Abstract
The lack of healthcare access contributes to large numbers of tuberculosis (TB) cases being missed and has led to renewed interest in outreach approaches to increase detection. It is however unclear whether outreach activities increase case detection or merely identify patients before they attend health facilities. We compared adults with cough of >2 weeks' duration recruited in health facilities (1202 participants) or in urban slums (2828 participants) in Nigeria. Participants provided demographic and clinical information and were screened using smear microscopy. The characteristics of smear-positive and smear-negative individuals were compared stratified by place of enrolment. Two hundred nine health facility participants (17.4%) and 485 community-based participants (16.9%) were smear positive for pulmonary TB. Community-based smear-positive cases were older (mean age, 36.3 vs. 31.8 years), had longer cough duration (10.3 vs. 6.8 weeks) and longer duration of weight loss (4.6 vs. 3.6 weeks) than facility-based cases; and they complained more of fever (87.4% vs. 74.6%), chest pain (89.0% vs. 67.0%) and anorexia (79.5% vs. 55.5%). Community smear-negative participants were older (mean, 39.4 vs. 34.0 years), were more likely to have symptoms and were more likely to have symptoms of longer duration than smear-negative facility-based participants. Patients with pulmonary TB identified in the community had more symptoms and longer duration of illness than facility-based patients, which appeared to be due to factors differentially affecting access to healthcare. Community-based activities targeted at urban slum populations may identify a different TB case population than that accessing stationary services.
Highlights
Health services are often inaccessible to ill individuals in the community, and this is pertinent to tuberculosis (TB) in low- and middle-income countries
The Federal Capital Territory (FCT) arm of this study was conducted in the ambulatory clinics of the FCT Tuberculosis and Leprosy Control Programme (TBLCP) based at five district hospitals within Abuja Metropolitan Area Council (AMAC)
The population screened in the community had a longer duration of cough (9.9 vs. 4.4 weeks) and a more frequent presence and longer duration of fever, weight loss, chest pain and anorexia compared to health facility–based participants
Summary
Health services are often inaccessible to ill individuals in the community, and this is pertinent to tuberculosis (TB) in low- and middle-income countries. Despite the scaling up of TB services, it is widely acknowledged there is still a large burden of undiagnosed TB [1], and worldwide, an estimated one third of the 9.5 million cases occurring each year are missed by public health services [2]. An important proportion of these cases are missed because individuals with symptomatic TB fail to seek medical advice for various reasons. The nonspecific presentation of TB, an expectation that symptoms will improve spontaneously and factors such as widespread stigma and misunderstanding about TB can delay or prevent individuals from seeking health services [3,4]. Missed or delayed TB diagnoses may lead to poorer individual outcomes
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