Screening

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 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.

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).

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.

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.

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;

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.

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).

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.

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).