‘A double-edged sword’: Perceived benefits and harms of active case-finding for people with presumptive tuberculosis and communities—A qualitative study based on expert interviews

Background Active case-finding (ACF), also referred to as community-based tuberculosis screening, is a component of the World Health Organization’s End TB Strategy. ACF has potential benefits but also harms, which need to be carefully assessed when developing and implementing ACF policies. While empirical evidence on the benefits of ACF is still weak, evidence on the harms is even weaker. This study aimed to explore experts’ views on the benefits and harms of ACF for people with presumptive TB and communities. Methods This was an exploratory study. Semi-structured interviews were conducted with a purposive sample of 39 experts from international, non-governmental/non-profit organizations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. Framework analysis was applied. Results Findings elaborated perceived benefits of ACF, including reaching vulnerable populations, reducing patient costs, helping raise awareness for tuberculosis among individuals and engaging communities, and reducing tuberculosis transmission. Perceived harms included increasing stigma and discrimination, causing false-positive diagnoses, as well as triggering other unintended consequences related to screening for tuberculosis patients, such as deportation of migrants once confirmed to have tuberculosis. Most of the perceived benefits of ACF could be linked to its objective of finding and treating persons with tuberculosis early (theme 1), while ACF was also perceived as a “double-edged sword” and could cause harms, if inappropriately designed and implemented (theme 2). The analysis underlined the importance of considering the benefits and harms of ACF throughout the screening pathway. The study provides new insights into the perceived benefits and harms of ACF from the perspectives of experts in the field. Conclusion This study highlights gaps in the evidence base surrounding ACF and can stimulate further research, debate and analysis regarding the benefits and harms of ACF to inform contextual optimization of design and implementation of ACF strategies.

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The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal

Infectious Diseases of Poverty ◽

10.1186/s40249-019-0603-z ◽

2019 ◽

Vol 8 (1) ◽

Cited By ~ 7

Author(s):

Suman Chandra Gurung ◽

Kritika Dixit ◽

Bhola Rai ◽

Maxine Caws ◽

Puskar Raj Paudel ◽

...

Keyword(s):

Social Protection ◽

Case Finding ◽

World Health ◽

Active Case Finding ◽

Annual Household Income ◽

Chi Square ◽

Active Case ◽

Pre Treatment ◽

Health Organization

Abstract Background The World Health Organization (WHO) End TB Strategy has established a milestone to reduce the number of tuberculosis (TB)- affected households facing catastrophic costs to zero by 2020. The role of active case finding (ACF) in reducing patient costs has not been determined globally. This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding (PCF), and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal. Methods The study was conducted in two districts of Nepal: Bardiya and Pyuthan (Province No. 5) between June and August 2018. One hundred patients were included in this study in a 1:1 ratio (PCF: ACF, 25 consecutive ACF and 25 consecutive PCF patients in each district). The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs. Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20% of their annual household income. The intensity of catastrophic costs was calculated using the positive overshoot method. The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs. Meanwhile, the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis. Results Ninety-nine patients were interviewed (50 ACF and 49 PCF). Patients diagnosed through ACF incurred lower costs during the pre-treatment period (direct medical: USD 14 vs USD 32, P = 0.001; direct non-medical: USD 3 vs USD 10, P = 0.004; indirect, time loss: USD 4 vs USD 13, P < 0.001). The cost of the pre-treatment and intensive phases combined was also lower for direct medical (USD 15 vs USD 34, P = 0.002) and non-medical (USD 30 vs USD 54, P = 0.022) costs among ACF patients. The prevalence of catastrophic direct costs was lower for ACF patients for all thresholds. A lower intensity of catastrophic costs was also documented for ACF patients, although the difference was not statistically significant. Conclusions ACF can reduce patient-incurred costs substantially, contributing to the End TB Strategy target. Other synergistic policies, such as social protection, will also need to be implemented to reduce catastrophic costs to zero among TB-affected households.

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Tuberculosis screening in high human immunodeficiency virus prevalence settings: turning promise into reality [State of the art series. Active case finding/screening. Number 5 in the series]

The International Journal of Tuberculosis and Lung Disease ◽

10.5588/ijtld.13.0117 ◽

2013 ◽

Vol 17 (9) ◽

pp. 1125-1138 ◽

Cited By ~ 22

Author(s):

E. L. Corbett ◽

P. MacPherson

Keyword(s):

Human Immunodeficiency Virus ◽

State Of The Art ◽

Case Finding ◽

Human Immunodeficiency Virus Prevalence ◽

Active Case Finding ◽

Tuberculosis Screening ◽

Active Case ◽

Virus Prevalence ◽

Immunodeficiency Virus

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Active Case Finding for Improved Ebola Virus Disease Case Detection in Nimba County, Liberia, 2014/2015: Lessons Learned

Advances in Public Health ◽

10.1155/2018/6753519 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 4

Author(s):

E. Namukose ◽

C. Bowah ◽

I. Cole ◽

G. Dahn ◽

P. Nyanzee ◽

...

Keyword(s):

Ebola Virus ◽

Health Workers ◽

Virus Disease ◽

Case Finding ◽

Lessons Learned ◽

Ebola Virus Disease ◽

World Health ◽

Case Detection ◽

Active Case Finding ◽

Active Case

Objectives. Early case detection and isolation of patients infected with highly infectious diseases are crucial in the management and control of epidemics such as Ebola Virus Disease (EVD). In this paper, we share the lessons learned from implementation of active case finding as a strategy for improved EVD case detection in Nimba County, Liberia. Methods. We adopted the World Health Organization (WHO) active surveillance strategy to identify and report suspected EVD cases, follow up contacts of confirmed cases, and report community deaths. We identified, trained, and deployed 1060 Community Health Volunteers (CHVs) in 718 communities in Nimba County. The CHVs were supervised by 142 health workers within their catchment area. The health workers were supervised by the District Health Officers (DHOs). The DHOs reported to the County Health Team (CHT) who provided supportive supervision. Data collection was based on the EVD contact tracing and active case finding forms adopted from WHO. Data analysis was based on epi-weeks. Results. The number of EVD suspected cases increased by more than 75% following the initiation of active case finding. Average duration between symptom onset and case detection reduced from between three and five days to within 24 hours. Collection of oral swabs from dead bodies increased from two to 15 within the first week of active case finding strategy implementation. Reporting of other IDSR priority diseases and conditions also improved. Conclusion. Active case finding strategy in Nimba increased suspected EVD case detection and reduced the duration between onset of symptoms and detection of cases.

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Examining the sensitivity of the surveillance system to detect TB cases in Afghanistan

10.21203/rs.3.rs-46734/v1 ◽

2020 ◽

Author(s):

Naqibullah Hamdard ◽

Alim Atarud ◽

Khalid Seddiq ◽

Anwar Hanif

Keyword(s):

Health Care ◽

Primary Health Care ◽

High Risk ◽

Surveillance System ◽

Risk Groups ◽

Case Finding ◽

World Health ◽

Active Case Finding ◽

Active Case ◽

Primary Health

Abstract BackgroundTuberculosis (TB) remains a global public health threat. World Health Organization (WHO) End TB strategy recommends that effective TB control relies on general health systems, especially, on integrated and well-functioning PHC facilities. Despite, integration in Basic Package of Health Services (BPHS), evidence demonstrates that a large number of TB cases are not captured. 25000 TB cases are missed every year (Aloudal, 2015). 49% of individuals, recorded at health facilities as presumptive to have TB have not been screened (HMIS, 2016). This study intended to evaluate different dimensions of TB surveillance system and the Primary Health Care (PHC) facilities' role in TB active case finding. MethodsWe conducted a cross-sectional study. The study was implemented in eleven provinces of Afghanistan in from August to November 2016. The geographic and demographic representativeness determined the choice of provinces. All primary health care facilities in studied provinces equated to 870, therefore, considering a 95 % confidence interval, a sample size of 161 facilities established the sample frame. A stratified sampling strategy facilitated the selection of sampled facilities within different categories from an inclusive list of all facilities.ResultsThe study found that the overall sensitivity of TB surveillance systems in-country is 56.30 %. This means that 43.70 % of 171 TB cases had remained undetected. 43.81 % of studies facilities used at least one accepted active case finding strategy while 56.20 % implemented none. In studied areas, 83.33 % of 11 studied DHs and 69.57 % of 35 studied CHCs had a referral system for MDR-TB patients.ConclusionTo enhance sensitivity and boost case findings, it is essential to implement case-finding strategies targeted at high-risk groups in specific areas. The high-risk groups include IDPs, returnees, slum residents, prisoners, and addicts. Additionally, it is necessary to train private pharmacists and traditional healers to identify and refer individuals with TB symptoms for follow up and further evaluation at the PHC level.

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How much is tuberculosis screening worth? Estimating the value of active case finding for tuberculosis in South Africa, China, and India

BMC Medicine ◽

10.1186/s12916-014-0216-0 ◽

2014 ◽

Vol 12 (1) ◽

Cited By ~ 42

Author(s):

Andrew S Azman ◽

Jonathan E Golub ◽

David W Dowdy

Keyword(s):

South Africa ◽

Case Finding ◽

Active Case Finding ◽

Tuberculosis Screening ◽

Active Case ◽

China And India

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Identifying TB hotspots through mobile X-rays in Karachi, Pakistan: spatial analysis of data from an active case-finding program

10.21203/rs.3.rs-621306/v1 ◽

2021 ◽

Author(s):

Syed Mohammad Asad Zaidi ◽

Wafa Zehra Jamal ◽

Christina Mergenthaler ◽

Kiran Sohail Azeemi ◽

Nick Van Den Berge ◽

...

Keyword(s):

Cost Effectiveness ◽

Spatial Autocorrelation ◽

Case Finding ◽

World Health ◽

Moran’S I ◽

X Rays ◽

Active Case Finding ◽

Moran's I ◽

X Ray ◽

Active Case

Abstract IntroductionTuberculosis (TB) is the leading cause of avoidable deaths from an infectious disease globally and a large of number of people who develop TB each year remain undiagnosed. Active case-finding has been recommended by the World Health Organization to bridge the case-detection gap for TB in high burden countries. However, concerns remain regarding their yield and cost-effectiveness. MethodsData from mobile chest X-ray (CXR) supported active case-finding community camps conducted in Karachi, Pakistan from July 2017- March 2020 was retrospectively analyzed. After a CXR screening supported by computer-aided detection, those with presumptive TB were counselled to submit a sputum sample for Xpert MTB/RIF testing. Frequency analysis was carried out at the camp-level and outcomes of interest for the spatial analyses were mycobacterium TB positivity (MTB+) and X-ray abnormality ratios. The Moran’s I statistic was used to test for spatial autocorrelation for MTB+ and abnormal X-rays within Union Councils (UCs) in Karachi. Local Indicators of Spatial Autocorrelation analyses were performed for UCs within Karachi. Point-pattern analyses were carried out utilizing GPS coordinates recorded at the camp sites and were analyzed for spatial autocorrelation using Getis Ord Star tests.ResultsA total of 1,161 (78.1%) camps yielded no MTB+ cases, 246 (16.5%) camps yielded 1 MTB+, 52 (3.5%) camps yielded 2 MTB+ and 27 (1.8%) yielded 3 or more MTB+. A total of 79 (5.3%) camps accounted for 193 (44.0%) of MTB+ cases detected. Statistically significant clustering for MTB positivity (Moran’s I: 0.09) and abnormal chest X-rays (Moran’s I: 0.36) ratios was identified within UCs in Karachi. Clustering of UCs with high MTB positivity were identified in Karachi West district. Clusters of camp locations with high MTB+ ratios were identified in Karachi South and Karachi West districts and in several locations in the north and eastern peripheries of the city. ConclusionStatistically significant spatial variation was identified in yield of bacteriologically positive TB cases and in abnormal CXR through active case-finding in Karachi. Cost-effectiveness of active case-finding programs can be improved by identifying and focusing interventions in hotspots and avoiding locations with no known TB cases reported through routine surveillance.

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