World Health Organization · 4th edition, 2025 · 182 pages
Comprehensive operational guidance for implementing WHO-recommended TB diagnostic tests, algorithms and infection testing for national TB programmes and laboratories.
- Issuer
- World Health Organization
- Edition
- 4th edition, 2025
- Audience
- National TB programme managers, laboratory managers, ministry of health officials, clinicians, implementing partners, donors and stakeholders engaged in TB laboratory strengthening
- Evidence
- Based on WHO consolidated guidelines on tuberculosis module 3 (2025) which used GRADE methodology, systematic reviews, and technical advisory group assessments for class-based and within-class product recommendations
- Reviewed
- 17 Oct 2026 · GMJ
What this guideline says
GMJ summary
This handbook consolidates for the first time WHO’s operational guidance on tests for TB diagnosis and TB infection into a single reference document. It provides practical implementation guidance for nine classes of WHO-recommended diagnostic tests covering more than 25 products, including newly established classes of low-complexity automated and manual nucleic acid amplification tests (NAATs), updated interferon-gamma release assays (IGRAs), and targeted next-generation sequencing (NGS) solutions for drug resistance detection.
The handbook details diagnostic algorithms for detection of TB disease with and without drug resistance, follow-on testing for multidrug-resistant TB (MDR-TB), and testing for TB infection to guide preventive treatment. Key updates include recommendations on concurrent testing strategies for people living with HIV and children, using combinations of respiratory samples, stool and urine to improve diagnostic yield in populations at highest risk of TB-associated mortality.
The document provides step-by-step guidance on implementing new diagnostic tests across ten implementation areas, placement of tests within tiered laboratory networks, quality assurance requirements, and model diagnostic algorithms that reflect current WHO recommendations for the BPaLM regimen and detection of resistance to bedaquiline, linezolid and fluoroquinolones.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Low-complexity automated NAATs (Xpert MTB/RIF Ultra, Truenat MTB Plus/MTB-RIF Dx) should be used as initial diagnostic tests for pulmonary TB rather than smear microscopy, with 90.4% sensitivity and 94.9% specificity for TB detection
- Concurrent testing is recommended for adults/adolescents with HIV using LC-aNAATs on respiratory samples plus LF-LAM on urine, and for children with HIV adding stool samples to respiratory and urine testing
- Targeted NGS may be used to detect resistance to rifampicin, isoniazid, fluoroquinolones, bedaquiline, linezolid, clofazimine, pyrazinamide, ethambutol, amikacin and streptomycin in people with rifampicin-resistant TB
- Critical concentrations for pretomanid DST are 0.5 mg/L and 2.0 mg/L using MGIT method; growth at 0.5 mg/L but not 2.0 mg/L is susceptible with interpretive uncertainty requiring close follow-up
- Critical concentration for cycloserine is 16 mg/L in MGIT media and may be used as surrogate for terizidone resistance
- Moderate-complexity automated NAATs detect TB with 93.0% sensitivity and resistance to both rifampicin (96.7% sensitivity) and isoniazid (86.4% sensitivity) in a single test
- Five IGRAs are now WHO-recommended for TB infection testing, including two new chemiluminescence-based assays (STANDARD E TB-Feron ELISA and LIAISON QFT-PLUS CLIA)
- Phenotypic DST on MGIT or 7H11 media is reliable for bedaquiline (CC 1.0 mg/L), linezolid (CC 1.0 mg/L) and clofazimine (CC 1.0 mg/L) and should be performed at treatment initiation for MDR/RR-TB
Critical concentrations for medicines recommended for treatment of MDR/RR-TB
Table extracted from the guideline
| Medicine | Löwenstein-Jensen (µg/mL) | Middlebrook 7H10 (µg/mL) | Middlebrook 7H11 (µg/mL) | BACTEC MGIT (µg/mL) |
|---|---|---|---|---|
| Levofloxacin (CC) | 2.0 | 1.0 | – | 1.0 |
| Moxifloxacin (CC) | 1.0 | 0.5 | 0.5 | 0.25 |
| Bedaquiline | – | – | 0.25 | 1.0 |
| Linezolid | – | 1.0 | 1.0 | 1.0 |
| Clofazimine | – | – | – | 1.0 |
| Cycloserine/terizidone | – | – | – | 16.0 |
| Delamanid | – | – | 0.016 | 0.06 |
| Pyrazinamide | – | – | – | 100.0 |
| Amikacin | 30.0 | 2.0 | – | 1.0 |
| Pretomanid | – | – | – | 0.5 and 2.0 |
Source: World Health Organization, Operational handbook on tuberculosis. Module 3: Diagnosis. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- First consolidation of operational guidance on TB diagnosis and TB infection testing into a single handbook
- Introduction of two new diagnostic classes: low-complexity automated NAATs (LC-aNAATs) and low-complexity manual NAATs (LC-mNAATs) for initial TB detection
- Addition of two new IGRAs to the class: STANDARD E TB-Feron ELISA (SD Biosensor) and LIAISON QFT-PLUS CLIA (Diasorin), introducing chemiluminescent detection method
- Updated AmPORE-TB targeted NGS solution now recommended for detection of resistance to three additional drugs: pyrazinamide, bedaquiline and clofazimine
- New WHO recommendations on concurrent testing for people living with HIV (respiratory samples plus LF-LAM) and children (respiratory and stool samples)
- Establishment of critical concentrations for pretomanid (0.5 and 2.0 mg/L) and cycloserine (16 mg/L) for phenotypic DST
- Algorithm 1 restructured into two parts: sample collection/initial testing pathways by population, and result interpretation pathways
- New Algorithm 2 specific to DST in settings with and without access to targeted NGS
- New quality assurance subsection specific to TB testing added to Section 3
From the guideline
Verbatim
“For adults and adolescents with signs or symptoms of TB or who screened positive for pulmonary TB, low-complexity automated NAATs should be used on respiratory samples as initial diagnostic tests for TB, rather than smear microscopy or culture.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and WHO consultant on health and migration, I recognise this handbook as essential for Georgia's TB programme, which notified 2,247 TB cases in 2023 with an estimated MDR-TB proportion of 11% among new cases. The most critical recommendation for Georgian clinicians is the implementation of concurrent testing for people living with HIV using both Xpert Ultra on sputum and LF-LAM on urine, given that co-infection significantly increases mortality risk and Georgia's universal HIV testing policy in TB clinics. Our National TB Reference Laboratory should prioritise establishing phenotypic DST capacity for bedaquiline and linezolid using the newly validated critical concentrations, as Georgia has been implementing BPaLM regimens since 2022 and baseline resistance surveillance is urgently needed. The realistic implementation caveat for the South Caucasus region is that while targeted NGS offers comprehensive resistance profiling, the requirement for high-speed internet connectivity, large data storage capacity and bioinformatics expertise may initially limit its placement to national or supranational reference laboratories rather than the decentralised model suggested, necessitating robust sample referral networks and digital connectivity investments before widespread deployment.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 17 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, this handbook is immediately applicable as the region continues to face high burdens of drug-resistant TB, particularly MDR-TB and pre-XDR-TB. Georgia’s national TB programme would benefit from implementing the concurrent testing recommendations for people living with HIV and the targeted NGS platforms for comprehensive drug resistance detection to support BPaLM regimen eligibility. The critical concentrations for bedaquiline, linezolid and pretomanid are essential for national reference laboratories in Armenia, Azerbaijan and Georgia as these countries scale up use of new TB regimens. The handbook’s emphasis on placing low-complexity automated NAATs at peripheral laboratory level aligns with ongoing decentralisation efforts in the region, while the updated IGRA class offers cost-effective options for TB infection testing in contact investigation and pre-treatment screening programmes that are priorities across the South Caucasus.
Questions this guideline answers
Quick answers
What is the difference between low-complexity and moderate-complexity automated NAATs?
Low-complexity automated NAATs (LC-aNAATs) like Xpert MTB/RIF Ultra require minimal pipetting (none or one step), basic technical skills, no precision pipetting, and can be used in basic laboratories. Moderate-complexity automated NAATs (MC-aNAATs) require multiple pipetting steps with possible precision pipetting, moderate technical skills, may need special infrastructure, but can simultaneously detect resistance to both rifampicin and isoniazid in one test with higher throughput (up to 94 samples per 8-hour shift versus 3-4 per module for LC-aNAATs).
When should concurrent testing be used instead of a single molecular test?
Concurrent testing is strongly recommended for adults and adolescents with HIV who have TB symptoms, screen positive for TB, are seriously ill (respiratory rate ≥30/min, temperature ≥39°C, heart rate ≥120/min, unable to walk unaided) or have advanced HIV disease (CD4 <200 cells/mm³). Use LC-aNAATs on respiratory samples plus LF-LAM on urine. For children with HIV, concurrent testing with LC-aNAATs on respiratory and stool samples plus LF-LAM on urine may be used. For children without HIV or unknown status, concurrent testing with LC-aNAATs on respiratory and stool samples should be used.
How should pretomanid DST results be interpreted when testing at two concentrations?
No growth at 0.5 mg/L = susceptible. Growth at 0.5 mg/L but no growth at 2.0 mg/L = susceptible with interpretive uncertainty (add comment to laboratory report; BPaL/BPaLM regimens may remain effective; close patient follow-up required; if poor response, consider regimen change). Growth at 2.0 mg/L = resistant. The interpretive uncertainty zone is important because Mtb lineage 1 isolates frequently have MICs of 0.5-2.0 mg/L, yet BPaL/M regimens appear to retain clinical efficacy in this range.
Which targeted NGS solutions can detect bedaquiline and linezolid resistance?
Two targeted NGS solutions are WHO-recommended for detection of bedaquiline and linezolid resistance in people with rifampicin-resistant TB: Deeplex Myc-TB (GenoScreen/Illumina) detects resistance to RIF, INH, PZA, EMB, FQ, BDQ, LZD, CFZ, AMK and STR. AmPORE-TB (Oxford Nanopore Technologies) now detects resistance to RIF, INH, PZA, FQ, BDQ, LZD, CFZ, AMK and STR following its 2025 update. Sensitivity for bedaquiline detection is 68% and for linezolid 69%, with specificity ≥95% for both drugs.
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- Issuer
- World Health Organization
- Type
- Handbook
- Edition
- 4th edition, 2025
- Replaces
- WHO operational handbook on tuberculosis. Module 3: diagnosis – rapid diagnostics for tuberculosis detection, 3rd edition, 2021 and Operational handbook on tuberculosis. Module 3: diagnosis – tests for tuberculosis infection, 2022
- Status
- Current
- Published
- 2025-08-05
- Languages
- English
- Scope
- Operational guidance for implementing WHO-recommended diagnostic tests for TB disease and TB infection, including placement in laboratory networks, quality assurance, and model diagnostic algorithms
- Audience
- National TB programme managers, laboratory managers, ministry of health officials, clinicians, implementing partners, donors and stakeholders engaged in TB laboratory strengthening
- Pages
- 182
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-011099-1
- Evidence
- Based on WHO consolidated guidelines on tuberculosis module 3 (2025) which used GRADE methodology, systematic reviews, and technical advisory group assessments for class-based and within-class product recommendations
- Next review
- Not specified; updates expected as new diagnostic products meet class criteria and undergo WHO prequalification
- Record history
- Created 17 Oct 2026 · updated 17 Oct 2026 · next check Apr 2027
World Health Organization. WHO operational handbook on tuberculosis. Module 3: diagnosis. Geneva: World Health Organization; 2025. 182 p. Licence: CC BY-NC-SA 3.0 IGO. ISBN 978-92-4-011099-1.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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