Tuberculosis prevalence among children with severe acute malnutrition: a systematic review and meta-analysis

Introduction: Control of tuberculosis (TB) in children remains a major challenge globally. There is growing recognition that children with severe acute malnutrition (SAM) are a high-risk population for TB, but the global burden of TB in this group has never been comprehensively quantified. Methods: We conducted a systematic review and meta-analysis to estimate the prevalence of TB among children with SAM. Following PRISMA guidelines, we searched PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and WHO Global Index Medicus from database inception to June 15, 2026. We included studies reporting TB among systematically sampled cohorts of children <15 years with SAM as defined by the World Health Organization. Methodological study quality was assessed with adapted versions of the Newcastle-Ottawa Scale or the Joanna Briggs Institute critical appraisal checklist. Pooled TB prevalence was calculated using a random-effects model with predefined stratification of studies by geographic region, national TB incidence, and study quality. We also conducted subgroup analyses by age, sex, HIV status, SAM type, and TB exposure. Results: We included 73 studies comprising 33,869 children with SAM across 15 countries, predominantly from sub-Saharan Africa and South Asia, and predominantly reporting on hospitalized children. The pooled TB prevalence was 13% (95% CI: 11-16%), but there was substantial heterogeneity (I2=98%). Studies conducted in Southern Africa had the highest pooled TB prevalence (36%, 95% CI: 19-56%) compared to other regions (p<0.01). Pooled TB prevalence was higher in those with history of TB household exposure compared to those without (74% vs. 17%, p=0.01). Conclusions: Approximately one in eight children hospitalized with SAM have TB, greatest among children with history of TB exposure and those in Southern Africa. These findings highlight opportunities for improved early TB diagnosis and routine, integrated TB screening within hospital-based SAM care pathways.