Protocol · WHO TB guidelines
Presumptive TB: screen, test and refer
Most people with TB are seen in primary care before they are diagnosed. Ask the screening questions, especially in people with HIV and TB contacts, send a WHO-recommended rapid molecular test, and make sure nobody with TB is lost between the test and the first dose.
- Based on WHO TB guidelines
- For doctors, clinical officers, nurses and community health workers
- Reviewed October 2026
1Who / when
- People with HIV: screen at every visit.
- Household and close contacts of anyone with TB, adults and children.
- Anyone with cough, fever, weight loss or night sweats; people with diabetes, malnutrition, silica work, prison history, or a past TB scar on X-ray.
- Children with cough, fever or poor weight gain, especially if a family member has TB.
2Red flags: refer now
- Seriously ill: breathing over 30 per minute, temperature over 39 °C, pulse over 120 per minute, or unable to walk unaided.
- Coughing up a lot of blood, or severe breathlessness.
- Headache with neck stiffness, confusion or fits (possible TB meningitis).
- Child with any general danger sign or severe acute malnutrition.
- Person with advanced HIV (CD4 below 200, WHO stage 3 or 4, or any child under 5 with HIV) who is unwell.
Seriously ill: refer nowRefer the same day. Do not wait for sputum results; send samples with the patient if you have already collected them.
3Assess
Screen
- Adults and adolescents with HIV: any one of current cough, fever, weight loss or night sweats means possible TB.
- Children with HIV (under 10): current cough, fever, poor weight gain, or close contact with TB.
- Child contacts (under 15): any one of cough, fever or poor weight gain; chest X-ray if available.
- Others: any TB symptom is more sensitive; cough for 2 weeks or more is more specific. Chest X-ray is the most accurate screen where available.
- People with HIV: C-reactive protein above 5 mg/L may be used as a screen.
Test
- Rapid molecular test (Xpert MTB/RIF Ultra, Truenat or similar) is the first test, not smear microscopy. It also shows rifampicin resistance.
- Adults: one good sputum sample. Children: sputum, gastric aspirate, nasopharyngeal aspirate or stool.
- Urine LF-LAM in people with HIV who have TB symptoms, are seriously ill, or (inpatients) have advanced HIV or CD4 below 200; outpatients without symptoms only if CD4 below 100. It adds to other tests; it does not replace them.
- Offer an HIV test to everyone with presumptive or confirmed TB.
4Classify
| Result | Classify as | Action |
|---|---|---|
| Seriously ill or danger sign | Severe or complicated TB possible | Refer urgently; send samples |
| Molecular test or LAM positive, rifampicin resistance detected | Rifampicin-resistant TB | Refer to the drug-resistant TB service promptly |
| Molecular test or LAM positive, no rifampicin resistance | Bacteriologically confirmed TB | Register and start treatment per national TB programme, same day if possible |
| Test negative but symptoms persist, X-ray suggestive, or child with contact and symptoms | Possible TB, not confirmed | Clinical review by a TB-trained clinician; repeat test or other samples; treat if clinically diagnosed |
| No symptoms, no X-ray changes | TB unlikely | Offer TB preventive treatment if eligible; screen again at next visit |
5Treat
Treatment is given through the national TB programme with treatment support. WHO-recommended regimens for drug-susceptible TB:
- Standard 6 months: 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol, then 4 months of isoniazid and rifampicin (2HRZE/4HR), daily, as fixed-dose combinations.
- Children and adolescents 3 months to 16 years with non-severe TB: 4-month regimen (2HRZ(E)/2HR).
- Age 12 and over: a 4-month regimen of isoniazid, rifapentine, moxifloxacin and pyrazinamide may be used where the programme offers it.
- TB with HIV: start ART as soon as possible within 2 weeks of starting TB treatment, whatever the CD4 count (except TB meningitis: specialist advice). Give co-trimoxazole prophylaxis.
- TB preventive treatment: offer to people with HIV and to household contacts once active TB is ruled out, per national regimen.
6Follow-up
- Result not back in the expected time: trace it. Contact anyone with a positive result the same day.
- On treatment: review at least monthly for adherence, side effects (jaundice, vomiting, rash, tingling feet, vision change) and weight. Monitor sputum per programme schedule.
- Screen all household contacts and record them.
- Test negative but still unwell after 2 weeks: reassess and retest or refer.
7Counsel
- TB is curable when the full course is taken; stopping early can cause drug resistance.
- Cover coughs, open windows, sleep apart from young children in the first weeks if possible.
- Bring household members, especially children, for screening.
- Report yellow eyes, persistent vomiting or rash at once.
We need to test your sputum for TB. If it is TB, it can be cured with daily tablets for about six months. Please bring your family to be checked too.
8When to refer
- Urgently: seriously ill, coughing a lot of blood, possible TB meningitis, child with danger signs or severe malnutrition.
- Rifampicin resistance detected, or a previous TB treatment failure.
- Child with presumptive TB where you cannot collect samples or make a clinical diagnosis.
- Advanced HIV disease needing the full package (CD4, cryptococcal antigen, LAM).
- Symptoms persist after a negative test, or no improvement after 2 months of treatment.
9Sources
- World Health Organization. WHO consolidated guidelines on tuberculosis. Module 2: screening – systematic screening for tuberculosis disease. 2021.
- World Health Organization. WHO consolidated guidelines on tuberculosis. Module 3: diagnosis – rapid diagnostics for tuberculosis detection, third edition. 2024.
- World Health Organization. WHO consolidated guidelines on tuberculosis. Module 4: treatment and care. 2025.
- World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring. 2021. HIV retesting for presumptive TB, TB preventive treatment and co-trimoxazole in people with HIV.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.