From Mosques to Classrooms: Mobilizing the Community to Enhance Case Detection of Tuberculosis

Abstract

In response to the global challenge of inadequate case detection of tuberculosis (TB), the Fund for Innovative DOTS Expansion through Local Initiatives to Stop Tuberculosis (FIDELIS) was developed in 2003 to rapidly assess and implement innovative approaches to increase the detection of new smear-positive TB cases. As previously reported, a wide range of target populations and interventions has been incorporated into successful FIDELIS projects.

KEY FINDINGS.

• A wide range of community-based activities to increase awareness of TB was implemented rapidly on a wide scale.

• FIDELIS support provided an opportunity to consider innovative approaches that might not otherwise have been attempted.

• Increases in the detection of new smear-positive cases in FIDELIS sites compared with the previous year and compared with non-FIDELIS sites may be partly the result of the intensive community-based activities.

• Further evaluation of each specific approach will be needed to assist TB control partners in prioritizing approaches to a broad scale-up in the TB control effort.

ONE PROJECT OF THE FUND for Innovative DOTS Expansion through Local Initiatives to Stop Tuberculosis (FIDELIS) in Bangladesh implemented by a nongovernmental organization, BRAC (formerly the Bangladesh Rural Advancement Committee), introduced a comprehensive set of community-based activities to increase awareness of tuberculosis (TB) and the steps necessary to be properly diagnosed and treated for the disease. One year of project activities covered 10 districts and a population of 27.56 million. A total of 21718 new smear-positive cases were detected during the 12 months of project activities—5756 more than the previous year.

An estimated 8.8 million people became ill with TB and 1.6 million people died from this disease in 2005.1 A failure of countries to reach global case-detection targets remains one of the greatest barriers to achieving global TB control. In the early 2000s, several initiatives were introduced to address the global case-finding challenge. FIDELIS is a US$31-million fund launched in April 2003 to increase case detection of new smear-positive cases of TB while maintaining high cure rates within the Directly Observed Therapy Short Course strategy.2 Funding for FIDELIS came from the Canadian International Development Agency, and the project is managed by the International Union against Tuberculosis and Lung Disease (the Union). As part of the FIDELIS initiative, locally designed approaches to increase TB case detection are rapidly implemented and evaluated.

PROGRAM DESCRIPTION

In Bangladesh, between November 1, 2005, and October 31, 2006, FIDELIS supported a comprehensive set of community-based activities aimed at increasing community awareness of TB, as well as the necessary actions to be taken for proper diagnosis and treatment of the disease. The activities took place in 10 rural districts of Bangladesh and covered a population of 27.56 million.

Popular Theater Performances

TB information was disseminated through popular theater in all subdistricts of the 10 project districts. A total of 130 events (approximately 2 per sub-district) were held during the project period. A typical theater session attracted between 50 and 100 people and conveyed messages about the symptoms and signs of TB and how one can seek diagnosis and care for the disease. The theater shows were performed by BRAC’s local theater groups, which received specific orientation regarding TB. These local dramas were conducted in the local language in places in which people commonly gather.

Primary-School Orientation

School age–appropriate sessions on TB diagnosis and care were given at BRAC primary schools in the rural project districts. A total of 1964 orientations were conducted, reaching almost 60000 students, who ranged in age from 9 to 14 years. The students were encouraged to identify suspects in their family and community and refer them for appropriate diagnosis and care. Bookmarks printed with messages about TB were given to the students as part of the sessions. The classroom sessions were conducted jointly by the BRAC field workers and the primary school teachers. The BRAC field workers were trained as part of their general health posts and received specific training on TB as part of the project.

Religious Leader Engagement

BRAC field supervisor (left) visiting patient who was diagnosed after hearing an imam speak about tuberculosis.

Orientation of Muslim religious leaders (imams) on TB diagnosis and care were conducted. The imams then disseminated these messages during their Friday prayer in the local mosques. Imams were given a small travel allowance to participate in the orientation sessions. A total of 148 religious- and community-leader sessions were held, and 4165 people attended the sessions. One patient visited during a routine FIDELIS monitoring visit discussed the role of a religious leader in his own recent diagnosis. The 26-year-old man had been unwell for several months with classic symptoms of pulmonary TB. He sought care from several private and traditional health care workers without a successful diagnosis. In the week prior to his diagnosis, the patient attended a local mosque where the information on TB was provided, including instructions on where to seek care and treatment. The patient followed the instructions and was promptly diagnosed, and appropriate treatment was initiated.

“TB Club” Meetings

Small groups (20–30 in each session) of successfully treated patients were oriented in their potential roles to identify suspects in the community and support new TB patients in initiating and completing their treatment. These sessions were held on 227 occasions and reached 6241 successfully treated patients.

Television Messages

In project districts, there are some local cable television channels. TB messages were broadcast from the available channels as both a message text strip and a short commercial. These commercials were broadcast during popular television programs. A total of 1778 broadcast days for all project sites was reported.

Diagnosis and Treatment

All suspects identified through the various community-based activities were assessed through the routine services of the National Tuberculosis Program in accordance with national guidelines. Sufficient resources and supplies were available for the diagnosis and full treatment of anyone identified through the project. Three sputum samples were routinely collected for identified suspects and examined by the Ziehl–Neelsen method to detect acid-fast bacilli. Treatment of patients included the use of community-based workers to ensure adherence to treatment.

Discussion and evaluation.

Between November 1, 2005, and October 31, 2006, 21718 new smear-positive cases were detected in 10 FIDELIS districts. This represents an increase of 5756 new smear-positive cases compared with the previous year in the same areas (Table 1 ▶). Attribution of these observed increases to the individual community-based approaches remains elusive, given the multiple activities implemented simultaneously in the target districts. Furthermore, prevailing trends for case detection in Bangladesh are increasing, further complicating the evaluation of specific approaches. Nonetheless, comparison with neighboring districts without similar intensive community-based efforts may provide some insight into the effectiveness of engaging the community through multiple avenues. In other BRAC-supported districts, neither funded by FIDELIS during the project period nor implementing similar intensive community-based efforts, there was a 29% increase in case detection (from 65 to 84 per 100000 population) compared with the 36% increase in FIDELIS sites (Table 1 ▶).

TABLE 1—

Case Detection in FIDELIS and Non-FIDELIS Districts Prior to and During Project Activities: BRAC-Covered Districts, Bangladesh

	FIDELIS Project Areas	Non-FIDELIS Project Areasa
No. of districts	10	32
Population (millions)	27.56	50.90
Cases detected prior to project (November 1, 2004, to October 31, 2005)	15 962	32 963
Baseline case detection rate per 100 000 population	58	65
Cases detected during project (November 1, 2005, to October 31, 2006)	21 718	42 842
Case detection rate during project per 100 000 population	79	84
Increase in case detection per 100 000 population, %	36.2	29.2

Note. FIDELIS = Fund for Innovative Directly Observed Therapy Short Course Expansion through Local Initiatives to Stop Tuberculosis.

^aExcludes city corporations.

The financial resources required to implement this extensive collection of community activities was relatively modest. An approved budget of US$188544 covered all activities under FIDELIS and related administrative costs during the 1-year project.

Next steps.

Given the complexities highlighted above, additional evaluation of individual approaches is required to further guide investment in TB-control activities. Results of these FIDELIS-supported activities suggest that intensive efforts in the community may lead to increased identification of TB patients. BRAC plans to conduct a further evaluation of newly diagnosed TB cases in the districts supported by FIDELIS to determine which of the community-based approaches is most commonly identified by new patients as their source of information on TB. This should contribute to the developing evidence base on the effectiveness of community-based approaches to TB control.