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. 2022 Mar 23;3(3):CD010890.
doi: 10.1002/14651858.CD010890.pub2.

Symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status

Anja Van't Hoog  1 , Kerri Viney  2   3   4 , Olivia Biermann  2 , Bada Yang  5 , Mariska Mg Leeflang  6 , Miranda W Langendam  5
Affiliations

Symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status

Anja Van't Hoog et al. Cochrane Database Syst Rev. .

Abstract

Background: Systematic screening in high-burden settings is recommended as a strategy for early detection of pulmonary tuberculosis disease, reducing mortality, morbidity and transmission, and improving equity in access to care. Questioning for symptoms and chest radiography (CXR) have historically been the most widely available tools to screen for tuberculosis disease. Their accuracy is important for the design of tuberculosis screening programmes and determines, in combination with the accuracy of confirmatory diagnostic tests, the yield of a screening programme and the burden on individuals and the health service.

Objectives: To assess the sensitivity and specificity of questioning for the presence of one or more tuberculosis symptoms or symptom combinations, CXR, and combinations of these as screening tools for detecting bacteriologically confirmed pulmonary tuberculosis disease in HIV-negative adults and adults with unknown HIV status who are considered eligible for systematic screening for tuberculosis disease. Second, to investigate sources of heterogeneity, especially in relation to regional, epidemiological, and demographic characteristics of the study populations.

Search methods: We searched the MEDLINE, Embase, LILACS, and HTA (Health Technology Assessment) databases using pre-specified search terms and consulted experts for unpublished reports, for the period 1992 to 2018. The search date was 10 December 2018. This search was repeated on 2 July 2021.

Selection criteria: Studies were eligible if participants were screened for tuberculosis disease using symptom questions, or abnormalities on CXR, or both, and were offered confirmatory testing with a reference standard. We included studies if diagnostic two-by-two tables could be generated for one or more index tests, even if not all participants were subjected to a microbacteriological reference standard. We excluded studies evaluating self-reporting of symptoms.

Data collection and analysis: We categorized symptom and CXR index tests according to commonly used definitions. We assessed the methodological quality of included studies using the QUADAS-2 instrument. We examined the forest plots and receiver operating characteristic plots visually for heterogeneity. We estimated summary sensitivities and specificities (and 95% confidence intervals (CI)) for each index test using bivariate random-effects methods. We analyzed potential sources of heterogeneity in a hierarchical mixed-model.

Main results: The electronic database search identified 9473 titles and abstracts. Through expert consultation, we identified 31 reports on national tuberculosis prevalence surveys as eligible (of which eight were already captured in the search of the electronic databases), and we identified 957 potentially relevant articles through reference checking. After removal of duplicates, we assessed 10,415 titles and abstracts, of which we identified 430 (4%) for full text review, whereafter we excluded 364 articles. In total, 66 articles provided data on 59 studies. We assessed the 2 July 2021 search results; seven studies were potentially eligible but would make no material difference to the review findings or grading of the evidence, and were not added in this edition of the review. We judged most studies at high risk of bias in one or more domains, most commonly because of incorporation bias and verification bias. We judged applicability concerns low in more than 80% of studies in all three domains. The three most common symptom index tests, cough for two or more weeks (41 studies), any cough (21 studies), and any tuberculosis symptom (29 studies), showed a summary sensitivity of 42.1% (95% CI 36.6% to 47.7%), 51.3% (95% CI 42.8% to 59.7%), and 70.6% (95% CI 61.7% to 78.2%, all very low-certainty evidence), and a specificity of 94.4% (95% CI 92.6% to 95.8%, high-certainty evidence), 87.6% (95% CI 81.6% to 91.8%, low-certainty evidence), and 65.1% (95% CI 53.3% to 75.4%, low-certainty evidence), respectively. The data on symptom index tests were more heterogenous than those for CXR. The studies on any tuberculosis symptom were the most heterogeneous, but had the lowest number of variables explaining this variation. Symptom index tests also showed regional variation. The summary sensitivity of any CXR abnormality (23 studies) was 94.7% (95% CI 92.2% to 96.4%, very low-certainty evidence) and 84.8% (95% CI 76.7% to 90.4%, low-certainty evidence) for CXR abnormalities suggestive of tuberculosis (19 studies), and specificity was 89.1% (95% CI 85.6% to 91.8%, low-certainty evidence) and 95.6% (95% CI 92.6% to 97.4%, high-certainty evidence), respectively. Sensitivity was more heterogenous than specificity, and could be explained by regional variation. The addition of cough for two or more weeks, whether to any (pulmonary) CXR abnormality or to CXR abnormalities suggestive of tuberculosis, resulted in a summary sensitivity and specificity of 99.2% (95% CI 96.8% to 99.8%) and 84.9% (95% CI 81.2% to 88.1%) (15 studies; certainty of evidence not assessed).

Authors' conclusions: The summary estimates of the symptom and CXR index tests may inform the choice of screening and diagnostic algorithms in any given setting or country where screening for tuberculosis is being implemented. The high sensitivity of CXR index tests, with or without symptom questions in parallel, suggests a high yield of persons with tuberculosis disease. However, additional considerations will determine the design of screening and diagnostic algorithms, such as the availability and accessibility of CXR facilities or the resources to fund them, and the need for more or fewer diagnostic tests to confirm the diagnosis (depending on screening test specificity), which also has resource implications. These review findings should be interpreted with caution due to methodological limitations in the included studies and regional variation in sensitivity and specificity. The sensitivity and specificity of an index test in a specific setting cannot be predicted with great precision due to heterogeneity. This should be borne in mind when planning for and implementing tuberculosis screening programmes.

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Conflict of interest statement

Anja van't Hoog: an earlier version of this work was funded by the WHO/TB‐CARE 1, through a contract with AvH’s employer at the time, Amsterdam Institute for Global Health and Development. This work is included in the current version of the review. At the WHO’s request, AvH presented the results to the guideline development group for the updated TB screening guidelines. She received financial compensation for the time spent on the presentations, but not for the actual work on the Cochrane Review itself.

Kerri Viney works for the Global TB Programme, WHO and this review contributed to WHO guidelines. KV started work on the review prior to employment with WHO.

Olivia Biermann has no known conflicts of interest.

Bada Yang has no known conflicts of interest.

Mariska Leeflang has no known conflicts of interest.

Miranda Langendam has no known conflicts of interest.

Figures

1
1
Algorithms composed of one or more screening methods and one or more confirmatory tests. In panel A one screening tool is applied (e.g. symptoms) and screen positives are further evaluated by one confirmatory test with high sensitivity and high specificity (e.g. Xpert MTB/RIF). In panel B one screening tool is applied (e.g. symptoms) and screen positives are further evaluated by a confirmatory test with low sensitivity (e.g. sputum smear microscopy), and persons with a negative test receive a second test or procedure (e.g. clinical diagnosis, or sputum culture). In panel C two screening tools are applied (e.g. symptoms and chest radiography) and screen positives on either one or on both are further evaluated with a confirmatory test. In panel D two screening tools are applied sequentially. Screen positives on the first screen (e.g. symptoms) undergo a second screen (e.g. CXR) and if also positive on the second a confirmatory test is applied. The single confirmatory test in panels C and D could also be replaced by two steps as in panel B (van't Hoog 2014a).
2
2
Study flow diagram.
3
3
Risk of bias and applicability concerns graph for CXR index tests: review authors' judgements about each domain presented as percentages across included studies.
4
4
Risk of bias and applicability concerns summary for CXR index tests: review authors' judgements about each domain for each included study.
5
5
Risk of bias and applicability concerns graph for symptom question index tests: review authors' judgements about each domain presented as percentages across included studies.
6
6
Risk of bias and applicability concerns summary for symptom question index tests: review authors' judgements about each domain for each included study.
7
7
QUADAS‐2 summary of symptom index tests.
8
8
QUADAS‐2 summary for each CXR index test.
9
9
Risk of bias and applicability concerns graph: review authors' judgements about each domain presented as percentages across included studies.
10
10
Forest plot of studies providing data on index test 'Cough for 2 or more weeks'. CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive.
11
11
Summary ROC plot of index tests: 'Any tuberculosis symptom', 'Cough of any duration', 'Cough for 2 or more weeks'. The plot shows summary estimates, 95% confidence (dotted lines) and 95% prediction intervals (dashed lines).
12
12
Forest plot studies providing data on index test 'Cough of any duration'. CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive.
13
13
Forest plot of studies providing data on index test 'Any tuberculosis symptom'. CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive.
14
14
Forest plot of studies providing data on index test 'Any CXR abnormality'. CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive.
15
15
Summary ROC plot of index test 'Any CXR abnormality', stratified by studies restricting to pulmonary abnormalities only versus studies that also included extrapulmonary abnormalities like cardiomegaly. The plot shows summary estimates, 95% confidence (dotted lines) and 95% prediction intervals (dashed lines).
16
16
Forest plot of studies providing data on index test 'CXR abnormalities suggestive of tuberculosis'. CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive.
17
17
Summary ROC plot of index tests 'Any CXR abnormality' and 'CXR abnormalities suggestive of tuberculosis' each stratified by high versus low risk of bias in the QUADAS‐2 reference standard domain (see Footnote). The plot shows summary estimates, 95% confidence (dotted lines) and 95% prediction intervals (dashed lines). The number of studies with low risk was too low for meta‐analyses, hence a summary estimate is not shown. Footnote: The full QUADAS‐2 question referred to in the legend is: Could the reference standard, its conduct, or its interpretation have introduced bias?
18
18
Forest plot of studies providing data on index test 'Parallel CXR and symptom screening'. CI: confidence interval; FN: false negative; FP: false positive; TN: true negative; TP: true positive.
19
19
Summary ROC plot of studies providing data on Index Test 'Parallel CXR and symptom screening'. The plot shows the summary estimate, 95% confidence (dotted lines) and 95% prediction intervals (dashed lines). Circles denote studies that applied (prolonged) cough as the symptom screen, and squares denote studies that applied another symptom combination as the symptom screen.
20
20
Summary ROC plot: 'Cough for 2 or more weeks' and 'Cough for 3 or more weeks' in studies reporting on both tests.
1
1. Test
Any CXR abnormality
2
2. Test
CXR abnormalities suggestive of tuberculosis
3
3. Test
Cough for 2 or more weeks
4
4. Test
Cough of any duration
5
5. Test
Any tuberculosis symptom
6
6. Test
Parallel CXR and symptom screening
7
7. Test
CXR for parallel comparison
8
8. Test
Cough for 3 or more weeks
9
9. Test
Combination of tuberculosis symptoms ‐ out of several
See this image and copyright information in PMC

Update of

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    1. Morishita F, Garfin AM, Lew W, Oh KH, Yadav RP, Reston JC, et al.Bringing state-of-the-art diagnostics to vulnerable populations: the use of a mobile screening unit in active case finding for tuberculosis in Palawan, the Philippines. PLOS One 2017;12(2):e0171310. [DOI: 10.1371/journal.pone.0171310] - DOI - PMC - PubMed
Morishita 2017b {published data only}
    1. Morishita F, Garfin AM, Lew W, Oh KH, Yadav RP, Reston JC, et al.Bringing state-of-the-art diagnostics to vulnerable populations: the use of a mobile screening unit in active case finding for tuberculosis in Palawan, the Philippines. PLOS One 2017;12(2):e0171310. [DOI: 10.1371/journal.pone.0171310] - DOI - PMC - PubMed
Morishita 2017c {published data only}
    1. Morishita F, Garfin AM, Lew W, Oh KH, Yadav RP, Reston JC, et al.Bringing state-of-the-art diagnostics to vulnerable populations: the use of a mobile screening unit in active case finding for tuberculosis in Palawan, the Philippines. PLOS One 2017;12(2):e0171310. [DOI: 10.1371/journal.pone.0171310] - DOI - PMC - PubMed
Morishita 2017d {published data only}
    1. Morishita F, Garfin AM, Lew W, Oh KH, Yadav RP, Reston JC, et al.Bringing state-of-the-art diagnostics to vulnerable populations: the use of a mobile screening unit in active case finding for tuberculosis in Palawan, the Philippines. PLOS One 2017;12(2):e0171310. [DOI: 10.1371/journal.pone.0171310] - DOI - PMC - PubMed
Morishita 2017e {published data only}
    1. Morishita F, Garfin AM, Lew W, Oh KH, Yadav RP, Reston JC, et al.Bringing state-of-the-art diagnostics to vulnerable populations: the use of a mobile screening unit in active case finding for tuberculosis in Palawan, the Philippines. PLOS One 2017;12(2):e0171310. [DOI: 10.1371/journal.pone.0171310] - DOI - PMC - PubMed
Muyoyeta 2017 {published data only}
    1. Muyoyeta M, Kasese NC, Milimo D, Mushanga I, Ndhlovu M, Kapata N, et al.Digital CXR with computer aided diagnosis versus symptom screen to define presumptive tuberculosis among household contacts and impact on tuberculosis diagnosis. BMC Infectious Diseases 2017;17(1):301. - PMC - PubMed
Nair 2016a {published data only}
    1. Nair A, Guleria R, Kandasamy D, Sharma R, Tandon N, Singh UB, et al.Prevalence of pulmonary tuberculosis in young adult patients with Type 1 diabetes mellitus in India. Multidisciplinary Respiratory Medicine 2016;11:22. [DOI: 10.1186/s40248-016-0058-z] - DOI - PMC - PubMed
Nair 2016b {published data only}
    1. Nair A, Guleria R, Kandasamy D, Sharma R, Tandon N, Singh UB, et al.Prevalence of pulmonary tuberculosis in young adult patients with Type 1 diabetes mellitus in India. Multidisciplinary Respiratory Medicine 2016;11:22. [DOI: 10.1186/s40248-016-0058-z] - DOI - PMC - PubMed
Ntinginya 2012 {published data only}
    1. Ntinginya EN, Squire SB, Millington KA, Mtafya B, Saathoff E, Heinrich N, et al.Performance of the Xpert MTB/RIF assay in an active case-finding strategy: a pilot study from Tanzania. International Journal of Tuberculosis and Lung Disease 2012;16(11):1468-70. - PubMed
NTP Bangladesh 2017 {published data only}
    1. National TB Control Programme (Dr Mahmudur Rahman).National Tuberculosis Prevalence Survey, Bangladesh, 2015-2016. Report 2017. [BAN5010] [Summary available in WHO 2021b (who.int/publications/i/item/9789240022430) page 73]
NTP Philippines 2018 {unpublished data only}
    1. National TB Control Programme, Department of Health/Philippine Council for Health Research and Development (PCHRD)/Foundation for the Advancement of Clinical Epidemiology (FACE, Inc).National Tuberculosis Prevalence Survey 2016. Report 2018. [PHI5023] [Summary available in WHO 2021b (who.int/publications/i/item/9789240022430) page 201]
Pelissari 2018 {published data only}
    1. Pelissari DM, Kuhleis DC, Bartholomay P, Barreira D, Oliveira CLP, Jesus RS, et al.Prevalence and screening of active tuberculosis in a prison in the South of Brazil. International Journal of Tuberculosis and Lung Disease 2018;22(10):1166-71. - PubMed
Qadeer 2016 {published data only}
    1. Qadeer E, Fatima R, Yaqoob A, Tahseen S, Ul Haq M, Ghafoor A, et al.Population based National Tuberculosis Prevalence Survey among Adults (>15 Years) in Pakistan, 2010-2011. PLOS One 2016;11(2):e0148293. [DOI: 10.1371/journal.pone.0148293] - DOI - PMC - PubMed
Republic of Uganda 2018 {unpublished data only}
    1. The Republic of Uganda.The Uganda National Tuberculosis Prevalence Survey, 2014-2015. Survey Report. Available at health.go.ug/cause/the-uganda-national-tuberculosis-prevalence-survey-20.... [UGA5027]
Republic of Zimbabwe 2015 {unpublished data only}
    1. Republic of Zimbabwe – Ministry of Health and Child Care.Report of the First National Population-based Tuberculosis Prevalence Survey. Report 2015. [Summary available in WHO 2021b (who.int/publications/i/item/9789240022430) page 265] [ZIM5031]
Rwanda MoH 2014 {unpublished data only}
    1. Republic of Rwanda Ministry of Health.Report of the First National Pulmonary Tuberculosis Prevalence Survey in Rwanda. Report 2014. [RWA5024] [Summary available in WHO 2021b (who.int/publications/i/item/9789240022430) page 209]
Seri 2017 {published data only}
    1. Séri B, Koffi A, Danel C, Ouassa T, Blehoué MA, Ouattara E, et al.Prevalence of pulmonary tuberculosis among prison inmates: a cross-sectional survey at the Correctional and Detention Facility of Abidjan, Côte d'Ivoire. PLOS One 2017;12(7):e0181995. [DOI: 10.1371/journal.pone.0181995] - DOI - PMC - PubMed
Singh 2013 {published data only}
    1. Singh J, Sankar MM, Kumar S, Gopinath K, Singh N, Mani K, et al.Incidence and prevalence of tuberculosis among household contacts of pulmonary tuberculosis patients in a peri-urban population of South Delhi, India. PLOS One 2013;8(7):e69730. - PMC - PubMed
Telisinghe 2014 {published data only}
    1. Hanifa Y, Telisinghe L, Fielding KL, Malden JL, Churchyard GJ, Grant AD, et al.The diagnostic accuracy of urine lipoarabinomannan test for tuberculosis screening in a South African correctional facility. PLOS One 2015;10(5):e0127956. [DOI: 10.1371/journal.pone.0127956] [#1406] - DOI - PMC - PubMed
    1. Telisinghe L, Fielding KL, Malden JL, Hanifa Y, Churchyard GJ, Grant AD, et al.High tuberculosis prevalence in a South African prison: the need for routine tuberculosis screening. PLOS One 2014;9(1):e87262. [DOI: 10.1371/journal.pone.0087262] - DOI - PMC - PubMed
van't Hoog 2011 {published data only}
    1. van't Hoog AH, Meme HK, Deutekom H, Mithika AM, Olunga C, Onyino F, et al.High sensitivity of chest radiograph reading by clinical officers in a tuberculosis prevalence survey. International Journal of Tuberculosis and Lung Disease 2011;15(10):1308-14. - PubMed
van't Hoog 2012 {published data only}
    1. van't Hoog AH, Laserson KF, Githui WA, Meme HK, Agaya JA, Odeny LO, et al.High prevalence of pulmonary tuberculosis and inadequate case finding in rural western Kenya. American Journal of Respiratory & Critical Care Medicine 2011;183(9):1245-53. - PubMed
    1. van't Hoog AH, Meme HK, Laserson KF, Agaya JA, Muchiri BG, Githui WA, et al.Screening strategies for tuberculosis prevalence surveys: the value of chest radiography and symptoms. PLOS One 2012;7(7):e38691. - PMC - PubMed
Wei 2014 {published data only}
    1. Wei X, Zhang X, Yin J, Walley J, Beanland R, Zou G, et al.Changes in pulmonary tuberculosis prevalence: evidence from the 2010 population survey in a populous province of China. BMC Infectious Diseases 2014;14:21. - PMC - PubMed
Wood 2007 {published data only}
    1. Wood R, Middelkoop K, Myer L, Grant AD, Whitelaw A, Lawn SD, et al.Undiagnosed tuberculosis in a community with high HIV prevalence: implications for tuberculosis control. American Journal of Respiratory & Critical Care Medicine 2007;175(1):87-93. - PMC - PubMed

References to studies excluded from this review

Abboud 2013 {published data only}
    1. Abboud S, Weiss F, Siegel E, Jeudy J.TB or Not TB: interreader and intrareader variability in screening diagnosis on an iPad versus a traditional display. Journal of the American College of Radiology 2013;10(1):42-4. - PubMed
Abebe 2011 {published data only}
    1. Abebe DS, Bjune G, Ameni G, Biffa D, Abebe F.Prevalence of pulmonary tuberculosis and associated risk factors in Eastern Ethiopian prisons. International Journal of Tuberculosis and Lung Disease 2011;15(5):668-73. - PubMed
Abubakar 2010 {published data only}
    1. Abubakar I, Story A, Lipman M, Bothamley G, Hest R, Andrews N, et al.Diagnostic accuracy of digital chest radiography for pulmonary tuberculosis in a UK urban population. European Respiratory Journal 2010;35(3):689-92. - PubMed
Aerts 2000 {published data only}
    1. Aerts A, Habouzit M, Mschiladze L, Malakmadze N, Sadradze N, Menteshashvili O, et al.Pulmonary tuberculosis in prisons of the ex-USSR state Georgia: results of a nation-wide prevalence survey among sentenced inmates. International Journal of Tuberculosis and Lung Disease 2000;4(12):1104-10. - PubMed
Al 2013 {published data only}
    1. Al Hosani FI, Yahia GA.Prevalence of pulmonary tuberculosis among expatriates subjected to medical visa screening in Abu Dhabi, United Arab Emirates. Journal of Epidemiology and Global Health 2013;3(1):23-30. - PMC - PubMed
Alamo 2012 {published data only}
    1. Alamo ST, Kunutsor S, Walley J, Thoulass J, Evans M, Muchuro S, et al.Performance of the new WHO diagnostic algorithm for smear-negative pulmonary tuberculosis in HIV prevalent settings: a multisite study in Uganda. Tropical Medicine & International Health 2012;17(7):884-95. - PubMed
Alcântara 2012 {published data only}
    1. Alcântara CCS, Kritski AL, Ferreira VG, Façanha MC, Pontes RS, Mota RS, et al.Factors associated with pulmonary tuberculosis among patients seeking medical attention at referral clinics for tuberculosis [Fatores associados à tuberculose pulmonar em pacientes que procuraram serviços de saúde de referência para tuberculose]. Jornal Brasileiro de Pneumologia 2012;38(5):622-9. - PubMed
Aldridge 2010 {published data only}
    1. Aldridge RW, Story A, Stagg H, Lipman M, Knight J, Taubman D, et al.Sensitivity and specificity of mobile digital chest radiography for the diagnosis of active pulmonary tuberculosis. a cohort study in high risk groups in London. Thorax 2010;65:A6.
Ali 2012 {published data only}
    1. Ali H, Zeynudin A, Mekonnen A, Abera S, Ali S.Smear Posetive Pulmonary Tuberculosis (PTB) prevalence amongst patients at Agaro Teaching Health Center, South West Ethiopia. Ethiopian Journal of Health Sciences 2012;22(1):71-6. - PMC - PubMed
Alsedà 2003 {published data only}
    1. Alsedà M, Godoy P.Study investigating infection in contacts of tuberculosis patients in a semi-urban area [Estudio de contactos de enfermos tuberculosos en un área semiurbana]. Enfermedades Infecciosas y Microbiologia Clinica 2003;21(6):281-6. - PubMed
Arenas 2008 {published data only}
    1. Arenas NE, Torres E, Durango CJ, Cuervo LI, Coronado SM, Gómez A.Detecting active tuberculosis in Calarc -Quind¡o, Colombia, during 2005 [Búsqueda activa de individuos con tuberculosis pulmonar y extrapulmonar en Calarcá-Quindío, Colombia-2005]. Revista de Salud Pública 2008;10(2):279-89. - PubMed
Arpaz 2003 {published data only}
    1. Arpaz S, Keskin S, Kiter G, Sezgin N, Budin D, Algan A, et al.Evaluation of Nazilli tuberculosis dispensary activities executed between June 1996-May 2000: pre-DOT situation. Tuberkuloz ve toraks 2003;51(3):289-97. - PubMed
Arzhaeva 2009 {published data only}
    1. Arzhaeva Y, Hogeweg L, Jong PA, Viergever MA, Ginneken B.Global and local multi-valued dissimilarity-based classification: application to computer-aided detection of tuberculosis. Medical Image Computing & Computer-Assisted Intervention 2009;12(Pt 2):724-31. - PubMed
Assefzadeh 2009 {published data only}
    1. Assefzadeh M, Barghi RGh, Shahidi ShS.Tuberculosis case--finding and treatment in the central prison of Qazvin province, Islamic Republic of Iran. Eastern Mediterranean Health Journal 2009;15(2):258-63. - PubMed
Bai 2001 {published data only}
    1. Bai GH, Kim SJ, Lee EK, Lew WJ.Incidence of pulmonary tuberculosis in Korean civil servants: second study, 1992-1994. International Journal of Tuberculosis and Lung Disease 2001;5(4):346-53. - PubMed
Balasangameshwara 1993 {published data only}
    1. Balasangameshwara VH, Chakraborty AK.Validity of case-finding tools in a national tuberculosis programme. Tubercle and Lung Disease 1993;74(1):52-8. - PubMed
Balasubramanian 1995 {published data only}
    1. Balasubramanian R, Sadacharam K, Selvaraj R, Xavier T, Gopalan BN, Shanmugam M, et al.Feasibility of involving literate tribal youths in tuberculosis case-finding in a tribal area in Tamil Nadu. Tubercle and Lung Disease 1995;76(4):355-9. - PubMed
Balasubramanian 2004 {published data only}
    1. Balasubramanian R, Garg R, Santha T, Gopi PG, Subramani R, Chandrasekaran V, et al.Gender disparities in tuberculosis: report from a rural DOTS programme in south India. International Journal of Tuberculosis and Lung Disease 2004;8(3):323-32. - PubMed
Banda 1998 {published data only}
    1. Banda HT, Harries AD, Welby S, Boeree MJ, Wirima JJ, Subramanyam VR, et al.Prevalence of tuberculosis in TB suspects with short duration of cough. Transactions of the Royal Society of Tropical Medicine & Hygiene 1998;92(2):161-3. - PubMed
Banda 2009 {published data only}
    1. Banda HT, Gausi F, Harries AD, Salaniponi FM.Prevalence of smear-positive pulmonary tuberculosis among prisoners in Malawi: a national survey. International Journal of Tuberculosis and Lung Disease 2009;13(12):1557-9. - PubMed
Banu 2010 {published data only}
    1. Banu S, Hossain A, Uddin MK, Uddin MR, Ahmed T, Khatun R, et al.Pulmonary tuberculosis and drug resistance in Dhaka central jail, the largest prison in Bangladesh. PLOS One 2010;5(5):e10759. - PMC - PubMed
Basta 2005 {published data only}
    1. Basta PC.Tuberculosis Between the Native People Suruí of Rondonia, Amazonia, Brazil [A tuberculose entre o povo indígena Suruí de Rondônia, Amazônia, Brasil] [PhD thesis]. Rio de Janeiro (Brazil): Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, 2005.
Basta 2006 {published data only}
    1. Basta PC, Coimbra CE Jr, Escobar AL, Santos RV, Alves LC, Fonseca Lde S.Survey for tuberculosis in an indigenous population of Amazonia: the Surui of Rondonia, Brazil. Transactions of the Royal Society of Tropical Medicine & Hygiene 2006;100(6):579-85. - PubMed
Bates 2013 {published data only}
    1. Bates M, Ahmed Y, Chilukutu L, Tembo J, Cheelo B, Sinyangwe S, et al.Use of the Xpert(R) MTB/RIF assay for diagnosing pulmonary tuberculosis comorbidity and multidrug-resistant TB in obstetrics and gynaecology inpatient wards at the University Teaching Hospital, Lusaka, Zambia. Tropical Medicine & International Health 2013;18(9):1134-40. - PMC - PubMed
Becerra 2005 {published data only}
    1. Becerra MC, Pachao-Torreblanca IF, Bayona J, Celi R, Shin SS, Kim JY, et al.Expanding tuberculosis case detection by screening household contacts. Public Health Reports 2005;120(3):271-7. - PMC - PubMed
Beser 1993 {published data only}
    1. Beser E.The prevalence of pulmonary tuberculosis using different methods in group screenings. East African Medical Journal 1993;70(12):768-71. - PubMed
Beyanga 2018 {published data only}
    1. Beyanga M, Kidenya BR, Gerwing-Adima L, Ochodo E, Mshana SE, Kasang C.Investigation of household contacts of pulmonary tuberculosis patients increases case detection in Mwanza City, Tanzania. BMC Infectious Diseases 2018;18(110):1102018. - PMC - PubMed
Bhat 2009 {published data only}
    1. Bhat J, Rao VG, Gopi PG, Yadav R, Selvakumar N, Tiwari B, et al.Prevalence of pulmonary tuberculosis amongst the tribal population of Madhya Pradesh, central India. International Journal of Epidemiology 2009;38(4):1026-32. - PubMed
Bhatia 2002 {published data only}
    1. Bhatia S, Dranyi T, Rowley D.Tuberculosis among Tibetan refugees in India. Social Science & Medicine 2002;54(3):423-32. - PubMed
Binkin 1996 {published data only}
    1. Binkin NJ, Zuber PL, Wells CD, Tipple MA, Castro KG.Overseas screening for tuberculosis in immigrants and refugees to the United States: current status. Clinical Infectious Diseases 1996;23(6):1226-32. - PubMed
Bjerregaard‐Andersen 2010 {published data only}
    1. Bjerregaard-Andersen M, da Silva ZJ, Ravn P, Ruhwald M, Andersen PL, Sodemann M, et al.Tuberculosis burden in an urban population: a cross sectional tuberculosis survey from Guinea Bissau. BMC Infectious Diseases 2010;10:96. - PMC - PubMed
Bloss 2012 {published data only}
    1. Bloss E, Makombe R, Kip E, Smit M, Chirenda J, Gammino VM, et al.Lessons learned during tuberculosis screening in public medical clinics in Francistown, Botswana. International Journal of Tuberculosis & Lung Disease 2012;16(8):1030-2. - PMC - PubMed
Bonvin 1992 {published data only}
    1. Bonvin L, Zellweger JP.Mass miniature X-ray screening for tuberculosis among immigrants entering Switzerland. Tubercle & Lung Disease 1992;73(6):322-5. - PubMed
Borgdorff 2000 {published data only}
    1. Borgdorff MW, Nagelkerke NJ, Dye C, Nunn P.Gender and tuberculosis: a comparison of prevalence surveys with notification data to explore sex differences in case detection. International Journal of Tuberculosis & Lung Disease 2000;4(2):123-32. - PubMed
Borra 2009 {published data only}
    1. Borra H, Si TM, Morris MJ, Waibel KH, Arroyo RA, Merrill GA, et al. In:Reliability of tuberculosis screening tests in patients receiving tumor necrosis factor antagonist therapy in a United States rheumatology clinic. American College of Rheumatology/Association of Rheumatology Health Professional Annual Scientific Meeting (ACR/ARHP) 09; 2010 Nov 9; Atlanta (GA). Vol. 60. 2009:137.
Braden 1995 {published data only}
    1. Braden CR.Infectiousness of a university student with laryngeal and cavitary tuberculosis. Investigative team. Clinical Infectious Diseases 1995;21(3):565-70. - PubMed
Bucher 1994 {published data only}
    1. Bucher H, Weinbacher M, Gyr K.Compliance of asylum seekers with an expanded border health screening program in the Basel-Stadt canton 1992-1993. Schweizerische Medizinische Wochenschrift 1994;124(38):1660-5. - PubMed
Burgess 2001 {published data only}
    1. Burgess AL, Fitzgerald DW, Severe P, Joseph P, Noel E, Rastogi N, et al.Integration of tuberculosis screening at an HIV voluntary counselling and testing centre in Haiti. AIDS 2001;15(14):1875-9. - PubMed
Cain 2010 {published data only}
    1. Cain KP, McCarthy KD, Heilig CM, Monkongdee P, Tasaneeyapan T, Kanara N, et al.An algorithm for tuberculosis screening and diagnosis in people with HIV. New England Journal of Medicine 2010;362(8):707-16. - PubMed
Callister 2002 {published data only}
    1. Callister MEJ, Barringer J, Thanabalasingam ST, Gair R, Davidson RN.Pulmonary tuberculosis among political asylum seekers screened at Heathrow Airport, London, 1995-9. Thorax 2002;57(2):152-6. - PMC - PubMed
Carbonara 2005 {published data only}
    1. Carbonara S, Babudieri S, Longo B, Starnini G, Monarca R, Brunetti B, et al.Correlates of Mycobacterium tuberculosis infection in a prison population. European Respiratory Journal 2005;25(6):1070-6. - PubMed
Castro 2011 {published data only}
    1. Castro CB, Costa PA, Ruffino-Netto A, Maciel EL, Kritski AL.Assessment of a clinical score for screening suspected pulmonary tuberculosis cases. Revista de Saude Publica 2011;45(6):1110-6. - PubMed
Catanzaro 2013 {published data only}
    1. Catanzaro A, Daley C.A summary of the third global interferon-release assay symposium. Infection Control and Hospital Epidemiology 2013;34(6):619-24. - PubMed
Chadha 2012 {published data only}
    1. Chadha VK, Kumar P, Anjinappa SM, Singh S, Narasimhaiah S, Joshi MV, et al.Prevalence of pulmonary tuberculosis among adults in a rural sub-district of South India. PLOS One 2012;7(8):e42625. - PMC - PubMed
Chakraborty 1995 {published data only}
    1. Chakraborty AK, Suryanarayana HV, Murthy VV, Murthy MS, Shashidhara AN.Prevalence of tuberculosis in a rural area by an alternative survey method without prior radiographic screening of the population. Tubercle and Lung Disease 1995;76(1):20-4. - PubMed
Chang 2010 {published data only}
    1. Chang CM, Lee NY, Lee HC, Wu CJ, Chen PL, Lee CC, et al.Positive tuberculin skin tests in nursing home residents in Southern Taiwan. Archives of Gerontology & Geriatrics 2010;51(3):e129-32. - PubMed
Chan‐Yeung 2007 {published data only}
    1. Chan-Yeung M, Dai DL, Cheung AH, Chan FH, Kam KM, Tam CM, et al.Tuberculin skin test reaction and body mass index in old age home residents in Hong Kong. Journal of the American Geriatrics Society 2007;55(10):1592-7. - PubMed
Chen 2011 {published data only}
    1. Chen CY, Sheng WH, Cheng A, Tsay W, Huang SY, Tang JL, et al.Clinical characteristics and outcomes of Mycobacterium tuberculosis disease in adult patients with hematological malignancies. BMC Infectious Diseases 2011;11:324. - PMC - PubMed
Chen 2012 {published data only}
    1. Chen W, Xia Y, Li X, Zhou L, Li C, Wan K, et al.A tuberculosis outbreak among senior high school students in China in 2011. Journal of International Medical Research 2012;40(5):1830-9. - PubMed
Chen 2013 {published data only}
    1. Chen SC, Chen KL, Chen KH, Chien ST, Chen KT.Updated diagnosis and treatment of childhood tuberculosis. World Journal of Pediatrics 2013;9(1):9-16. - PubMed
China 2004 {published data only}
    1. China Tuberculosis Control Collaboration.The effect of tuberculosis control in China. Lancet 2004;364(9432):417-22. - PubMed
Churchyard 1999 {published data only}
    1. Churchyard GJ, Kleinschmidt I, Corbett EL, Mulder D, De Cock KM.Mycobacterial disease in South African gold miners in the era of HIV infection. International Journal of Tuberculosis & Lung Disease 1999;3(9):791-8. - PubMed
Churchyard 2010 {published data only}
    1. Churchyard GJ, Fielding KL, Lewis JJ, Chihota VN, Hanifa Y, Grant AD.Symptom and chest radiographic screening for infectious tuberculosis prior to starting isoniazid preventive therapy: yield and proportion missed at screening. AIDS 2010;24(Suppl 5):S19-27. - PubMed
Claassens 2013 {published data only}
    1. Claassens M, Schalkwyk C, den Haan L, Floyd S, Dunbar R, Helden P, et al.High prevalence of tuberculosis and insufficient case detection in two communities in the Western Cape, South Africa. PLOS One 2013;8(4):e58689. - PMC - PubMed
Claassens 2013a {published data only}
    1. Claassens MM, Jacobs E, Cyster E, Jennings K, James A, Dunbar R, et al.Tuberculosis cases missed in primary health care facilities: should we redefine case finding? International Journal of Tuberculosis and Lung Disease 2013;17(5):608-14. - PubMed
Clarke 2003 {published data only}
    1. Clarke M, Dick J, Zwarenstein M, Diwan V.DOTS for temporary workers in the agricultural sector. An exploratory study in tuberculosis case detection. Curationis 2003;26(4):66-71. - PubMed
Coelho 2011 {published data only}
    1. Coelho Filho JC, Caribé MA, Caldas SCC, Martins Netto E.Is tuberculosis difficult to diagnose in childhood and adolescence? [A tuberculose na infância e na adolescência é difícil de diagnosticar?]. Jornal Brasileiro De Pneumologia 2011;37(3):1-5. - PubMed
Corbett 2004 {published data only}
    1. Corbett EL, Charalambous S, Moloi VM, Fielding K, Grant AD, Dye C, et al.Human immunodeficiency virus and the prevalence of undiagnosed tuberculosis in African gold miners. American Journal of Respiratory & Critical Care Medicine 2004;170(6):673-9. - PubMed
Costa 2010 {published data only}
    1. Costa JT, Silva R, Sá R, Cardoso MJ, Ribeiro C, Nienhaus A.Comparison of interferon-gamma release assay and tuberculin test for screening in healthcare workers. Revista Portuguesa de Pneumologia 2010;16(2):211-21. - PubMed
Costa 2011 {published data only}
    1. Costa JC, Silva R, Ferreira J, Nienhaus A.Active tuberculosis among health care workers in Portugal. Jornal Brasileiro de Pneumologia 2011;37(5):636-45. - PubMed
Costantino 2010 {published data only}
    1. Costantino F, Faure G, Carvalho MD, Rat AC, Dintinger H, Loeuille D, et al. In:High level of disease activity in chronic inflammatory rheumatisms increases the rate of indeterminate interferon-gamma-release assay results for latent tuberculosis infection detection. American College of Rheumatology/Association of Rheumatology Health Professional Annual Scientific Meeting (ACR/ARHP) 10; 16 Oct 2009 Philadelphia (PA). Vol. 62. 2010:768.
Crampin 2011 {published data only}
    1. Crampin A, Kasimba S, Mwaungulu NJ, Dacombe R, Floyd S, Glynn JR, et al.Married to M. tuberculosis: risk of infection and disease in spouses of smear-positive tuberculosis patients. Tropical Medicine & International Health 2011;16(7):811-8. - PMC - PubMed
Cruz‐Hervert 2012 {published data only}
    1. Cruz-Hervert LP, García-García L, Ferreyra-Reyes L, Bobadilla-del-Valle M, Cano-Arellano B, Canizales-Quintero S, et al.Tuberculosis in ageing: high rates, complex diagnosis and poor clinical outcomes. Age and Ageing 2012;41(4):488-95. - PMC - PubMed
Cuevas 2011a {published data only}
    1. Cuevas LE, Al-Sonboli N, Lawson L, Yassin MA, Arbide I, Al-Aghbari N, et al.LED fluorescence microscopy for the diagnosis of pulmonary tuberculosis: a multi-country cross-sectional evaluation. PLOS Medicine 2011;8(7):e1001057. - PMC - PubMed
Cuevas 2011b {published data only}
    1. Cuevas LE, Yassin MA, Al-Sonboli N, Lawson L, Arbide I, Al-Aghbari N, et al.A multi-country non-inferiority cluster randomized trial of frontloaded smear microscopy for the diagnosis of pulmonary tuberculosis. PLOS Medicine 2011;8(7):e1000443. - PMC - PubMed
Dara 2013 {published data only}
    1. Dara M, Gushulak BD, Posey DL, Zellweger JP, Migliori GB.The history and evolution of immigration medical screening for tuberculosis. Expert Review of Anti-Infective Therapy 2013;11(2):137-46. - PubMed
Datta 2001 {published data only}
    1. Datta M, Radhamani MP, Sadacharam K, Selvaraj R, Rao DL, Rao RS, et al.Survey for tuberculosis in a tribal population in North Arcot District. International Journal of Tuberculosis and Lung Disease 2001;5(3):240-9. - PubMed
de Vries 2007 {published data only}
    1. Vries G, Hest RA, Richardus JH.Impact of mobile radiographic screening on tuberculosis among drug users and homeless persons. American Journal of Respiratory and Critical Care Medicine 2007;176(2):201-7. - PubMed
Eckhoff 2000 {published data only}
    1. Eckhoff CT.Evaluation of a clinical index among adult contacts of children with tuberculosis in rural Haiti. International Journal of Tuberculosis and Lung Disease 2000;4(12):1143-8. - PubMed
Forman 2003 {published data only}
    1. Forman PD, Kinney C.Evaluation of a tuberculosis screening questionnaire for use in an Alaskan homeless population. Alaska Medicine 2003;45(4):94-101. - PubMed
Fox 2011 {published data only}
    1. Fox GJ, Sy D, Nhung NV, Lien LT, Cuong NK, Britton WJ, et al.Prevalence of tuberculosis among household contacts of smear positive tuberculosis patients in four districts in Ha Noi, Viet Nam. American Journal of Respiratory and Critical Care Medicine 2011;183:A1843.
Fox 2012a {published data only}
    1. Fox GJ, Sy DNS, Nhung NV, Lien LT, Cuong NK, Britton WJ, et al.Active case-finding of tuberculosis among household contacts in Hanoi, Vietnam - a 12-month prospective study. American Journal of Respiratory and Critical Care Medicine 2012;185:A3248.
Gopi 2003 {published data only}
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References to studies awaiting assessment

Assefa 2019 {published data only}
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References to other published versions of this review

van't Hoog 2013a
    1. van't Hoog AH, Langendam MW, Mitchell E, Cobelens FG, Sinclair D, Leeflang MMG, et al.A systematic review of the sensitivity and specificity of symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative persons and persons with unknown HIV status. March 2013. who.int/tb/Review2Accuracyofscreeningtests.pdf?ua=1 (accessed 1 November 2021).
van't Hoog 2014b
    1. van't Hoog AH, Langendam M, Mitchell E, Cobelens FG, Sinclair D, Leeflang M, et al.Symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No: CD010890. [DOI: 10.1002/14651858.CD010890] - DOI - PMC - PubMed

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