ReacciónThis section of the guidelines consolidates existing recommendations on TB screening among people with undernutrition and in food insecure settings (12) with existing, updated and new recommendations on nutritional interventions for people with TB and their household contacts.
For the updated and new recommendations, three systematic reviews on the following questions worded in the PICO (population, intervention, comparator, outcome) format were conducted:
- Among people with TB with or without undernutrition, who are receiving TB treatment, do nutritional interventions,⁵ both alone and in combination with micronutrient supplementation, improve physical and mental health and well-being compared with TB treatment alone?
- Among people with TB with or without undernutrition, who are receiving TB treatment, do micronutrient supplements improve physical and mental health and well-being compared with TB treatment alone?
- Among household contacts of people with TB disease, do nutritional interventions,⁵ both alone and in combination with micronutrient supplementation, reduce the incidence of TB disease, compared with not receiving nutritional interventions?
Background reviews were also conducted on the composition and duration of nutritional supplementation, and the cost–effectiveness, feasibility and acceptability of nutritional interventions for people with TB and their household contacts. In addition, WHO commissioned a survey among staff of national TB and nutrition programmes in high-burden countries, and interviews with people who had completed TB treatment (also known as TB survivors) and household contacts, to assess the feasibility and acceptability of nutritional interventions.
The GDG reviewed the evidence from the three systematic reviews and associated studies, and formulated recommendations based on the evidence. When formulating recommendations, the GDG members considered the evidence for effectiveness and safety of the interventions, as well as the other dimensions important to both affected individuals and programmes; that is, values, preferences, resource requirements, costs, cost–effectiveness, impact on health equity, acceptability and feasibility, in alignment with the process outlined in the WHO handbook for guideline development (13). The full methodology for the development of recommendations is described in Web Annex A. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence profiles are published in Web Annex B, and the GRADE evidence-to-decision tables in Web Annex C. The wording of one previous recommendation was revised to improve clarity and to reflect current language use, while 10 recommendations were retired because they were considered redundant or no longer valid. The supplementary table summarizes all recommendations, including changes to a previous recommendation. The GDG reached consensus for all recommendations. The recommendations in this document supersede the recommendations in the 2013 guidelines.
These guidelines will be accompanied by a corresponding section on undernutrition in the latest edition of the WHO operational handbook on tuberculosis. Module 6: tuberculosis and comorbidities, which contains guidance on actions to establish and strengthen mechanisms for effective collaboration between and within sectors, as well as implementation considerations for delivering collaborative activities on TB and undernutrition. WHO’s Framework for collaborative action on TB and comorbidities (14) provides further guidance for establishing and strengthening mechanisms for effective collaboration to deliver people-centred services for TB and comorbidities in general.
The guidelines and operational handbook will be found on the TB Knowledge Sharing Platform (15). This platform also hosts all other WHO guidelines and operational handbooks on TB, including those on prevention, screening, diagnosis, treatment, childhood and adolescent TB, and TB and comorbidities.
5 For the purposes of PICOs 1 and 3, and as defined in the systematic review protocols, nutritional interventions include assessment, nutritional counselling and administration of macronutrients through different sources or initiatives (free food, nutrient-dense food, food vouchers or cash transfers).