Consolidated Guidelines

Nutrition assessment and counselling

• All individuals with active TB should receive (i) an assessment of their nutritional status and (ii) appropriate counselling based on their nutritional status at diagnosis and throughout treatment (strong recommendation, no evidence).

Management of severe acute malnutrition

Systematic reviews were conducted to address the following questions (see Annex 3 for questions in PICO format)

1. What is the optimal composition of the diet for patients receiving treatment for active TB?

2. Should macronutrient supplements be recommended to improve TB treatment and health outcomes for well-nourished or undernourished patients (children, adolescents, adults and pregnant and lactating women) being treated for active TB?

TB is a contagious disease related to poverty, undernutrition and poor immune function. TB morbidity and mortality are highest in developing countries. In 2012, there were an estimated 8.6 million new cases of TB (13% coinfected with HIV). There were 950 000 deaths due to TB among people who were HIV negative and another 320 000 among people who were HIV positive (7). While TB is more common among men than women, it is one of the top killers of women worldwide; including HIV-positive women, half a million women died from TB in 2012.

WHO thanks the Government of Luxembourg, the National Institutes of Health (NIH), the United States Agency for International Development (USAID) and the Bill & Melinda Gates Foundation for financial support for this work. Donors do not fund specific guidelines and do not participate in any decision related to the guideline development process, including the composition of research questions, membership of the guideline groups, conduct and interpretation of systematic reviews, or formulation of recommendations.

This guideline was coordinated by Dr Maria del Carmen Casanovas and Dr Knut Lönnroth, with technical input from Dr Luz Maria De-Regil, Dr Ernesto Jaramillo, Dr Juan Pablo Peña-Rosas, Mrs Randa Saadeh and Mrs Diana Weil. This work was initiated as part of the general programme of work of the Department of Nutrition for Health and Development, and the Global TB Programme (GTB) in the World Health Organization (WHO) Geneva.

The Global Tuberculosis Programme of the World Health Organization (WHO) gratefully acknowledges the contributions that many individuals and organizations (listed in Web Annex A) have made to the development of these guidelines.

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%.

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.

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).