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CheckTB! liaises with WHO and Stop TB Partnership team members for the design of innovative case detection projects and operational research to further validate the effectiveness of digital radiology and CAD (e.g. in systematic screening and large-scale prevalence surveys). These field data can serve to perform comparative analyses and to update WHO guidelines and recommendations on the use of chest X-rays also for instance in combination with Xpert® MTB/RIF molecular tests.


At various UNION Conferences the high sensitivity of Chest X-ray was illustrated by findings in the TB prevalence surveys in Viet Nam, Cambodia, Ethiopia, Ghana and Rwanda. The fact that screening on symptoms only can result in missing more than 50% of the TB cases, now makes Chest X-ray with high sensitivity levels a mandatory part of any TB prevalence survey, as mentioned in the WHO Workshops on TB Prevalence Surveys.

Quality Assurance of CXR; by Dr I Onozaki

"Limitations on the wider use of Chest X-rays, such as non-availability at peripheral health facilities and the difficulty of interpreting results, even by trained physicians, need to be addressed."

"Research is needed to identify innovative ways to enhance the ability of clinicians, including non-physicians, to interpret Chest X-rays accurately."

"Chest  X-ray plays an important role in the diagnostics of TB and non-TB chest diseases common among people living with HIV."

"Chest X-rays play a significant role in shortening delays in diagnosis."

"Avoiding films by using digital Chest X-ray is an important advantage; Digital technology has a potential to solve most CXR problems"


Source: "Improving the diagnosis and treatment of
smear-negative pulmonary and extrapulmonary tuberculosis
among adults and adolescents" WHO /HTM /TB /2007.379

 

From WHO Radiography Factsheet

 

About Chest Radiography

X-ray based examinations are crucial in a variety of medical setting and at all major levels of health care. Chest radiography, or chest X-ray (CXR) is an essential tool for early detection of tuberculosis (TB), and therefore fundamental to achieving the targets set out in WHO’s End TB Strategy. CXR is a rapid imaging tool that allows for easy identification of lung abnormalities. CXR has high sensitivity, but limited specificity for the diagnosis of pulmonary TB. It is therefore especially suitable for screening and triaging. Recommendations on CXR are included in several WHO policies, summarized below.

 

Chest Radiography: An Essential Tool To End TB

CXR IS A SENSITIVE TOOL FOR SCREENING FOR ACTIVE TB

Reference: Guidelines on systematic screening for active TB

  • CXR has much higher sensitivity for pulmonary TB than screening for TB symptoms.
  • CXR can also be used as a supplementary diagnostic tool, although the specificity is low. A bacteriologically-confirmed diagnosis is always preferred.

AN ABNORMAL CXR IS AN INDICATION FOR FULL DIAGNOSTIC EVALUATION

Reference: The International Standards of TB Care

  • All patients with unexplained findings suggestive of tuberculosis on CXR should be evaluated for TB with a bacteriological diagnostic test.

CXR IS AN IMPORTANT TOOL FOR CHILDHOOD TB DIAGNOSIS

Reference: Guidelines on childhood TB

  • CXR is useful in the diagnosis of pulmonary and extrapulmonary TB in children, in combination with history, evidence of TB infection and microbiological testing.

CXR CAN IMPROVE THE EFFICIENCY OF XPERT MTB/RIF USE

Reference: Implementation manual on Xpert MTB/RIF

  • CXR and further clinical assessment can be used to triage who should be tested with Xpert MTB/RIF in order to reduce the number of individuals to be tested with Xpert MTB/RIF, as well as to improve pre-test probability of TB.

CXR CAN ASSIST THE DIAGNOSIS OF TB AMONG PEOPLE LIVING WITH HIV

Reference: Consolidated guidelines on the use of ARV drugs for treating and preventing HIV infection (forthcoming publication)

  • CXR can assist the diagnosis of TB among people living with HIV. It is particularly useful to rule out TB disease before the provision of treatment for latent TB.

CXR HELPS RULE OUT ACTIVE TB BEFORE TREATING LATENT TB INFECTION

Reference: Guidelines on management of latent TB infection

  • Symptom screening and CXR should be done to exclude active TB before initiating treatment of latent TB infection.
  • Individuals with TB symptoms or any radiological abnormality should be investigated further for active TB and other conditions.

CXR IS AN ESSENTIAL TECHNOLOGY FOR PREVALENCE SURVEYS

Reference: Guidelines on TB prevalence surveys

  • CXR is a necessary screening tool to identify survey participants eligible for bacteriological examination.

 

KEY ACTIONS MOVING FORWARD

The following actions will be taken by WHO in 2016:

  • Prepare an operational guide on chest radiography and organize a global consultation for its finalization;
  • Perform a review of available evidence on computer-aided radiographic TB detection (CAD), and organize a scoping meeting to determine if WHO guidelines should be developed and determine the research needs.