Screening for Tuberculosis Infection in Rheumatology Practice: An Update

Background: India carries one of the world’s highest tuberculosis burdens, with nearly one-fourth of adults estimated to harbour tuberculosis infection (TBI). Consequently, patients with systemic inflammatory rheumatic diseases (SIRDs) receiving biological disease-modifying antirheumatic drugs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs) are at significant risk of reactivation. The World Health Organization (WHO) has recently revised terminology; ‘latent TB infection’ (LTBI) is now termed TBI , while active disease continues as TB disease . Accordingly, WHO and India’s National TB Elimination Programme (NTEP) have updated TBI screening recommendations. Objective: This article provides India-specific clinical guidance for TBI screening before initiating b/tsdmards, considering high TB prevalence, universal Bacille Calmette-Guérin (BCG) vaccination, and limited national resources. Methods: This article summarises NTEP-endorsed screening tools-tuberculin skin test (TST), interferon-gamma release assays (IGRAs), chest radiography, and the newer Cy-Tb test-evaluating their performance, strengths, and limitations in immunomodulated patients. Results: TST remains inexpensive and accessible but is confounded by BCG-induced false positives and reduced sensitivity in immunosuppressed individuals. IGRAs offer greater specificity and single-visit convenience but are costly and infrastructure-dependent. Chest radiography remains essential to exclude active or prior TB. Emerging Indian data support Cy-Tb as a promising alternative. A tiered approach is recommended: (a) TST + chest X-ray in resource-limited settings; (b) IGRA alone in moderately resourced clinics; and (c) combined TST + IGRA + X-ray in tertiary centres or high-risk cases. Conclusion: Mandatory, resource-sensitive TBI screening before b/ts-DMARD therapy provides a practical, evidence-based strategy to prevent TB reactivation in Indian SIRD patients.