Active Community-Based Case Finding for Tuberculosis With Limited Resources.
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ABSTRACT:
SUBMITTER: Karki B
PROVIDER: S-EPMC5349312 | biostudies-literature | 2017 Jan
REPOSITORIES: biostudies-literature
Publications
Active Community-Based Case Finding for Tuberculosis With Limited Resources.
Karki Bindu B Kittel Guenter G Bolokon Ignatius I Duke Trevor T
Asia-Pacific journal of public health 20161229 1
Papua New Guinea is one of the 14 highest-burden countries for tuberculosis (TB) infection, but few community-based studies exist. We evaluated a low-cost method of active community case finding in Kabwum and Wasu in Morobe Province, Papua New Guinea. Over 3 months we visited 26 villages and screened adults and children for symptoms and signs of TB. Sputum samples were examined using smear microscopy. A total of 1700 people had chronic symptoms, of which 267 were suspicious for TB on further exa ...[more]
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Project description:BackgroundCommunity-based active case-finding interventions might identify and treat more people with tuberculosis disease than standard case detection. We aimed to assess whether active case-finding interventions can affect tuberculosis epidemiology in the wider community.MethodsWe did a systematic review by searching PubMed, Embase, Scopus, and Cochrane Library for studies that compared tuberculosis case notification rates, tuberculosis disease prevalence, or tuberculosis infection prevalence or incidence in children, between populations exposed and unexposed to active case-finding interventions. We included studies published in English between Jan 1, 1980, and April 13, 2020. Studies of active case-finding in the general population, in populations perceived to be at high risk for tuberculosis, and in closed settings were included, whereas studies of tuberculosis screening at health-care facilities, among household contacts, or among children only, and studies that screened fewer than 1000 people were excluded. To estimate effectiveness, we extracted or calculated case notification rates, prevalence of tuberculosis disease, and incidence or prevalence of tuberculosis infection in children, and compared ratios of these outcomes between groups that were exposed or not exposed to active case-finding interventions.Results27 883 abstracts were screened and 988 articles underwent full text review. 28 studies contributed data for analysis of tuberculosis case notifications, nine for prevalence of tuberculosis disease, and two for incidence or prevalence of tuberculosis infection in children. In one cluster-randomised trial in South Africa and Zambia, an active case-finding intervention based on community mobilisation and sputum drop-off did not affect tuberculosis prevalence, whereas, in a cluster-randomised trial in Vietnam, an active case-finding intervention based on sputum tuberculosis tests for everyone reduced tuberculosis prevalence in the community. We found inconsistent, low-quality evidence that active case-finding might increase the number of cases of tuberculosis notified in populations with structural risk factors for tuberculosis.InterpretationCommunity-based active case-finding for tuberculosis might be effective in changing tuberculosis epidemiology and thereby improving population health if delivered with high coverage and intensity. If possible, active case-finding projects should incorporate a well designed, robust evaluation to contribute to the evidence base and help elucidate which delivery methods and diagnostic strategies are most effective.FundingWHO Global TB Programme.
| S-EPMC8082281 | biostudies-literature
Project description:BackgroundThe barriers to access diagnosis and receive treatment, in addition to insufficient case identification and reporting, lead to tuberculosis (TB) spreads in communities, especially among hard-to-reach populations. This study evaluated a community-based active case finding (ACF) strategy for the detection of tuberculosis cases among high-risk groups and general population in China between 2013 and 2015.MethodsThis retrospective cohort study conducted an ACF in ten communities of Dongchuan County, located in northeast Yunnan Province between 2013 and 2015; and compared to 136 communities that had passive case finding (PCF). The algorithm for ACF was: 1) screen for TB symptoms among community enrolled residents by home visits, 2) those with positive symptoms along with defined high-risk groups underwent chest X-ray (CXR), followed by sputum microscopy confirmation. TB incidence proportion and the number needed to screen (NNS) to detect one case were calculated to evaluate the ACF strategy compared to PCF, chi-square test was applied to compare the incidence proportion of TB cases' demography and the characteristics for detected cases under different strategies. Thereafter, the incidence rate ratio (IRR) and multiple Fisher's exact test were applied to compare the incidence proportion between general population and high-risk groups. Patient and diagnostic delays for ACF and PCF were compared by Wilcoxon rank sum test.ResultsA total of 97?521 enrolled residents were visited with the ACF cumulatively, 12.3% were defined as high-risk groups or had TB symptoms. Sixty-six new TB patients were detected by ACF. There was no significant difference between the cumulative TB incidence proportion for ACF (67.7/100000 population) and the prevalence for PCF (62.6/100000 population) during 2013 to 2015, though the incidence proportion in ACF communities decreased after three rounds active screening, concurrent with the remained stable prevalence in PCF communities. The cumulative NNS were 34, 39 and 29 in HIV/AIDS infected individuals, people with positive TB symptoms and history of previous TB, respectively, compared to 1478 in the general population. The median patient delay under ACF was 1 day (Interquartile range, IQR: 0-27) compared to PCF with 30?days (IQR: 14-61).ConclusionsThis study confirmed that massive ACF was not effective in general population in a moderate TB prevalence setting. The priority should be the definition and targeting of high-risk groups in the community before the screening process is launched. The shorter time interval of ACF between TB symptoms onset and linkage to healthcare service may decrease the risk of TB community transmission. Furthermore, integrated ACF strategy in the National Project of Basic Public Health Service may have long term public health impact.
| S-EPMC6819334 | biostudies-literature
Project description:Active case-finding (ACF) for tuberculosis can help find the "missing millions" with undiagnosed tuberculosis. In a cluster-randomised trial, we investigated impact of ACF on case-notifications in Blantyre, Malawi, where ACF has been intensively implemented following 2014 estimates of ~1,000 per 100,000 adults with undiagnosed TB. Following a pre-intervention prevalence survey (May 2019 to March 2020), constrained randomisation allocated neighbourhoods to either door-to-door ACF (sputum microscopy for reported cough >2 weeks) or standard-of-care (SOC). Implementation was interrupted by COVID-19. Cluster-level bacteriologically-confirmed case-notification rate (CNR) ratio within 91 days of ACF was our redefined primary outcome; comparison between arms used Poisson regression with random effects. Secondary outcomes were 91-day CNR ratios comparing all tuberculosis registrations and all non-ACF registrations. Interrupted time series (ITS) analysis of CNRs in the SOC arm examined prevalence survey impact. (ISRCTN11400592). 72 clusters served by 10 study-supported tuberculosis registration centres were randomised to ACF (261,244 adults, 58,944 person-years follow-up) or SOC (256,713 adults, 52,805 person-years). Of 1,192 ACF participants, 13 (1.09%) were smear-positive. Within 91 days, 113 (42 bacteriologically-confirmed) and 108 (33 bacteriologically-confirmed) tuberculosis patients were identified as ACF or SOC cluster residents, respectively. There was no difference by arm, with adjusted 91-day CNR ratios 1.12 (95% CI: 0.61-2.07) for bacteriologically-confirmed tuberculosis; 0.93 (95% CI: 0.68-1.28) for all tuberculosis registrations; and 0.86 (95%CI: 0.63-1.16) for non-ACF (routinely) diagnosed. Of 7,905 ACF and 7,992 SOC pre-intervention survey participants, 12 (0.15%) and 17 (0.21%), respectively, had culture/Xpert-confirmed tuberculosis. ITS analysis showed no survey impact on SOC CNRs. Despite residual undiagnosed tuberculosis of 150 per 100,000 population, there was no increase in tuberculosis notifications from this previously successful approach targeting symptomatic disease, likely due to previous TB ACF and rapid declines in TB burden. In such settings, future ACF should focus on targeted outreach and demand creation, alongside optimised facility-based screening. Trial Registration: ISRCTN11400592.
| S-EPMC10697577 | biostudies-literature
Project description:This study aimed to estimate the costs and incremental cost-effectiveness of two community-based tuberculosis (TB) active case-finding (ACF) strategies in Cambodia. We also assessed the number needed to screen and test to find one TB case. Program and national TB notification data from a quasi-experimental study of a cohort of people with TB in 12 intervention operational districts (ODs) and 12 control ODs between November 2018 and December 2019 were analyzed. Two ACF interventions (ACF seed-and-recruit (ACF SAR) model and one-off roving (one-off) ACF) were implemented concurrently. The matched control sites included PCF only. We estimated costs using the program and published data in Cambodia. The primary outcome was disability-adjusted life years (DALY) averted over 14 months. We considered the gross domestic product per capita of Cambodia in 2018 as the cost-effectiveness threshold. ACF SAR needed to test 7.7 people with presumptive TB to identify one all-forms TB, while one-off ACF needed to test 22.4. The costs to diagnose one all-forms TB were USD 458 (ACF SAR) and USD 191 (one-off ACF). The incremental cost per DALY averted was USD 257 for ACF SAR and USD 204 for one-off ACF. Community-based ACF interventions that targeted key populations for TB in Cambodia were highly cost-effective.
| S-EPMC8656683 | biostudies-literature
Project description:IntroductionCase detection by passive case finding (PCF) strategy alone is inadequate for detecting all tuberculosis (TB) cases in high burden settings especially Sub-Saharan Africa. Alternative case detection strategies such as community Active Case Finding (ACF) and Household Contact Investigations (HCI) are effective but empirical evidence of their cost-effectiveness is sparse. The objective of this study was to determine whether adding ACF or HCI compared with standard PCF alone represent cost-effective alternative TB case detection strategies in urban Africa.MethodsA static decision modeling framework was used to examine the costs and effectiveness of three TB case detection strategies: PCF alone, PCF+ACF, and PCF+HCI. Probability and cost estimates were obtained from National TB program data, primary studies conducted in Uganda, published literature and expert opinions. The analysis was performed from the societal and provider perspectives over a 1.5 year time-frame. The main effectiveness measure was the number of true TB cases detected and the outcome was incremental cost-effectiveness ratios (ICERs) expressed as cost in 2013 US$ per additional true TB case detected.ResultsCompared to PCF alone, the PCF+HCI strategy was cost-effective at US$443.62 per additional TB case detected. However, PCF+ACF was not cost-effective at US$1492.95 per additional TB case detected. Sensitivity analyses showed that PCF+ACF would be cost-effective if the prevalence of chronic cough in the population screened by ACF increased 10-fold from 4% to 40% and if the program costs for ACF were reduced by 50%.ConclusionsUnder our baseline assumptions, the addition of HCI to an existing PCF program presented a more cost-effective strategy than the addition of ACF in the context of an African city. Therefore, implementation of household contact investigations as a part of the recommended TB control strategy should be prioritized.
| S-EPMC4319733 | biostudies-literature
Project description:IntroductionSocial trust is an important driver of health seeking behaviours and plays a particularly important role for diseases that have a high degree of stigma associated with them, such as tuberculosis (TB). Individuals experiencing poverty also face additional social and financial barriers in accessing care for TB. We examined an active case finding (ACF) initiative embedded in a program targeting those living in poverty (Transform) implemented by International Care Ministries (ICM), a Philippine-based non-governmental organization (NGO), and analyzed how different forms of social trust may affect the initial uptake of ACF.MethodsProgram monitoring data and a cross-sectional survey conducted at the beginning of Transform included six dimensions of social trust: satisfaction with family life, satisfaction with friendships, and level of trust in relatives, neighbours, pastor or religious leader, and local government officials. Amongst individuals suspected of having TB who received referrals post-screening, multilevel modelling examined the effects of social trust on rural health unit (RHU) attendance.ResultsAmong the subset of 3350 individuals who received TB screening in 51 communities, 889 (26.5%) were symptom positive and required referral to the RHU, but only 24.1% of those who received referrals successfully attended the RHU. Multilevel regression analysis showed that for each unit increase on the Likert scale in baseline level of family satisfaction and level of trust in relatives, the odds of attending an RHU was 1.03 times (95% CI: 0.99, 1.07) and 1.06 times greater (95% CI: 1.00, 1.11), respectively, independent of other factors.ConclusionThese results suggest that social trust in family members could play a valuable role in addressing stigma and rejection, both cited as barriers to higher screening rates. It is recommended that ACF programs that target TB, or other diseases that are stigmatized, prioritize trust-building as an important component of their intervention.
| S-EPMC7522854 | biostudies-literature
Project description:Intensive case finding is endorsed for tuberculosis (TB) control in high-risk populations. Novel case-finding strategies are needed in hard-to-reach rural populations with high prevalence of TB and human immunodeficiency virus (HIV).We performed community-based integrated HIV and TB intensive case finding in a rural South African subdistrict from March 2010 to June 2012. We offered TB symptom screening, sputum collection for microbiologic diagnosis, rapid fingerstick HIV testing, and phlebotomy for CD4 cell count. We recorded number of cases detected and calculated population-level rates and number needed to screen (NNS) for drug-susceptible and -resistant TB.Among 5615 persons screened for TB at 322 community sites, 91.2% accepted concurrent HIV testing, identifying 510 (9.9%) HIV-positive individuals with median CD4 count of 382 cells/mm3 (interquartile range = 260-552). Tuberculosis symptoms were reported by 2049 (36.4%), and sputum was provided by 1033 (18.4%). Forty-one (4.0%) cases of microbiologically confirmed TB were detected for an overall case notification rate of 730/100000 (NNS = 137); 11 (28.6%) were multidrug-resistant or extensively drug-resistant TB. Only 5 (12.2%) TB cases were HIV positive compared with an HIV coinfection rate of 64% among contemporaneously registered TB cases (P = .001).Community-based integrated intensive case finding is feasible and is high yield for drug-susceptible and -resistant TB and HIV in rural South Africa. Human immunodeficiency virus-negative tuberculosis predominated in this community sample, suggesting a distinct TB epidemiology compared with cases diagnosed in healthcare facilities. Increasing HIV/TB integrated community-based efforts and other strategies directed at both HIV-positive and HIV-negative tuberculosis may contribute to TB elimination in high TB/HIV burden regions.
| S-EPMC5499582 | biostudies-other
Project description:BackgroundThere is a need to identify scalable tuberculosis screening strategies among high burden populations. The WHO has identified a non-sputum-based triage test as a development priority.MethodsWe performed a diagnostic case-control study of point-of-care C-reactive protein (CRP) and Prototype-Xpert-MTB-Host-Response (Xpert-MTB-HR) assays in the context of a mass screening program for tuberculosis in two prisons in Brazil. All incarcerated individuals irrespective of symptoms were screened by sputum Xpert MTB/RIF and sputum culture. Among consecutive, Xpert MTB/RIF or culture-confirmed cases and Xpert MTB/RIF and culture-negative controls, CRP was quantified in serum by a point-of-care assay (iChroma-II) and a 3-gene expression score was quantified from whole blood using the Xpert-MTB-HR cartridge. We evaluated receiver operating characteristic area under the curve (AUC) and assessed specificity at 90% sensitivity and sensitivity at 70% specificity, consistent with WHO target product profile (TPP) benchmarks.FindingsTwo hundred controls (no TB) and 100 culture- or Xpert MTB/RIF-positive tuberculosis cases were included. Half of tuberculosis cases and 11% of controls reported any tuberculosis symptoms. AUC for CRP was 0·79 (95% CI: 0·73-0·84) and for Xpert-MTB-HR was 0·84 (95% CI: 0·79-0·89). At 90% sensitivity, Xpert-MTB-HR had significantly higher specificity (53·0%, 95% CI: 45·0-69·0%) than CRP (28·1%, 95% CI: 20·2-41·8%) (p = 0·003), both well below the TPP benchmark of 70%. Among individuals with medium or high sputum Xpert MTB/RIF semi-quantitative load, sensitivity (at 70% specificity) of CRP (90·3%, 95% CI: 74·2-98·0) and Xpert-MTB-HR (96·8%, 95% CI: 83·3-99·9%) was higher.InterpretationFor active case finding in this high tuberculosis-burden setting, CRP and Xpert-MTB-HR did not meet TPP benchmarks for a triage test. However, Xpert-MTB-HR was highly sensitive in detecting individuals with medium or high sputum bacillary burden.FundingNational Institutes of Health (R01 AI130058 and R01 AI149620) and Brazilian National Council for Scientific and Technological Development (CNPq-404182/2019-4).
| S-EPMC8020164 | biostudies-literature
Project description:IntroductionIn high-burden settings, low-complexity screening tests for tuberculosis (TB) could expand the reach of community-based case-finding efforts. The potential costs and cost-effectiveness of approaches incorporating these tests are poorly understood.MethodsWe developed a microsimulation model assessing 3 approaches to community-based case-finding in hypothetical populations (India-, South Africa-, The Philippines-, Uganda-, and Vietnam-like settings) with TB prevalence 4 times that of national estimates: (1) screening with a point-of-care C-reactive protein (CRP) test, (2) screening with a more sensitive "Hypothetical Screening test" (95% sensitive for Xpert Ultra-positive TB, 70% specificity; equipment/labor costs similar to Xpert Ultra, but using a $2 cartridge) followed by sputum Xpert Ultra if positive, or (3) testing all individuals with sputum Xpert Ultra. Costs are expressed in 2023 US dollars and include treatment costs.ResultsUniversal Xpert Ultra was estimated to cost a mean $4.0 million (95% uncertainty range: $3.5 to $4.6 million) and avert 3200 (2600 to 3900) TB-related disability-adjusted life years (DALYs) per 100 000 people screened ($670 [The Philippines] to $2000 [Vietnam] per DALY averted). CRP was projected to cost $550 (The Philippines) to $1500 (Vietnam) per DALY averted but with 44% fewer DALYs averted. The Hypothetical Screening test showed minimal benefit compared to universal Xpert Ultra, but if specificity were improved to 95% and per-test cost to $4.5 (all-inclusive), this strategy could cost $390 (The Philippines) to $940 (Vietnam) per DALY averted.ConclusionsScreening tests can meaningfully improve the cost-effectiveness of community-based case-finding for TB but only if they are sensitive, specific, and inexpensive.
| S-EPMC10810711 | biostudies-literature
Project description:BackgroundWhile community-based active case finding (ACF) for tuberculosis (TB) holds promise for increasing early case detection among hard-to-reach populations, limited data exist on the acceptability of active screening. We aimed to identify barriers and explore facilitators on the pathway from diagnosis to care among TB patients and health providers.MethodsMixed-methods study. We administered a survey questionnaire to, and performed in-depth interviews with, TB patients identified through ACF from poor urban settlements in Phnom Penh, Cambodia. Additionally, we conducted focus group discussions and in-depth interviews with community and public health providers involved in ACF, respectively.ResultsAcceptance of home TB screening was strong among key stakeholders due to perceived reductions in access barriers and in direct and indirect patient costs. Privacy and stigma were not an issue. To build trust and facilitate communication, the participation of community representatives alongside health workers was preferred. Most health providers saw ACF as complementary to existing TB services; however, additional workload as a result of ACF was perceived as straining operating capacity at public sector sites. Proximity to a health facility and disease severity were the strongest determinants of prompt care-seeking. The main reasons reported for delays in treatment-seeking were non-acceptance of diagnosis, high indirect costs related to lost income/productivity and transportation expenses, and anticipated side-effects from TB drugs.ConclusionsTB patients and health providers considered home-based ACF complementary to facility-based TB screening. Strong engagement with community representatives was believed critical in gaining access to high risk communities. The main barriers to prompt treatment uptake in ACF were refusal of diagnosis, high indirect costs, and anticipated treatment side-effects. A patient-centred approach and community involvement were essential in mitigating barriers to care in marginalised communities.
| S-EPMC4519312 | biostudies-literature