Abstract
BackgroundThe findings of a prevalence survey conducted in western Kenya, in a population with 14.9% HIV prevalence suggested inadequate case finding. We found a high burden of infectious and largely undiagnosed pulmonary tuberculosis (PTB), that a quarter of the prevalent cases had not yet sought care, and a low case detection rate.Objective and methodsWe aimed to identify factors associated with inadequate case finding among adults with PTB in this population by comparing characteristics of 194 PTB patients diagnosed in a health facility after self-report, i.e., through passive case detection, with 88 patients identified through active case detection during the prevalence survey. We examined associations between method of case detection and patient characteristics, including HIV-status, socio-demographic variables and disease severity in univariable and multivariable logistic regression analyses.FindingsHIV-infection was associated with faster passive case detection in univariable analysis (crude OR 3.5, 95% confidence interval (CI) 2.0–5.9), but in multivariable logistic regression this was largely explained by the presence of cough, illness and clinically diagnosed smear-negative TB (adjusted OR (aOR) HIV 1.8, 95% CI 0.85–3.7). Among the HIV-uninfected passive case detection was less successful in older patients aOR 0.76, 95%CI 0.60–0.97 per 10 years increase), and women (aOR 0.27, 95%CI 0.10–0.73). Reported current or past alcohol use reduced passive case detection in both groups (0.42, 95% CI 0.23–0.79). Among smear-positive patients median durations of cough were 4.0 and 6.9 months in HIV-infected and uninfected patients, respectively.ConclusionHIV-uninfected patients with infectious TB who were older, female, relatively less ill, or had a cough of a shorter duration were less likely found through passive case detection. In addition to intensified case finding in HIV-infected persons, increasing the suspicion of TB among HIV-uninfected women and the elderly are needed to improve TB case detection in Kenya.
Highlights
Prompt case finding is an important pillar of global tuberculosis (TB) control [1]
In addition to intensified case finding in HIV-infected persons, increasing the suspicion of TB among HIV-uninfected women and the elderly are needed to improve TB case detection in Kenya
Most studies on case finding have investigated risk factors associated with delay in diagnosis of TB patients found through passive case detection [3,4]
Summary
Prompt case finding is an important pillar of global tuberculosis (TB) control [1]. The 5.8 million TB cases that were notified globally in 2009 represented only 63% of the estimated number of new TB cases, and case detection was lower in the African region [2]. Delays in diagnosis through passive case detection have been associated with patient- and provider-related factors [3,4]. Most studies on case finding have investigated risk factors associated with delay in diagnosis of TB patients found through passive case detection [3,4]. Few studies have compared TB patients found through passive case detection with those identified through prevalence surveys or other active case finding efforts. These studies were in populations with low HIV prevalence [5,6,7,8], had small sample sizes [6] or were restricted to household contacts only [9,10]. We found a high burden of infectious and largely undiagnosed pulmonary tuberculosis (PTB), that a quarter of the prevalent cases had not yet sought care, and a low case detection rate
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