TB-Free Chuuk: community-wide tuberculosis prevention and treatment with an integrated disease screening approach in Chuuk Lagoon, Federated States of Micronesia

Abstract

Introduction

Tuberculosis (TB) is a global public health threat and a leading cause of morbidity and mortality. To reduce long-term TB burden and address related diseases in Chuuk, Federated States of Micronesia, a community-wide campaign was conducted, incorporating an integrated approach to screening and treatment for TB disease, TB infection (TBI), Hansen’s disease (HD) and diabetes. Here we present its design and initial outcomes.

Methods

Public health workers administered tuberculin skin tests (TSTs) door-to-door among persons residing in areas of high TB incidence in the Chuuk Lagoon islands. Persons then attended a local screening site and were assessed for TB (TST measurement, verbal symptom review and chest x-ray, where indicated), HD (skin exam for rash or other cutaneous findings) and diabetes (haemoglobin A1c for adults). Persons diagnosed with either TB disease or TBI were offered treatment on-site. Persons with exam findings consistent with HD were referred for evaluation. Persons with a haemoglobin A1c of ≥6.5% were referred for follow-up.

Results

During May–October 2023, 12 319 persons were screened through the community-wide campaign. An on-site panel of expert clinicians diagnosed 184 persons with TB disease and 2134 persons with TBI. Among those diagnosed with TB disease, 76.6% completed treatment. Among those diagnosed with TBI, 74.6% completed once-weekly rifapentine with isoniazid (3HP) treatment from community health workers. 17 new cases of HD and 395 new cases of diabetes were diagnosed.

Conclusions

This cross-sectional analysis of the TB-Free Chuuk campaign demonstrated the success of community-wide screening to identify new cases of TB disease, TBI, HD and diabetes. Integrated screening provided the opportunity to address related public health priorities simultaneously, increasing the community’s public health benefit. The development of local health worker capacity was key to achieving high treatment completion. Similar campaigns could be considered for other areas with high TB incidence with the goal of accelerating pathways to TB elimination.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Community-wide screening and treatment programmes for tuberculosis (TB) have demonstrated mixed success with widely different methodologies.

• Despite recent overall progress in reducing the TB burden, Chuuk State in the Federated States of Micronesia reports a high annual burden of TB and its comorbidities, Hansen’s disease (HD) and diabetes.

• The Chuuk State Department of Health Services implemented an integrated screening approach to reduce the high burden of TB, HD and diabetes in Chuuk to a level that could be addressed by local public health capacity.

WHAT THIS STUDY ADDS

• Extensive field-based screening for TB disease, TB infection (TBI), HD and diabetes is feasible in areas with high TB burden, such as Chuuk, with the support of volunteers and technical assistance from international partners.

• Active case-finding for TB can be coupled with diagnosis and treatment of TBI to reduce future cases.

• Community-wide screening programmes require expanded local TB programme capacity to provide treatment for persons newly identified with TB and TBI, which can be achieved with trained community health workers.

• An integrated screening approach provides increased community benefit by addressing multiple local public health priorities.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study serves as a potential model for a successful community-wide screening approach to address TB and other related diseases in high TB burden areas.

• This study also presents evidence for the feasibility of community-wide TB prevention with traditional active case-finding efforts to support TB elimination goals.

Introduction

Tuberculosis (TB) remains a major global health threat. In 2023, 10.8 million new TB cases and 1.25 million TB deaths are estimated to have occurred globally.¹ The Western Pacific region experiences the highest burden of TB worldwide, though the epidemiology of TB among Pacific Islands countries and territories (PICTs) varies.^{2 3} In 2021, the US-affiliated Federated States of Micronesia (FSM) reported a TB incidence of 98 TB cases per 100 000 population, among the highest in the Pacific.^{3 4}

Chuuk State is one of four states in FSM, comprising 290 remote islands within an area spanning over 100 000 square miles of ocean. Chuuk is home to nearly 50 000 persons, three-quarters of whom live on islands within the Chuuk Lagoon, including the capital island of Weno and 15 other islands known as Lagoon Islands (figure 1).⁵ Despite recent overall progress in reducing the TB burden, several villages in Chuuk continue to report annual TB rates of more than 300 new cases per 100 000 population. FSM also reports the second-highest incidence rate of Hansen’s disease (HD) globally, with 1122 new cases detected per 100 000 population in 2020, the majority of whom live within Chuuk State.^{6 7}

Figure 1. Map of villages with high incidence of tuberculosis and Hansen’s disease that participated in TB-Free Chuuk community-wide screening with cumulative reported tuberculosis case rates, by island, during 2013–2021, Chuuk Lagoon, Federated States of Micronesia, May–October 2023. Geometries: Chuuk Municipalities, Digital Atlas of Micronesia, 2020. Case data: Chuuk State Department of Health Services. Population data: Micronesia Population and Housing Census 2010. TB, tuberculosis.

People living in Chuuk are exposed to a convergence of TB risk factors. Families often live in crowded multigenerational homes, which can drive the transmission of TB within households.⁸ After changes in diet and devaluation of local forms of physical activity since World War II, communities in PICTs developed high rates of diabetes, a known risk factor in the progression from TB infection (TBI) to TB disease.⁹ In Chuuk, 15% of adults are estimated to have diabetes, which has nearly doubled since 2016.¹⁰ Additionally, the geographic isolation and dispersal of populations in FSM limit access to adequate healthcare, another factor reported to contribute to high TB burden.^{10 11}

The WHO recommends active case-finding (ACF) for TB in high-burden settings.¹² To address the high burden of TB and HD in Chuuk, the Chuuk State Department of Health Services (DHS) replicated a community-wide screening and treatment programme for TB, TBI, HD and diabetes, which was completed in 2017 and 2018 in the Republic of the Marshall Islands.^{13 14} The programme aimed to conduct intensive case-finding and treatment activities for TB disease, TBI, HD and diabetes to reduce incidence to a level that could be addressed with local public health capacity. This paper describes the design and initial outcomes of a community-wide TB, HD and diabetes screening initiative in Chuuk Lagoon during May–October 2023.

Methods

Programme planning

To plan the campaign, the US Centers for Disease Control and Prevention (CDC) and DHS analysed incidence trends of TB disease and HD in all areas of Chuuk during 2013–2021 to identify high-priority villages with the highest disease incidence for screening (figure 1). Local administrative input from community leaders, including mayors, was also sought. The “TB-Free Chuuk” campaign was planned to screen villages that comprise 33% of the general population of Chuuk, representing 81% of persons with TB disease diagnosed in the last 9 years.

The FSM national government funded this programme, with support for technical assistance, testing supplies, information technology and workforce development from the FSM National TB Program, CDC, the United Nations Development Programme and the Pacific Island Health Officers Association. The Chuuk Community Health Center partnered with DHS to allow use of their clinics on Weno and provided staff members to administer diabetes screening.

More than 30 full-time DHS staff members were involved in the campaign, including those from the TB programme, logistics, surveillance, immunisation and laboratory services. DHS also hired and trained 111 local community health outreach workers (CHOWs) to provide directly observed therapy (DOT) for TBI in villages on Weno and the Lagoon Islands. Volunteer physicians, nurses and epidemiologists were recruited from the National TB Coalition of America. Teams of local and volunteer public health workers were formed to staff the tuberculin skin test (TST) team, screening site teams and epidemiology teams. The campaign occurred for 153 days, often with two screening sites operating simultaneously.

During the campaign, local DHS health staff members and local CHOWs were trained to develop long-term capacity for administering TSTs, including reading test results, TBI treatment and monitoring and TB disease monitoring. The first team of volunteers conducted training on TST result reading, TB and TBI treatment and monitoring and data collection before the programme’s launch. On-site training and guidance were provided throughout the programme duration. As the programme moved from village to village, CHOWs from the next planned village were hired and trained by DHS TB programme nurses for TBI treatment and monitoring.

Programme initiation and protocol

Phase 1 of the campaign was conducted for all 11 villages on Weno and began on 8 May 2023 in the north-easternmost village of Sapuk. Phase 2 began on 12 June 2023 and was focused on 36 villages in the Lagoon Islands. Screening was completed on 6 October 2023 with treatment for those persons with newly diagnosed TB disease or TBI concluding in May 2024.

The programme was carried out Monday through Saturday of each week using the screening algorithm (online supplemental figure 1). Public health workers visited each village, registering all members of each household for screening door-to-door and administering TSTs among persons aged ≥5 years. TSTs were also administered at traditional meeting centres, gymnasiums, stores and boat docks. The TST team completed initial registration forms with demographic characteristics for all persons living in each household. The team also partnered with large local employers, such as grocery stores, to administer TSTs to employees at the worksite. Screening was extended to persons who were incarcerated at the local jail. Persons were counselled to return to a designated local clinic site 2–3 days after TST placement.

Village leaders preselected the clinic sites, including schools, remote health centres, church meeting halls, traditional community meeting houses, central medical dispensaries or other community buildings. The pace of the TST team determined the pace at which the clinical team moved from site to site.

At the screening site, local and volunteer nurses registered participants and measured their height and weight. Persons (or their responsible guardians) were then queried regarding previous history of TB disease, TBI treatment, history of exposure to a person with TB disease in the last 5 years and any current TB symptoms (eg, cough for longer than 2 weeks, fever, fatigue, unexplained weight loss or haemoptysis), and the TST was measured. Persons aged ≥18 years received a point-of-care haemoglobin A1c test (‘HbA1c’; Bayer A1CNow+, Leverkusen, Germany) to assess the presence and severity of diabetes. All persons with HbA1c ≥6.5% were referred for follow-up.

An on-site chest X-ray was performed with one of two portable radiograph machines (MinXray (Northbrook, Illinois, USA) or Fuji FDR Xair (Tokyo, Japan)) for any of the following conditions: TST result ≥10 mm; previous history of TB disease or TBI; history of exposure to a person with TB disease in the last 5 years; symptoms compatible with TB disease or HbA1c ≥6.5%. Chest radiographs were interpreted by a volunteer expert TB physician in real time. The image and film interpretation were shared with the person undergoing radiographic examination. Using a combination of clinical and radiographic findings, on-site physicians made a preliminary TB disease diagnosis, referring persons with possible TB disease for sputum collection on-site and case review. Sputum was transported daily to the Chuuk State Laboratory at the central hospital for TB nucleic acid amplification testing using GeneXpert MTB/RIF Ultra (Cepheid, Sunnyvale, California, USA).

Persons with a TST result ≥10 mm who were determined not to require sputum collection (and had not completed TBI treatment within the last 3 years) were diagnosed with TBI. Local and volunteer staff members counselled persons about safety and side effects using a standardised flip chart, and persons were offered once-weekly rifapentine with isoniazid (3HP) for 12 weeks. Persons with TBI who chose to initiate treatment completed their first dose of treatment at the screening site and were then referred to CHOWs for follow-up DOT. At each DOT visit, CHOWs completed a checklist for potential adverse drug events. Each CHOW was trained (and retrained whenever possible) to elicit and recognise common side effects, especially skin rashes and jaundice. Persons who reported potential drug-related symptoms from their 3HP were referred to the screening clinic or the Chuuk TB Clinic, including several home visits to those who were homebound. Local and external clinical staff members assessed each person individually to determine the best course of action.

The final step of screening was a brief skin examination completed by a physician or nurse to identify potential HD lesions. Persons with lesions concerning for HD were referred to the DHS HD programme for follow-up and diagnosis. Persons who completed the entire screening process (registration through HD evaluation) were given a small incentive, such as small toys and stickers for children or a $10 phone card or cash-power card for adults.

The epidemiology team compiled clinical, radiological and microbiological information for each person for whom sputum collection was requested for case review. A morning review of the compiled information for each of these persons was presented to the panel of local and volunteer TB physicians and nurses to determine their final screening diagnosis of probable or confirmed TB, unlikely TB but TBI, or no treatment required. Occasionally, persons were deferred for 2 months to determine a TB diagnosis, but this option was discouraged. Laboratory confirmation of TB disease was not required to initiate a four-drug TB regimen; persons with radiographic findings consistent with TB disease but without laboratory confirmation were classified as probable cases and then referred for TB treatment.

For all persons treated with a four-drug regimen, DHS TB programme nurses collected two additional sputum samples for mycobacterial culture and drug sensitivity testing with GeneXpert MTB/RIF (Cepheid, Sunnyvale, California, USA) at the regional referral lab (Diagnostic Laboratory Services, Honolulu, Hawai‘i, USA). TB programme nurses also coordinated treatment by DOT.

Data management and analysis

Data from the screening encounter and follow-up referrals were collected and entered into a Microsoft Access-based database. Data for TB follow-up were extracted and managed by the DHS TB programme to coordinate DOT and case management. Data for TBI follow-up were extracted and managed by the TB programme for coordination with CHOWs. TBI tracking progress was updated when CHOWs returned to the office to collect additional medications for DOT. Data for HD follow-up were extracted and managed by the DHS HD programme to coordinate follow-up for diagnosis and treatment, if necessary. Treatment outcomes for persons who were diagnosed with TB disease or TBI were assigned after treatment completion or at 1 year after programme initiation by the DHS TB programme. Records were reviewed for quality monthly, with routine situation reports disseminated to partners.

To describe the initial outcomes of TB-Free Chuuk, a cross-sectional analysis was conducted. Descriptive statistics were calculated for persons who were screened. For registered persons, the proportions of those who returned to the clinic were calculated by age group, sex and municipality. For persons who were screened, the proportion of those with TST positivity, TB disease, TBI, HD and diabetes diagnosis was calculated. TST results were considered positive if the induration was ≥10 mm. Treatment completion was calculated for persons diagnosed with TB disease or TBI. TB disease treatment outcome proportions were calculated by 10-year age group. Persons were considered to have completed TBI treatment if they took at least 11 doses of 3HP treatment within a 16-week period. TBI treatment cascade was developed using TBI treatment follow-up data collected after 1 year and analysed by geographic region.

All data were compiled and analysed using Microsoft Excel and R statistical software (V.4.4.1). Proportions of persons who returned to the clinic site, had a positive TST test result and completed TBI treatment were compared by age group, sex and municipality using Pearson’s χ² test using gtsummary.¹⁵ Population-based rates were calculated using population counts from 2010 FSM census data.⁵ Figures were created using ggplot2.¹⁶ Geometries of Chuuk Lagoon municipalities were retrieved from the Digital Atlas of Micronesia.¹⁷

Results

During May–October 2023, 15 014 persons in the community were registered and instructed to report to the clinic site. A total of 12 319 (82.1%) persons returned and were screened (table 1). Among persons screened, the most common TB risk factor reported was history of exposure to a person with TB disease in the last 5 years (1358 of 12 319, 11.0%), followed by current TB symptoms (1160 of 12 319, 9.4%) and previous history of TB disease (261 of 12 319, 2.1%).

Table 1. Descriptive statistics of persons who were screened, TB-Free Chuuk community-wide screening, Chuuk Lagoon, Federated States of Micronesia, May–October 2023.

Characteristic	Total (n=12 319)
Age (years)*	20 (10–42)
Sex
Female	6713 (54.5%)
Male	5606 (45.5%)
History of exposure to a person with TB disease	1358 (11.0%)
At least one TB symptom	1160 (9.4%)
Previous history of TB disease	261 (2.1%)
Chest X-ray consistent with TB	338 (2.7%)
Adults only (aged ≥18 years, n=6685)
BMI (kg/m2)	29.4 (24.5–34.8)
Current tobacco use	2417 (36.2%)

Data are presented as median (IQR) or number (%).

^*Missing: age (n=29).

BMI, body mass index; TB, tuberculosis.

A significant difference was observed in the proportions of persons who returned to the clinic site by sex, age group and municipality (online supplemental table 1). A larger proportion of women (6713 of 7938, 84.6%) returned to the clinic than men (5606 of 7076, 79.2%; p<0.001). When clinic return was analysed by sex, more than 80% of persons in all age groups returned to the clinic, except girls and boys aged 0–4 years (girls: 523 of 761, 68.7%; boys: 540 of 764, 70.7%) and men aged 20–39 years (1172 of 1620, 72.3%). Persons living in the Lagoon Islands (5989 of 7053, 84.9%) returned to the clinic more than those living in Weno (6330 of 7961, 79.5%; p<0.001).

TST screening results

TSTs were administered for 13 609 persons aged ≥5 years. TST results were available for 11 093 persons (81.5% of total TSTs). Among persons with a TST result, 19.7% (2189 of 11 093) had a positive test result (≥10 mm). TST positivity increased by age group, ranging from 7.4% (360 of 4858) among persons aged 5–19 years to 38.5% (336 of 873) among those aged ≥60 years (figure 2). Overall, TST positivity was higher among men than women (1272 of 5014, 25.4% among men vs 917 of 6079, 15.1% among women; p<0.001). TST positivity also varied by municipality. All municipalities demonstrated an increase in positivity with age.

Figure 2. Tuberculin skin test positivity (≥10 mm) by age group and sex among persons with a positive test result, by age group and sex, TB-Free Chuuk community-wide screening, Chuuk Lagoon, Federated States of Micronesia, May–October 2023 (n=11 093).

Diagnosis and treatment of TB disease

A total of 422 persons were referred for case review. After consensus review, TB disease was diagnosed in 184 persons, for a prevalence of 1494 TB cases per 100 000 persons screened. The number needed to screen to find one person with TB disease was 67 persons. For persons with TB disease, 41.8% (77 of 184) reported being close contacts to a person with TB disease, 36.4% (67 of 184) reported at least one current TB symptom, and 95.7% (176 of 184) had radiologic findings consistent with TB. Among those diagnosed with TB disease, 76.6% (141 of 184) completed TB disease treatment during the 1-year follow-up period (figure 3).

Figure 3. Treatment outcomes among persons diagnosed with tuberculosis disease after 1 year of follow-up, by age group, TB-Free Chuuk community-wide screening, Chuuk Lagoon, Federated States of Micronesia, May 2023–2024 (n=184).

Sputum was collected from 78.3% (144 of 184) of persons diagnosed with TB disease. Of these, 9.7% (14 of 144) were bacteriologically confirmed by on-site or reference laboratory testing. No cases of drug-resistant TB were detected using mycobacterial culture or nucleic acid amplification testing.

Diagnosis and treatment of TBI

TBI was diagnosed in 2134 (2134 of 12 319, 17.3%) persons with a TST test result ≥10 mm, no TB disease and no previous TBI treatment within the past 3 years (figure 4). Treatment was initiated for 2077 of 2134 persons (97.3%). All treatment was delivered via DOT by newly trained CHOWs. At 1-year follow-up, 1593 persons (1593 of 2134, 74.6%) had completed TBI treatment. Treatment completion was higher among those living in the Lagoon Islands (660 of 812, 81.3%) compared with those living in Weno (933 of 1322, 70.6%; p<0.001). Treatment completion was significantly higher in the Lagoon Islands compared with Weno among persons aged 20–39 years (189 of 242, 78.1% vs 229 of 357, 64.1%; p<0.001) and among those aged 40–59 years (239 of 291, 82.1% vs 396 of 556, 71.2%; p<0.001). Among those diagnosed with TBI, 25.4% (541 of 2134) did not complete treatment for the following reasons: lost to follow-up (298 of 2134, 14.0%), refusal to continue medication (eg, experiencing side effects, alcohol use, etc) (128 of 2134, 6.0%), moving away from Chuuk Lagoon (87 of 2134, 4.1%), deferral (eg, pregnancy) (18 of 2134, 0.8%), provider decision (6 of 2134, 0.3%) and death (4 of 2134, 0.2%). Among those receiving TBI treatment, no serious adverse events were recorded by CHOWs or local review of hospital or clinic records.

Figure 4. Cascade of care in tuberculosis infection screening and management among people screened during TB-Free Chuuk community-wide screening, Chuuk Lagoon, Federated States of Micronesia, May 2023–2024. *Persons diagnosed with TB disease or who completed preventive treatment within the last three years were excluded from this analyis. §Treatment considered complete if person took 11 or more doses of 3HP treatment within 16-week period. TB, tuberculosis; TST, tuberculin skin test; 3HP, once-weekly rifapentine with isoniazid.

HD screening results

A total of 157 persons were referred to the DHS HD programme to assess skin examination findings. The HD programme completed follow-up assessment for 87% of persons (137 of 157). 17 persons received a new diagnosis of HD, yielding a prevalence of 13.8 HD cases per 10 000 persons screened.

Diabetes screening results

For the 6685 persons aged ≥18 years who participated in screening, 6027 (90.2%) received an HbA1c test. Of those tested, 14.9% (896 of 6027) had an HbA1c result of ≥6.5% and were diagnosed with diabetes. Among those with an HbA1c ≥6.5%, 44.1% (395 of 896) were newly diagnosed. A total of 7.6% (511 of 6685) persons aged ≥18 years reported a history of diabetes, with 59.9% (306 of 511) reporting taking diabetes medication. Among persons aged ≥18 years with an HbA1c result, diabetes was more common among persons diagnosed with TB disease (19 of 88, 21.6%) and TBI (318 of 1685, 18.9%) than among persons without TB disease or TBI (559 of 4254, 13.1%).

Discussion

Extensive field-based screening for TB disease, TBI, HD and diabetes is feasible in areas with high TB burden, such as Chuuk. During 6 months, nearly 1 in 3 people estimated to live in Chuuk Lagoon underwent integrated disease screening, resulting in the diagnosis and linkage to care of persons identified with any of these four diseases. Treatment completion for people diagnosed with TB disease and TBI within 1 year was high, demonstrating the agility of the Chuuk TB programme to rapidly expand capacity and provide care for the increased number of persons with TB and TBI identified by the campaign.

TB ACF efforts have demonstrated mixed success with widely different methodologies.¹⁸ One recent success from Vietnam employed 3 years of annual sputum-based testing and showed that community-wide screenings for TB can result in decreased prevalence of TB.¹⁹ The Chuuk campaign differed in several key components. The Chuuk campaign coupled ACF with diagnosis and treatment of TBI, which was not a feature of the Vietnam intervention. TBI treatment should reduce future cases, while the treatment of prevalent disease temporarily reduces transmission. TB-Free Chuuk also focused on known high-incidence villages in Chuuk Lagoon, whereas the Vietnam intervention randomly selected communes.

One key benefit of the campaign was the development of local health worker capacity—critical for continued aggressive TB strategies within Chuuk—particularly among local DHS staff members who were trained in TB screening, administering and reading TSTs and treatment support for TBI and TB disease. Newly trained CHOWs successfully administered 3HP treatment by DOT to persons with TBI and achieved a completion percentage nearly three times as high as that reported by 14 US programme-based targeted testing projects for persons from areas with high prevalence of TBI or TB disease.^{20 21} TBI treatment is effective and durable in preventing the progression of TBI to disease, even in high-burden settings, and completing community-wide TBI treatment may help mitigate the future risk of TB outbreaks in villages with high TB incidence.22,24

Integrated screening efforts require additional planning and cost; however, they provide valuable opportunities to address other public health priorities. The campaign highlighted challenges in Chuuk regarding diabetes diagnosis and control. Persons screened and identified with diabetes were frequently unaware of their diagnosis, and few aware of their diagnosis reported taking diabetes medication. By integrating diabetes screening into active case-finding for TB, persons with diabetes are linked to care, which may improve individual outcomes for both diseases.^{25 26}

The TB prevalence determined from the campaign was much higher than the incidence reported in 2021 under routine passive case detection service (2023 campaign prevalence of 1494 TB cases per 100 000 persons screened vs 2021 precampaign prevalence of 98 TB cases per 100 000 persons), which is consistent with ACF efforts in other high-incidence countries.^{27 28} This finding might be attributable to case-finding in the highest-incidence locations, treating persons with likely older self-healed TB disease, treating incipient TB disease and treating asymptomatic TB disease. Most persons treated for TB disease were asymptomatic (64%) and without laboratory confirmation (92%), consistent with other ACF campaigns.^{29 30} The true prevalence of TB in Chuuk might lie somewhere between the 2021 precampaign prevalence and the 2023 campaign prevalence. Population-based rates derived from ACF efforts should be interpreted with care; the population in Chuuk may have changed since the most recent FSM census in 2010.³¹

As in other Pacific campaigns, a final TB diagnosis was determined through a careful consensus of on-site clinical experts who reviewed chest radiographs, TST results, household TB history, potential TB exposures, TB symptoms, diabetes status and GeneXpert Ultra results. The campaign and the DHS TB programme had limited capacity to follow individuals over time; therefore, a decision to treat for TBI or TB disease was made within the 3-day review period. For some persons with abnormal findings on chest X-ray, the expert review panel determined that treatment with a four-drug regimen carried less risk and greater benefit to the individual when compared with providing a TBI regimen. Several recent studies have reported an elevated risk for new TB diagnoses among persons with abnormal chest radiographs who were not treated in previous screening strategies that required laboratory confirmation.^{29 32 33} Additionally, when determining a treatable TB case, the recent HbA1c score was not withheld from the medical team, as diabetes is a well-established risk factor for TB in the Pacific.¹⁸ It is possible that when cases were presented to the clinical teams, the presence of diabetes influenced the clinical threshold for diagnosing TB disease.

The TB-Free Chuuk campaign, like other community-wide screenings, increases TB awareness in these villages, highlights the need for prompt TB treatment and promotes implementation of TBI treatment after subsequent household re-exposure.¹⁸ Whether this intervention is sufficient to reduce TB prevalence to the level where existing programmatic capacity can progress towards the goals of the global ‘End TB Strategy’ remains to be seen.³⁴ The long-term impact will be assessed over time with annual follow-up and registry matching to evaluate TB rates in Chuuk.

TB-Free Chuuk was achieved primarily with FSM resources and smaller in-kind contributions from several regional and international partners. The effort was aided by external experts but relied mostly on local expertise, including sharing nurses and staff from other public health programmes during the screening. The campaign’s focus on capacity building was essential to assure sustainability of operations in Chuuk after the initial screening was completed. Extensive local resource requirements for community-wide screening in Chuuk could limit translation of this approach to other settings.

The TB-Free Chuuk community-wide campaign to deliver ACF for TB, HD and diabetes was feasible with the support of volunteers, materials, resources and technical assistance from international partners in the resource-limited, high-burden setting of Chuuk Lagoon. Similar campaigns could be considered for other areas with high TB incidence to reduce morbidity and mortality with the goal of accelerating pathways to TB elimination.

The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. References in this manuscript to any specific commercial products, process, service, manufacturer or company do not constitute its endorsement or recommendation by the US Government or CDC.

Data availability statement

Data are available upon reasonable request.