all people living with HIV in the studies was 7%,
ranging from 3% to 18%. Among outpatients on ART, the average prevalence was 2.6%.

CXR alone was found to have similar sensitivity to and similar or higher specificity than the W4SS
across all subpopulations. When combined in a sequence whereby CXR followed a positive W4SS
screen, CXR had a lower or similar sensitivity with higher or similar specificity. When combined and
used in parallel with the W4SS, it had a higher or similar sensitivity and similar specificity (see Table 7).
The IPD meta-analysis found this strategy to have the highest sensitivity (0.85; 95% CI: 0.69–0.94)
compared with the W4SS (0.53; 95% CI: 0.36–0.69) and the other tools and strategies assessed for
TB screening in outpatients on ART. While the data were limited for inpatients living with HIV, the
combined strategy of CXR and the W4SS had a very low specificity (0.07; 95% CI: 0.03–0.19), similar
to findings for using CRP or the W4SS alone (see Web Annex C, Table 7).
Table 7. Diagnostic accuracy among different subpopulations of people living with

HIV of the WHO-recommended four-symptom screen combined with chest X-ray (any
abnormality) compared with culture as the reference standard and using a positive or
abnormal result on either screen or both

Population
Inpatients 1 (52) 0.90 (0.33–0.99) 0.07 (0.03–0.19)
CD4 ≤ 200 cells/µL 8 (2 232) 0.94 (0.90–0.97) 0.14 (0.07–0.25)
Pregnant women living with HIV 1 (8) 0.75 (0.11–0.99) 0.56 (0.24–0.84)
3.3.1.4 Molecular WHO-recommended rapid diagnostic tests for medical inpatients

living with HIV in settings with a high TB burden
TB is the main cause of hospitalization and mortality among people living with HIV. The assessment
of the performance of an mWRD used as a combined TB screening and diagnostic strategy for
medical ward patients with HIV included 4 studies in Ghana, Myanmar and South Africa with a total
of 639 participants (see Web Annex B, Table 15, and Web Annex C, Table 8). The prevalence of TB
in the included studies was 23.8%, ranging from 7% to 26%. The mWRD test assessed in the IPD was
primarily the Xpert MTB/RIF assay.
Using the W4SS alone had 96% sensitivity and 11% specificity in the IPD meta-analysis of medical ward
inpatients living with HIV, 94% of whom were positive on the W4SS. Thus, the difference in accuracy
was minimal between the full screening and diagnostic strategy of using W4SS followed by mWRD and
using mWRD alone. Therefore, the value of the W4SS was judged to have limited utility in screening
for TB in this population prior to an mWRD test, and the GDG recommended that medical inpatients
should be screened and tested with an mWRD, irrespective of symptoms, to inform a decision about
whether to treat for TB. A 10% threshold TB prevalence among hospital inpatients living with HIV is
recommended, taking into account the TB prevalence among the participants studied and striking
a balance between ensuring rapid diagnosis in this critically ill population and the need to avoid
overtreatment. In lower prevalence settings, a screening and diagnostic strategy with mWRD alone
would give rise to higher numbers of false positives, with overtreatment and the related social and

32
economic consequences, including potential delay in starting ART. This recommendation may not
be applicable to settings with a lower pretest probability of TB.
3.3.1.5 Molecular WHO-recommended rapid diagnostic tests for all other people
living with HIV
The systematic review of the performance of an mWRD used to screen for TB among people living
with HIV included 14 studies with a total of 9 209 participants (see Web Annex B, Table 16, and
Web Annex C, Table 9). The Xpert MTB/RIF assay was the primary mWRD used in these studies.
The prevalence of TB in the studies ranged from 1% to 26%. The average TB prevalence among
participants attending outpatient facilities was 8.6%.
Using an mWRD alone was found to have sensitivity of 0.69 (95% CI: 0.60–0.76) and specificity of
0.98 (95% CI: 0.97–0.99) compared with using the W4SS followed by an mWRD as a diagnostic
test, which had sensitivity of 0.62 (95% CI: 0.56–0.69) and specificity of 0.99 (95% CI: 0.97–0.99) (see
Table 8). There were no significant differences in the accuracy of the mWRD between the different
subpopulations when compared with using the W4SS followed by the mWRD.
Due to the increased sensitivity of mWRDs, but also in consideration of the likely challenges relating
to access, high costs and feasibility in many countries, mWRDs are recommended as an option
for screening for TB disease among all adults and adolescents living with HIV who are not medical
inpatients in settings where the TB prevalence exceeds 10%. As with all screening tools, the GDG
emphasized the importance in all settings of following up an mWRD screen with a diagnostic
assessment to prevent the potential harm of overtreatment. In addition, due consideration should
be made to prioritizing mWRDs as a diagnostic test for all people with presumptive TB before scaling
up mWRD as a screening test.
Table 8. Diagnostic accuracy of molecular WHO-recommended rapid diagnostic

tests for screening for TB among different subpopulations of people living with HIV
compared with culture as a reference standard

Population
Inpatients 4 (639) 0.77 (0.69–0.84) 0.93 (0.89–0.96)
CD4 ≤ 200 cells/µL 12 (3 422) 0.76 (0.68–0.82) 0.97 (0.95–0.98)
Pregnant women living with HIV 4/473 0.55 (0.33–0.75) 0.99 (0.97–0.99)
3.3.2 Implementation considerations for all tools for screening people

living with HIV
Countries should position the W4SS, CRP, CXR and mWRD in combination with diagnostic evaluation
using mWRDs and LF-LAM (8) within national TB screening and diagnostic algorithms according to
their feasibility, the level of the health facility, resources and equity. Algorithms exploring the available

screening tools are presented in the operational handbook, including modelled performance of
accuracy and yield (7). While all of the screening tools presented are recommended for all people
living with HIV for ease of programming, evidence showed notable accuracy of CRP for TB screening
in people not yet receiving ART and that CXR enhanced the sensitivity of the W4SS among people
receiving ART, both of which might be considered when choosing algorithms.
Among inpatients on medical wards in settings with a high TB burden, evidence showed that the W4SS,
CRP and CXR had limited accuracy, either due to extremely low specificity or suboptimal sensitivity.
Therefore, using mWRD as an upfront screening and diagnostic test is warranted, particularly given
the urgency of timely diagnosis in this population.
While there are minimal data on optimal frequency of screening across all tools, data presented to
the GDG on results from the WHIP3TB trial (evaluating the effectiveness of weekly rifapentine plus
isoniazid for 3 months compared with periodic rifapentine plus isoniazid for 3 months and 6 months
of daily isoniazid in HIV-positive individuals) (79) underscored the need for more intensified routine
screening in addition to the W4SS, even among those receiving ART who have received TPT. The
GDG suggested that conducting more intensified screening in addition to the W4SS should occur
at the time of an initial diagnosis of HIV or during the first antenatal care visit for pregnant women,
and then annually thereafter. To reduce the burden on the patient, screening should be aligned with
other routine HIV care visits, such as those for viral load monitoring or for ruling out TB disease prior
to initiating TPT, depending on the setting and the national guidelines on HIV. Where applicable,
the W4SS should also be conducted as part of a comprehensive clinical evaluation and to inform
the need for increased infection control and for other diagnostic tests, such as LF-LAM. Otherwise
screening with the W4SS alone should be carried out during all other interactions between patients
and health care workers.
Consideration should also be given to the added benefit of including CRP for ruling out TB disease
prior to initiating TPT among people living with HIV. In a setting of 1% TB prevalence, among 1 000
outpatients screened with the W4SS followed by CRP, 742 would be true negatives and eligible for TPT
compared with only 416 found eligible by the W4SS. As is the case for using CXR for ruling out TB
disease prior to initiating TPT, restricted access to CRP or CXR should not be a barrier to initiating TPT.
When considering using an mWRD as a TB screening tool among people living with HIV, it should
be ensured that universal access to mWRD as a diagnostic test for everyone with presumptive
TB is achieved first. The use of an mWRD as a screening tool requires significant resources for
implementation, including increased capacity for diagnostic networks and expansion of sample
transportation networks. Depending on the feasibility and resources available, countries may choose
to prioritize TB screening using mWRDs among certain subpopulations, such as medical inpatients in
settings where the TB prevalence is less than 10%, among other patients who are acutely unwell or
among pregnant women living with HIV. Screening with an mWRD in lower prevalence settings than
those included in the IPD meta-analysis may result in higher false positives should the diagnosis not
be confirmed, with the associated overtreatment and related social and economic consequences,
including potential delays in starting ART. Careful clinical assessment is recommended to ensure that
TB is the primary cause of illness and that other conditions leading to the clinical presentation are
also managed. A negative mWRD does not exclude TB. Patients in such settings who are mWRD
negative but are manifestly sick may not be able to produce sputum of sufficient quality or may have
extrapulmonary TB. For patients with a history of TB within the past 5 years, a positive result may be
due to the presence of DNA detected from previously treated TB. Should the patient be unable to
provide sputum, other biological specimens should be considered, as indicated (69). The TB prevalence
among people living with HIV in medical wards may be calculated as the percentage of people with
HIV-related admissions during a 6–12-month period who are diagnosed with TB.
To inform programming and resource planning, countries are encouraged to monitor and evaluate
the yield of TB screening among people living with HIV, disaggregated by screening tool.

34
3.4 Tools for systematic screening for TB disease
among children and adolescents
16. Among individuals younger than 15 years who are close contacts of someone with TB,
systematic screening for TB disease should be conducted using a symptom screen including
any one of cough, fever or poor weight gain; or chest radiography; or both
(new recommendation: strong recommendation, moderate to low certainty of evidence for test
accuracy).
17. Among children younger than 10 years who are living with HIV, systematic screening for
TB disease should be conducted using a symptom screen including any one of current cough,
fever, poor weight gain or close contact with a TB patient
(new recommendation: strong recommendation, low certainty of evidence for test accuracy).

Case detection is a crucial step in the cascade of care for children with TB; however, for most children
who die from TB, the disease is never diagnosed (80). Children and adolescents who are younger
than 15 years represented approximately 12% of incident cases but 16% of the estimated 1.4 million
deaths from TB in 2019 (1). This relatively higher share of mortality in children highlights the urgent
need for improved case detection and subsequent access to preventive and curative treatment in
this age group, particularly for those at highest risk.
These recommendations relate to the two subpopulations of children for whom TB screening is strongly
recommended but for whom there is as yet no standard screening approach: children and adolescents
younger than 15 years who are close contacts of individuals with TB, and children younger than 10
years who are living with HIV. Adolescents living with HIV who are aged 10–19 years are covered in
previous recommendations for screening people living with HIV (see Recommendations 11–15),
and screening of contacts 15 years of age and older is covered in the previous recommendation on
screening tools (see Recommendations 9–10).
Data from a systematic review of the diagnostic accuracy of multiple screening tools used to detect
TB disease among children and adolescents, which were compared against a microbiological or
composite reference standard, were used to inform this recommendation. Because bacteriological
testing for TB is difficult in children, a composite reference standard is often used when evaluating
diagnostic accuracy in this age group.
3.4.1.1 Close contacts younger than 15 years

The evidence reviewed about the performance of symptom screening among children and adolescents
younger than 15 years who are close contacts of someone with TB included 4 studies with a total of
2 695 participants (see Web Annex B, Table 17, and Web Annex C, Table 10). In this population, a
symptom screen involving any one of cough, fever or poor weight gain (where the presence of any
symptom constitutes a positive screen), when compared against a composite reference standard, had
a pooled sensitivity of 0.89 (95% CI: 0.52–0.98) and a pooled specificity of 0.69 (95% CI: 0.51–0.83).
The evidence reviewed about the performance of chest radiography among close contacts
younger than 15 years of TB patients included 4 studies with a total of 2 550 participants (see Web
Annex B, Table 18, and Web Annex C, Table 8). Compared with a composite reference standard,
chest radiography using abnormalities suggestive of TB as a positive screen had a pooled sensitivity
of 0.84 (95% CI: 0.70–0.92) and a pooled specificity of 0.91 (95% CI: 0.90–0.92).

Despite the absence of high-certainty evidence for test accuracy, the GDG felt that a strong
recommendation was warranted for both of the tools being considered for close contacts younger than
15 years, given the high risk of disease and of mortality if the diagnosis is missed and TB is left untreated
3.4.1.2 Children younger than 10 years who are living with HIV
The evidence reviewed about the performance of symptom screening (any one of current cough,
fever, poor weight gain or close contact with someone with TB) included 2 studies conducted in the
outpatient setting with a total of 20 926 participants and including 20 3135 screens (see Web Annex B,
Table 19, and Web Annex C, Table 10). In this setting, the combined symptom screen (where the
presence of any symptom constitutes a positive screen) was found to have a pooled sensitivity of
0.61 (95% CI: 0.58–0.64) and a pooled specificity of 0.94 (95% CI: 0.86–0.98).
Again, despite the absence of high-certainty evidence, the GDG felt that a strong recommendation
was warranted for symptom screening for children younger than 10 years who are living with HIV,
given the high risk of disease and of mortality if the diagnosis is missed and TB is left untreated.
3.4.2 Considerations for screening children and adolescents

None of the screens investigated reached the target product profile of 90% minimum sensitivity in
these high-risk subpopulations of children, although CXRs came the closest. Concerns were noted
about the risk of incorporation bias when using a composite reference standard in this group, thus
potentially inflating the estimates of accuracy observed. Concerns were also noted about the increased
risk of false-positive diagnoses in children following a false-positive screening test compared with
the risk in adults because children are more likely to be diagnosed using clinical evaluation rather
than bacteriological confirmation, and the process of confirming a clinical diagnosis will weight the
results of the screening test or tests. When screening high-risk groups of children, including close
contacts and children living with HIV, the balance between the benefits of early case detection
arising from true-positive screening results and the possible risk of overtreatment from false-positive
screening results is in favour of screening. When screening populations of children with a lower
risk of TB or in lower prevalence settings, the trade-off between early case detection and possible
overdiagnosis will be different and should be carefully considered. In such situations, while a highly
sensitive screening approach is important in order to maximize early case detection, health care
workers must remain vigilant to possible false-positive diagnoses and monitor responses to treatment
carefully, including evaluating children and adolescents for other potential diagnoses if symptoms or
CXR abnormalities persist.
Given the high risk of TB and of mortality if TB is left untreated among children with HIV and among
those in close contact with TB patients, there is an urgent need to utilize any and all available screening
tests to increase timely diagnosis among these high-risk populations.
Children living with HIV represent an important group that should be considered for regular TB
screening and the provision of preventive therapy, given their high risk of TB and of poor outcomes if
not diagnosed in a timely manner. An essential minimum screening strategy for this group would be
to ensure regular screening for TB symptoms at each visit to a health centre. While data were lacking
to evaluate CXR as an initial screen for children living with HIV, CXR is a useful part of a diagnostic
evaluation for TB in all children, including those living with HIV, especially younger children in whom
bacteriological evaluation is commonly negative (68). Children and adolescents who are close contacts
of someone with TB likewise represent an important group for screening for TB disease and for the
initiation of preventive therapy, given their high risk for developing TB and rapid disease progression.
For children at high risk of TB, countries should position symptom screening and screening chest
radiography within national TB screening and diagnostic algorithms, according to their feasibility,
level of health facility, resources and equity. Algorithms exploring the different screening tools are
presented in the operational handbook (7).

36
4. Monitoring and evaluation
In this section, we consider the monitoring and evaluation required to support the implementation of
TB screening programmes. The operational handbook contains more details about the monitoring,
surveillance and evaluation of TB screening interventions (7).
When considering implementing screening in the general population, it is important to know the
epidemiology of TB and the prevalence of undetected TB in the community. This will help to estimate
the impact of any screening programme. TB disease prevalence surveys are used to assess the
baseline occurrence of TB in high-burden settings (81). However, these surveys represent a major
undertaking and are not practical in all situations. Surveillance data based on TB notifications can be
used as a starting point, but it must be carefully considered alongside other factors that affect the risk
of TB and the likelihood of diagnosis, including the availability of health services and the prevalence
of other risk factors for TB (e.g. HIV, diabetes mellitus, smoking, malnutrition, poverty, overcrowded
living conditions, older age, substance use disorder, and other lung conditions, including silicosis or
fibrotic chest lesions).
In settings that are generally considered to have a higher TB burden than is found in the overall
population, such as prisons, careful monitoring and surveillance to assess TB prevalence and incidence
should be done alongside TB screening. If the burden of TB is found to be low and sustained at a
low level for a period of time, then TB screening can be discontinued. However, surveillance should
be conducted to minimize the risks of TB disease and transmission.
4.1 Indicators
Continued monitoring can help programme managers assess the performance of the TB screening
components that are within their purview. The following indicators should be considered for each
targeted risk group:
1. the number of people eligible for screening;
2. the number of people screened (considering the first screening and second screening separately,
if applicable);
3. the proportion of those eligible for screening who were screened;
4. the number of people with presumptive TB who were identified;
5. the number of people undergoing diagnostic investigation;
6. the number of people diagnosed with TB, stratified by type of TB;
7. the proportion of those undergoing diagnostic investigation who have TB;
8. the NNS to detect one person with TB;
9. the proportion of initial defaulters (that is, the number of people diagnosed with TB who do NOT
start treatment divided by number of people diagnosed with TB);
10. the treatment success rate and the death rate (using standard cohort analyses).
Additional disaggregation may be done – for example, by age group and sex – but this requires that
more detailed data are collected for each individual who is screened.

The uptake of screening in a risk group (the proportion of those eligible for screening who are actually
screened) can be assessed only if the size of the target group has been well defined. It is normally
possible to obtain the relevant information when screening is conducted within health facilities or
closed settings (such as prisons) and through contact investigations. However, it is often difficult to
obtain this information from outreach screening programmes – for example, when screening is done
in the community – although the estimated population size of a targeted community may be used
to obtain a rough estimate of the eligible population.
4.2 Routines for recording and reporting

In order to obtain the required information for the indicators described above, a TB recording and
reporting system needs to include a minimal set of data elements. Although paper-based systems have
been used to collect such data, it is now becoming increasingly feasible to collect data electronically,
and this should be the standard aspired to for monitoring TB screening activities. The following
strategies can be used to collect the necessary data:
• maintain a log of the number of people screened in each risk group. A special register with
individual-level information for each person screened may be used to obtain more refined data
about subcategories of persons within a risk group. Collecting these data is resource intensive, but
it may be relevant when a screening programme is started as part of operational research. It may
be feasible to implement this type of data collection on a continual basis for certain risk groups,
such as people seeking care in medical facilities;
• maintain a register of all patients with presumptive TB who undergo further diagnostic evaluation
(if a register is used to collect individual-level information for all people who are screened, then
this information can be included in it);
• include a field in the laboratory register for noting whether the tested patient was identified through
screening and to which risk group the patient belongs;
• include a field in the treatment register to note whether the patient was identified through screening
and to which risk group the patient belongs.
4.3 Programmatic evaluations

A successful screening programme may lead to a diminishing yield, at least if the risk group is a fixed
population. Over time, changes in the background burden of TB, as well as changes in the profile
of TB patients in the community (e.g. a trend towards fewer patients with symptomatic TB) can lead
to a reduction in the yield from screening, an increase in the NNS, a reduction in cost–effectiveness
and a change in the ratio of benefits to harms. Trends in all of these indicators need to be monitored,
and the prioritization of risk groups, choice of screening approach and screening interval should be
regularly reassessed. Criteria for stopping screening should be established before a screening initiative
is implemented.
Monitoring the indicators discussed above may point to the need for a special assessment, for
example, to explore the reasons for a low uptake of screening, an unexpectedly low proportion of
people with presumptive TB that was identified through screening, a low proportion of those with
presumptive TB undergoing a diagnostic investigation and a higher than expected NNS. Additional
quantitative and qualitative analyses may be needed to determine whether there are barriers to
screening and to identify opportunities to improve the screening approach.

38
4.4 Initial calibration for computer-aided detection
technologies
When CAD is implemented, local calibration is advised to customize the score thresholds to the
requirements of the programme (see the operational handbook for more details about how this can
be done) (7). After this initial calibration, ongoing monitoring and analysis of CAD performance should
be carried out to assess the correlation with human readers’ interpretations and with bacteriological
confirmation, and with the proportion of images read as abnormal and requiring further investigation.

40
5. Research gaps
5.1 Screening for TB in targeted populations

5.1.1 The general population and high-risk groups
Well-designed trials and rigorous quasi-experimental studies in different settings are required to
investigate the effects of population-wide systematic screening for TB on individual-level outcomes
(diagnostic delay, treatment outcomes, costs to patients, social consequences) and population-
level outcomes (TB prevalence, incidence, transmission), as well as to guide implementation choices
(including the method of delivery, screening algorithms, the duration of screening intervals and
frequency of screening, and the mode of delivering the intervention).
Research on the longer-term impacts of screening, including any potential evidence of averted
morbidity or mortality, is not necessarily captured in the existing data. Research on the cost–
effectiveness of screening is needed, using a longer time horizon to adequately capture all potential
costs and longer-term effects, including potential reduced future prevalence and incidence.
Observational research and programmatic evaluations reporting the impact of community-wide
screening on TB case notification rates – which provide an important source of evidence on the
impacts of screening under programmatic conditions – must be carefully designed and analysed to
minimize bias.
Studies of screening interventions should incorporate both qualitative and quantitative assessment
of the indirect effects of screening, given the importance of health-seeking behaviour in TB care
engagement and the potential impact of population-wide screening to change it and the importance
of assessing any unintended mental, social or economic consequences of screening (including adverse
effects, the burden of the test and downstream outcomes of clinical management that is guided by
the outcomes of test results).
5.1.2 People living with HIV

Well-designed clinical trials are needed to strengthen the evidence about the accuracy, effectiveness
(including the impact on patient-important outcomes such as mortality), feasibility and cost implications
of using the W4SS, CRP, CXR and mWRD to screen for TB across all HIV subpopulations in settings
with low, medium and high burdens of HIV and TB with and without high ART coverage.
Subpopulations of people living with HIV for whom further investigation is required would include,
but not be limited to, inpatients, acute care service attendees, patients for whom ART has failed,
patients newly diagnosed as HIV-positive enrolling in ART clinics, stable patients established on ART,
pregnant women and children and adolescents living with HIV.
More data are needed on the effectiveness, cost–effectiveness, feasibility and acceptability, frequency
and optimal periodicity of routine, regular screening with the W4SS, CRP, CXR and mWRD among
people living with HIV. Specifically, more studies are needed that explore the optimal placement of
mWRDs for screening in antenatal care settings versus within ART clinics. Lastly, more research is
needed on the potential for screening people living with HIV with mWRDs using specimens other
than sputum.
5. Research gaps 41
5.1.3 Children and adolescents
The GDG considered data on using mWRDs for screening children and adolescent outpatients
accessing health care. They felt that the data, which included 2 studies with 787 participants and had
results demonstrating substantial heterogeneity, represented insufficient evidence to establish an
accurate and reliable estimate of the diagnostic accuracy of mWRDs, and, thus, the GDG decided not
to issue a recommendation for or against their use as a screening tool for children and adolescents.
This highlights as a research priority the need for more rigorous studies evaluating the use of mWRDs
for screening children and adolescents.
Also highlighted is the urgent overall need for more research and the development of better screening
tools and approaches for use in this population, including more data on screening approaches that
target specific and distinct age ranges including infants younger than 12 months, children younger
than 5 years, children up to the age of 10 years and those aged 10–19 years. More data are needed
to determine the frequency with which screening should be conducted among the subpopulations
of children at highest risk of TB, and further research is needed from well-designed clinical trials to
provide evidence on patient-important outcomes for TB screening in children.
5.2 Tools for screening for TB

5.2.1 Computer-aided detection
Further evidence is needed about the performance of CAD software stratified according to the
characteristics of the individual being evaluated (e.g. by smear status, HIV status, age cohort, history
of TB, smoking status, sex) to allow for better setting-specific and patient-specific calibration of
CAD programmes.
More research on users’ perspectives is needed about CAD technologies in TB screening and triage,
including their perceived acceptability to patients, providers and other stakeholders.
The development and evaluation of CAD programmes for automated detection of TB in children is
urgently needed, as CXR is an important tool for detecting pulmonary TB in children and adolescents,
given the difficulty of bacteriological testing and diagnosis.
5.2.2 C-reactive protein

For people living with HIV in settings with different TB prevalences, more research is needed to
evaluate the accuracy and predictive value of measuring CRP above any cut-off higher than 5 mg/L
for TB screening, when it is used either alone or in combination with other screening tests.
5.2.3 Screening algorithms

Across all populations and tools, more research is needed to evaluate the accuracy and effectiveness
of complete screening and diagnostic algorithms, including symptom screening, CXR, CRP and
mWRDs used in various combinations with diagnostic evaluation. Research into their effectiveness
should include measures of the impacts on patient-important outcomes, such as mortality and
treatment success.

42
5.3 Operational research
Standard monitoring and evaluation procedures may be complemented by operational research
aimed at improving the performance of screening in the local setting as well as research aimed at
improving the global evidence base for screening. Topics that may be explored include:
• assessing the accuracy and performance of different algorithms for screening and diagnosis;
• identifying operational challenges and solutions;
• identifying the best ways to improve acceptability and minimize the harms of screening;
• establishing the effectiveness and cost–effectiveness of screening in different risk groups and in
different epidemiological situations;
• establishing local calibration of CAD software for the specific case of a programme.
There is a need for more, larger and better randomized trials to assess the short-term and long-
term effectiveness and cost–effectiveness of screening. Implementing such studies requires careful
planning and considerable resources.
5. Research gaps 43
44
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(https://www.croiconference.org/abstract/effectiveness-of-3hp-annually-vs-once-for-hiv-positive-people-
the-whip3tb-trial/, accessed 19 February 2021).
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81. Tuberculosis prevalence surveys: a handbook. Geneva: World Health Organization; 2011 (https://apps.who.
int/iris/handle/10665/44481, accessed 4 March 2021).
6. References 49
Supplementary Table
Summary of changes to existing recommendations
2013 Recommendation 2021 Recommendation

Household contacts and other close contacts Household contacts and other close
should be systematically screened for active contacts of individuals with TB should be
TB (strong recommendation, very low- systematically screened for TB disease
quality evidence). (strong recommendation, moderate certainty
of evidence).
People living with HIV should be systematically People living with HIV should be systematically
screened for active TB at each visit to a health screened for TB disease at each visit to the
facility (strong recommendation, very low- health facility (strong recommendation, very
quality evidence). low certainty of evidence).
Current and former workers in Current and former workers in workplaces
workplaces with silica exposure should be with silica exposure should be systematically
systematically screened for active TB (strong screened for TB disease (strong
recommendation, low-quality evidence). recommendation, low certainty of evidence).
Systematic screening for active TB should be Systematic screening for TB disease should
considered in prisons and other penitentiary be conducted in prisons and penitentiary
institutions (conditional recommendation, very institutions (strong recommendation, very low
low-quality evidence). certainty of evidence).
Systematic screening for active TB should People with an untreated fibrotic lesion seen
be considered in people with an untreated on chest X-ray may be systematically screened
fibrotic chest X-ray lesion (conditional for TB disease (conditional recommendation,
recommendation, very low-quality evidence). very low certainty of evidence).
In settings where the TB prevalence in the In settings where the TB prevalence in the
general population is 100/100 000 population general population is 100/100,000 population
or higher, systematic screening for active TB or higher, systematic screening for TB disease
should be considered among people who may be conducted among people with a
are seeking health care or who are in health risk factor for TB who are seeking health
care and who belong to selected risk groups care or who are in health care (conditional
(conditional recommendation, very low- recommendation, very low certainty
quality evidence). of evidence).
Systematic screening for active TB may Systematic screening for TB disease may be
be considered for geographically defined conducted among the general population
subpopulations with extremely high levels in areas with an estimated TB prevalence of
of undetected TB (1% prevalence or higher) 0.5% or higher (updated recommendation –
(conditional recommendation, very low- conditional recommendation, low certainty
quality evidence). of evidence).

50
2013 Recommendation 2021 Recommendation
Systematic screening for active TB may be Systematic screening for TB disease may be
considered also for other subpopulations that conducted for subpopulations with structural
have very poor access to health care, such risk factors for TB. These include urban
as people living in urban slums, homeless poor communities, homeless communities,
people, people living in remote areas with communities in remote or isolated areas,
poor access to health care, and other indigenous populations, migrants, refugees,
vulnerable or marginalized groups including internally displaced persons , and other
some indigenous populations, migrants and vulnerable or marginalized groups with
refugees (conditional recommendation, very limited access to health care (conditional
low-quality evidence). recommendation, very low certainty
of evidence).
Adults and adolescents living with HIV and Among adults and adolescents living with HIV,
screened with a clinical algorithm for TB, systematic screening for TB disease should
and who report any one of the symptoms be conducted using the WHO-recommended
of current cough, fever, weight loss or night four symptom screen and those who report
sweats may have active TB and should any one of the symptoms of current cough,
be evaluated for TB and other diseases. fever, weight loss or night sweats may have
(strong recommendation, moderate quality TB and should be evaluated for TB and other
of evidence) diseases (strong recommendation, moderate
certainty of evidence).
Supplementary Table 51
For further information, please contact:
Global Tuberculosis Programme
World Health Organization
20, Avenue Appia CH-1211 Geneva 27 Switzerland
Web site: www.who.int/tb

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Design and layout by Inis Communication

2. Recommendations for systematic screening for TB disease in targeted

3. Recommendations for tools for systematic screening for TB disease 23

4. Monitoring and evaluation 37

Web Annex B. GRADE Summary of Findings Tables

Web Annex C. GRADE Evidence to Decision Tables

Guideline Development Group

External Reviewer Group

WHO Guideline Steering Group

WHO consolidated guidelines on tuberculosis:

WHO consolidated guidelines on tuberculosis:

WHO consolidated guidelines on tuberculosis:

Table 1. Recommendations in the WHO consolidated guidelines on tuberculosis.

Screening for TB in targeted populations

WHO consolidated guidelines on tuberculosis:

Tools for screening for TB

9 Among individuals aged 15 years and older in populations in which TB screening is

Box 1. Main changes to the guidance in the current update

Î Community-wide systematic screening using an accurate screening and diagnostic

WHO consolidated guidelines on tuberculosis:

1.2 Definition and objectives of systematic screening

1.3 Scope of the 2021 update

WHO consolidated guidelines on tuberculosis:

Increased TB knowledge, awareness, care-seeking (5)

Increased TB diagnosis and treatment initiation (4, 6)

1.4 Rationale for the guideline update

1.5 Objectives of the guideline update

WHO consolidated guidelines on tuberculosis:

1.6 Target audience

2. Recommendations for systematic screening for TB disease in targeted populations 11

WHO consolidated guidelines on tuberculosis:

2.1 Systematic screening for TB disease among the

2.1.1 Summary of the evidence and rationale

2. Recommendations for systematic screening for TB disease in targeted populations 13

WHO consolidated guidelines on tuberculosis:

2.2.1 Summary of evidence and rationale

2.2.2 Implementation considerations

2. Recommendations for systematic screening for TB disease in targeted populations 15

2.3.1 Summary of evidence and rationale

2.3.2 Implementation considerations

2.4 Systematic screening for TB disease among

2.4.1 Summary of evidence and rationale

WHO consolidated guidelines on tuberculosis:

2.4.2 Implementation considerations

2.4.3 Subgroup considerations

2. Recommendations for systematic screening for TB disease in targeted populations 17

2.5.1 Summary of evidence and rationale

2.5.2 Implementation considerations

WHO consolidated guidelines on tuberculosis:

2.6 Systematic screening for TB disease among

2.6.1 Summary of evidence and rationale

2.6.2 Implementation considerations

2.7 Systematic screening for TB disease among

2. Recommendations for systematic screening for TB disease in targeted populations 19

Table 2. Risk factors for tuberculosis (TB) to be considered when prioritizing TB

Risk factor Risk of TB or of poor outcomes

WHO consolidated guidelines on tuberculosis:

3. Recommendations for tools for systematic screening for TB disease 23

4. Monitoring and evaluation 37