Screening for tuberculosis: time to move beyond symptoms

To accelerate progress in ending the global tuberculosis epidemic, the first UN High-Level Meeting on tuberculosis, held in 2018, resolved to close the case detection gap by 2022. However, diagnosing an additional 4 million cases of tuberculosis annually, on top of what is currently being detected, requires the immediate and expanded scale-up of systematic tuberculosis screening, followed by confirmatory testing for all individuals who screen positive. Although new confirmatory tests that are substantially more sensitive than smear microscopy are available (eg, Xpert and Xpert Ultra MTB/RIF), annual reductions in tuberculosis incidence (1·5% per year) are still far from the 4–5% annual decline needed to meet global tuberculosis elimination targets. To realise the full potential of sensitive confirmatory tests in achieving these ambitious goals, attention must now be focused on the step in the tuberculosis diagnostic cascade that misses the most patients with tuberculosis; namely, the continued reliance on symptoms to select patients for confirmatory testing.