Recommendation

In settings where the tuberculosis (TB) prevalence in the general population is 100/100 000 population or higher, systematic screening for active TB should be considered for pregnant women as part of antenatal care.

(Context-specific recommendation)

 

Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016

 

Remarks

• This recommendation has been adapted and integrated from the 2013 WHO publication Systematic screening for active tuberculosis: principles and recommendations, where it was considered a conditional recommendation based on very low-quality evidence (1).
• Systematic screening is defined as the systematic identification of people with suspected active TB in a predetermined target group, using tests, examinations or other procedures that can be applied rapidly.
• Options for initial screening include screening for symptoms (either for cough lasting longer than two weeks, or any symptoms compatible with TB, including a cough of any duration, haemoptysis, weight loss, fever or night sweats) or screening with chest radiography. The use of chest radiography in pregnant women poses no significant risk but the national guidelines for the use of radiography during pregnancy should be followed (1).
• Before screening is initiated, high-quality TB diagnosis, treatment, care, management and support should be in place, and there should be the capacity to scale these up further to match the anticipated rise in case detection that may occur as a result of screening.
• The panel responsible for making this recommendation noted that it may not be possible to implement it in resource-constrained settings.
• Other recommendations relevant to ANC services from the same publication include the following (1):

–– Household contacts and other close contacts should be systematically screened for TB (strong recommendation, very low-quality evidence).

–– People living with HIV should be systematically screened for active TB at each visit to a health-care facility (strong recommendation, very low-quality evidence).

–– Systematic screening for active TB may be considered also for other subpopulations that have very poor access to health care, such as people living in urban slums, homeless people, people living in remote areas with poor access to health care, and other vulnerable or marginalized groups including some indigenous populations, migrants and refugees (conditional recommendation, very low-quality evidence).

• TB increases the risk of preterm birth, perinatal death and other pregnancy complications. Initiating TB treatment early is associated with better maternal and infant outcomes than late initiation (1).
• To better understand the local burden of TB in pregnancy, health systems may benefit from capturing pregnancy status in registers that track TB screening and treatment.
• Further information and considerations related to this recommendation can be found in the 2013 WHO recommendations (1)

 

​Background

Infants of mothers with TB have increased risks of premature birth and perinatal death; pregnant women with TB are more likely to have complications during pregnancy; initiating TB treatment is associated with better maternal and infant outcomes than late initiation. (1)

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (2). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (3) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)  (4) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (5) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

For pregnant women (P), does screening women for TB infection in ANC settings (I) compared with not screening for TB (C) improve health outcomes (O)?

 

Evidence summary

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at: http://www.who.int/entity/tb/GRADE_tables_screening.pdf

http://www.who.int/entity/tb/Decision_Tables_screening.pdf

 

Implementation considerations

• The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
• The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
• An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
• Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
• Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG did not identify any priority question related to this recommendation

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

WHO Health Topics: Tuberculosis

 

 

References

1. WHO publication Systematic screening for active tuberculosis: principles and recommendations, 2013. Geneva: World Health Organization; 2013 (http://www.who.int/tb/tbscreening/en/, accessed 29 September 2016).
2. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
3. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
4. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
5. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).

 

Citation: WHO Reproductive Health Library. WHO recommendation on tuberculosis testing in pregnancy. (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.