Abstract
Community-based active case-finding (ACF) may have important impacts on routine TB case-detection and subsequent patient-initiated diagnosis pathways, contributing "indirectly" to infectious diseases prevention and care. We investigated the impact of ACF beyond directly diagnosed patients for TB, using routine case-notification rate (CNR) ratios as a measure of indirect effect. We systematically searched for publications 01-Jan-1980 to 13-Apr-2020 reporting on community-based ACF interventions compared to a comparison group, together with review of linked manuscripts reporting knowledge, attitudes, and practices (KAP) outcomes or qualitative data on TB testing behaviour. We calculated CNR ratios of routine case-notifications (i.e. excluding cases identified directly through ACF) and compared proxy behavioural outcomes for both ACF and comparator communities. Full text manuscripts from 988 of 23,883 abstracts were screened for inclusion; 36 were eligible. Of these, 12 reported routine notification rates separately from ACF intervention-attributed rates, and one reported any proxy behavioural outcomes. Two further studies were identified from screening 1121 abstracts for linked KAP/qualitative manuscripts. 8/12 case-notification studies were considered at critical or serious risk of bias. 8/11 non-randomised studies reported bacteriologically-confirmed CNR ratios between 0.47 (95% CI:0.41-0.53) and 0.96 (95% CI:0.94-0.97), with 7/11 reporting all-form CNR ratios between 0.96 (95% CI:0.88-1.05) and 1.09 (95% CI:1.02-1.16). One high-quality randomised-controlled trial reported a ratio of 1.14 (95% CI 0.91-1.43). KAP/qualitative manuscripts provided insufficient evidence to establish the impact of ACF on subsequent TB testing behaviour. ACF interventions with routine CNR ratios >1 suggest an indirect effect on wider TB case-detection, potentially due to impact on subsequent TB testing behaviour through follow-up after a negative ACF test or increased TB knowledge. However, data on this type of impact are rarely collected. Evaluation of routine case-notification, testing and proxy behavioural outcomes in intervention and comparator communities should be included as standard methodology in future ACF campaign study designs.
Highlights
With over 1.4 million deaths per year [1], tuberculosis (TB) was second only to SARS-CoV-2 as an infectious cause of death globally in 2020
Of the 12 studies identified for the review of active case-finding” (ACF) impact on routinely-identified case-notifications, one was a randomised controlled trial [26], six were controlled before-and-after studies and five were before-after studies with no comparison group (Table 1)
Using calendar time-period, the case-notification rate (CNR) ratio was 1.14 implying a 14% relative increase in non-ACF-diagnosed case notification rate for ACF compared to ECF (Table 2)
Summary
With over 1.4 million deaths per year [1], tuberculosis (TB) was second only to SARS-CoV-2 as an infectious cause of death globally in 2020. As many as three million people are living with undiagnosed TB disease [1]. WHO defines both patient-initiated care-seeking and provider-initiated systematic screening approaches to identify people living with undiagnosed TB [3, 4]. Patient-initiated care-seeking can arise through people recognizing TB symptoms and presenting to a health facility (passive case-finding or PCF), or result from advocacy, communication and social mobilization activities (ACSM) that can prompt earlier care seeking for facilitybased TB screening (enhanced case-finding or ECF).The key difference between ACF and ECF is that ACF implies individual interaction between a participant and healthcare worker in the community (e.g. where the participant completes a symptom screen, submits sputum for TB testing or undergoes a chest X-ray)
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