Active Case Finding for Tuberculosis in India: A Syntheses of Activities and Outcomes Reported by the National Tuberculosis Elimination Programme.

Sharath Burugina Nagaraja,Srinath Satyanarayana,Karuna D. Sagili,Kuldeep Singh Sachdeva,Prathap Tharyan,Jamhoih Tonsing,Raghuram Rao,Pruthu Thekkur

doi:10.3390/tropicalmed6040206

Abstract

India launched a national community-based active TB case finding (ACF) campaign in 2017 as part of the strategic plan of the National Tuberculosis Elimination Programme (NTEP). This review evaluated the outcomes for the components of the ACF campaign against the NTEP’s minimum indicators and elicited the challenges faced in implementation. We supplemented data from completed pretested data proformas returned by ACF programme managers from nine states and two union territories (for 2017–2019) and five implementing partner agencies (2013–2020), with summary national data on the state-wise ACF outcomes for 2018–2020 published in annual reports by the NTEP. The data revealed variations in the strategies used to map and screen vulnerable populations and the diagnostic algorithms used across the states and union territories. National data were unavailable to assess whether the NTEP indicators for the minimum proportions identified with presumptive TB among those screened (5%), those with presumptive TB undergoing diagnostic tests (>95%), the minimum sputum smear positivity rate (2% to 3%), those with negative sputum smears tested with chest X-rays or CBNAAT (>95%) and those diagnosed through ACF initiated on anti-TB treatment (>95%) were fulfilled. Only 30% (10/33) of the states in 2018, 23% (7/31) in 2019 and 21% (7/34) in 2020 met the NTEP expectation that 5% of those tested through ACF would be diagnosed with TB (all forms). The number needed to screen to diagnose one person with TB (NNS) was not included among the NTEP’s programme indicators. This rough indicator of the efficiency of ACF varied considerably across the states and union territories. The median NNS in 2018 was 2080 (interquartile range or IQR 517–4068). In 2019, the NNS was 2468 (IQR 1050–7924), and in 2020, the NNS was 906 (IQR 108–6550). The data consistently revealed that the states that tested a greater proportion of those screened during ACF and used chest X-rays or CBNAAT (or both) to diagnose TB had a higher diagnostic yield with a lower NNS. Many implementation challenges, related to health systems, healthcare provision and difficulties experienced by patients, were elicited. We suggest a series of strategic interventions addressing the implementation challenges and the six gaps identified in ACF outcomes and the expected indicators that could potentially improve the efficacy and effectiveness of community-based ACF in India.

Highlights

Tuberculosis (TB) remains a major public health problem of global concern
Systematic screening for TB disease outside health facilities is called ‘enhanced case finding’ or ‘active case finding’, depending on whether the engagement with the target high-risk population occurs at the group or individual level
We followed the guidance provided in the PRISMA statement [18] in developing the protocol and reporting this synthesis of active case finding (ACF) activities and outcomes reported by the National Tuberculosis Elimination Programme (NTEP)

Summary

Introduction

Tuberculosis (TB) remains a major public health problem of global concern. In 2019, of the 10 million people estimated to have developed TB worldwide, only 7.2 million people were notified by the National TB Programs (NTP), indicating that around 2.8 million people with TB (28% of the estimated disease burden) were undetected or were detected but not notified [1]. In its ‘End TB Strategy’, the World Health Organization (WHO) advocated for the ‘systematic screening’ of high-risk population subgroups to increase TB case detection [3]. Systematic screening for TB disease at health facilities is called ‘intensified case finding’. Systematic screening for TB disease outside health facilities is called ‘enhanced case finding’ or ‘active case finding’, depending on whether the engagement with the target high-risk population occurs at the group or individual level. Educating high-risk groups about TB disease and advising those with symptoms to visit health facilities for diagnosis and treatment is called ‘enhanced case finding’ (ECF). Screening all individuals within high-risk groups outside health facilities for TB symptoms and linking those with symptoms to TB diagnostic services with an intention to diagnose and treat TB cases is termed ‘active case finding’ (ACF)

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Results

Conclusion