Risk Group Screening

Risk Group Screening

Every year, more than 10 million people fall sick with TB worldwide. Out of these, more than 3 million people are being missed, because they are either not diagnosed or treated or not receiving high quality of care. Systematic screening for active TB in high risk populations, provision of preventive treatment (TPT) and prompt access to appropriate treatment for confirmed active TB cases are crucial to END TB. Digital chest radiography, when used as a rapid triage to select individuals for TPT or bacteriological testing, facilitates screening of large groups at low costs.

TB screening is often defined as “systematic identification of people with suspected active TB in a predetermined target group, using tests, examinations, or other procedures which can be applied rapidly and do not only target individuals seeking care for symptoms or signs”. [1]

Enhanced efforts with targeted screening strategies are much needed for vulnerable communities and to accelerate the national TB control efforts towards TB control and elimination. [2] Symptom questionnaires and chest radiography are the most available and best documented methods to screen for active TB disease [3]. While the use of Xpert® in programmatic settings has expanded in recent years, the WHO has also recommended use of more cost effective diagnostic algorithms through screening tools such as CXR [4]. Digital radiology overcomes the barriers of using traditional film based chest X-rays with human readers for (cost)effective digital screening in low resource-high burden settings. Computer Aided Detection for TB now surpasses the performance of a trained human reader and can be used for passive and active TB case finding as well as in prevalence surveys [5]. Combining CAD and clinical information to estimate the risk of active disease is a promising tool for TB screening [6].

WHO on screening

The available evidence suggests that screening, if done in the right way and targeting the right people, may reduce suffering and death.

Knut Lönnroth, WHO - PSI/GTB UNION Liverpool, October 2016.

  • CXR alone cannot establish a diagnosis for TB – bacteriological confirmation must always be attempted
  • In absence of bacteriological confirmation, sometimes clinical diagnosis is needed
  • If patient is not critically ill, a wait-and-see approach can be used
  • WHO has no specific guidance on use of CXR in clinical diagnosis
  • Proportion of TB patients with non-confirmed TB is a possible indicator for quality control

The primary objective of systematic TB screening is early TB case detection, which requires a sensitive screening tool

  • High sensitivity of CXR for TB screening (87-98%)
    • Highly sensitive if using “any abnormality consistent with TB” as criteria for an abnormal result
    • Means the vast majority of those with TB who undergo CXR screening will have an abnormal result
  • Low specificity of CXR for TB screening (46-89%)
    • Means the test will also be abnormal in individuals with other lung abnormalities besides TB that also need to be followed up (e.g. cancer, pneumonia, emphysema) -> benefit to individual being screened
    • Also identifies individuals with inactive TB/fibrotic lesions, who are at high risk of developing active TB in future and require follow-up
    • However, means it needs to be coupled with a bacteriological test with high sensitity and specificity for diagnosis

WHO recommends that priority be given to populations with:

  • High TB prevalence (risk factor profile and/or poor access/delay)
  • High risk of severe negative consequences if diagnosis is missed
  • High transmission risk

In particular systematic screening for TB disease should always be conducted for:

  • Households and close contacts of TB patients
  • People living with HIV
  • Miners exposed to silica dust
  • Prisoners

Conditionally recommended systematic screening for TB disease among:

  • People with clinical risk factors for TB seeking healthcare, in settings with TB prevalence of 0.1% or higher
    • Malnourishment, diabetes, history of previous TB, chronic lung disease, etc.
  • Populations with limited access to healthcare
    • Urban poor, refugees, homeless, other vulnerable or marginalized groups
  • General population in settings with TB prevalence of 0.5% of higher

For the above conditional screening populations consideration should be given to weighing benefits and risks of screening and prioritizing groups that have the greatest burden of vulnerability in a particular setting.

WHO Operational Handbook on Systematic screening for tuberculosis disease – March 2021

In particular people living with HIV are 16 (uncertainty interval 14–18) times more likely to fall ill with TB disease than people without HIV. TB is the leading cause of death among people with HIV. HIV and TB form a lethal combination, each speeding the other's progress. Without timely detection, hence no access to proper treatment, 60% of HIV-negative people with TB on average and nearly all HIV-positive people with TB will die, according to WHO.

Stop TB partnership

A Paradigm Shift is needed in the way we fight TB. Unless we speak about Active Case Finding, X-ray, contacts, prevention (amongst others) we will not reach our targets.

“We are committed to providing an inclusive and supportive platform, including our technical expertise and catalytic funding, to strengthen the innovation ecosystem and accelerate the introduction and scale-up of novel approaches and new tools”

ACF innovations to support Paradigm Shift implementation

  • Systematic screening aims to detect more cases, and to detect them early
  • Innovations in diagnostic imaging make screening in high risk groups faster and more sustainable
  • Digital Chest X-ray (dCXR) with Computer Aided Detection (CAD) as a rapid and automated triage test before Xpert® MTB/RIF can significantly reduce screening cost
  • To scale up ACF in risk groups rapid and more affordable diagnostic pathways are required
  • Relatively high cost and 2 hours processing time still limit the uptake of Xpert® as point-of-care test
  • CAD4TB automatically scores chest radiographs between 0 -100 on abnormalities consistent with TB in 1 minute and surpasses trained human reader performance
  • These innovations support the Stop TB Partnership Paradigm Shift implementation through new diagnostic pathways to detect more TB cases earlier at much lower cost