Experience of active tuberculosis case finding in nearly 5 million households in India

Abstract

In India, to increase tuberculosis (TB) case detection under the National Tuberculosis Programme, active case finding (ACF) was implemented by the Global Fund-supported Project Axshya, among high-risk groups in 300 districts. Between April 2013 and December 2014, 4.9 million households covering ~20 million people were visited. Of 350 047 presumptive pulmonary TB cases (cough of ⩾2 weeks) identified, 187 586 (54%) underwent sputum smear examination and 14 447 (8%) were found to be smear-positive. ACF resulted in the detection of a large number of persons with presumptive pulmonary TB and smear-positive TB. Ensuring sputum examination of all those with presumptive TB was a major challenge.

Globally, India accounts for one third of the ‘missing’ 3 million tuberculosis (TB) cases that are not notified under national tuberculosis control programmes.¹ This is primarily due to underdiagnosis, misdiagnosis, and diagnosis and treatment of TB patients in the vast private sector.^2–5 To address these challenges, the government of India's Revised National Tuberculosis Control Programme (RNTCP) has formulated several strategies, including active case finding (ACF), among clinically vulnerable and socially marginalised populations.^6,7 Some of these strategies are implemented through the Project Axshya (http://www.axshya-theunion.org), supported by the Global Fund. Implemented in mid-2010 in 300 of 650 districts in 21 of the 36 states in India, the primary aim of Project Axshya is to enhance the visibility and reach of the RNTCP services among vulnerable and marginalised populations.

ASPECT OF INTEREST

TB case finding in India is predominantly passive, and consists of detection of cases among those visiting health facilities. During 2013–2014, the Project Axshya initiated ACF in households located in urban slums and tribal and rural areas that are relatively far from the public health facilities in these 300 districts. This intervention was in addition to ongoing passive case finding by the RNTCP. The populations living in these areas within a district were operationally defined as ‘marginalised and vulnerable’, and were identified by a population mapping exercise that involved multiple stakeholders such as programme managers, community representatives and non-government organisations (NGOs). Thereafter, the NGOs identified community volunteers (CVs) in these selected areas and trained them to disseminate messages on TB using interpersonal communication tools and to conduct ACF.

The CVs visited approximately 1000 new households in each district every month. Each household was visited only once, similar to a cross-sectional study design. During the visit, the volunteers informed household members about specific aspects of TB: transmission, symptoms and the availability of free diagnostic and treatment services under the RNTCP. In addition, the CVs screened the household members and identified persons with presumptive pulmonary TB (PPPTB), i.e., those with a cough of ⩾2 weeks. The PPPTBs were line-listed and referred to the nearest RNTCP-designated microscopy centre (DMC) for sputum smear examination. For those unable to visit the DMC for any reason, the CVs undertook sputum collection and transportation (SCT) of their sputum samples (one spot and one early morning). An additional visit was made to collect the early morning sputum specimen. Sputum smear-positive (SSP) patients were initiated on anti-tuberculosis treatment under the RNTCP. Smear-negative patients were not followed up by the CVs, but were advised to visit public health facilities for further evaluation. To ensure continuity, the CVs provided their contact details to all the households visited as well as to the village headman for future assistance. The activity (including recording and reporting) was supervised by the staff of the local NGO, the sub-recipient partners and the International Union Against Tuberculosis and Lung Disease (The Union) South-East Asia Regional Office, New Delhi, India, all recipients of the Global Fund grant. The compiled data were routinely shared with the RNTCP programme managers at district, state and national levels.

In this study, we report the results of the ACF from April 2013 to December 2014 in terms of the number of households visited, the number of PPPTB identified and the number of SSP cases detected and initiated on treatment.

This manuscript was reviewed and approved by the Ethics Advisory Group of The Union (Reference no 02/2015) and the Central Tuberculosis Division, Ministry of Health & Family Welfare, Government of India.

RESULTS

Of the 300 districts, we obtained data from 281 (Figure). ACF was conducted in 4.9 million households, covering a population of approximately 20 million (Table). In these households, 350 047 PPPTB were identified, among whom SCT was undertaken for 142 606 (41%). The remaining 207 441 persons were referred to the nearest DMC. Of these, only 44 980 (22%) underwent sputum smear examination. In total, 187 586 (54%) PPPTB underwent sputum smear examination as a result of referral or SCT. Of these, 14 447 (8%) were found to be SSP (10 973 [76%] from SCT and 3474 [24%] from referrals reaching DMC independently), and 13 971 (97%) were initiated on treatment.

FIGURE.

Map of India depicting the districts and states (shaded in grey) where active tuberculosis case finding was implemented under Project Axshya.

TABLE.

Results of active case finding in India through Project Axshya, April 2013–December 2014

The number of PPPTB identified per 100 000 population varied from 642 in the state of Goa to 2296 in Uttar Pradesh. Similarly, the proportion that underwent sputum examination ranged from 26% in Delhi to 66% in West Bengal. Sputum positivity among those who underwent sputum examination ranged from 2% in Goa to 12% in Delhi.

DISCUSSION

This is one of the first reports on the large-scale implementation of ACF in India, and it has several important observations. First, the number of TB patients detected is within the ranges reported in similar epidemiological settings.⁸ Second, the study confirms that ACF can be implemented efficiently by CVs with adequate training and a supportive supervisory structure in place, as per the World Health Organization systematic screening guidelines.⁹ Third, ACF can identify a large number of PPPTB, especially in communities that face difficulties in accessing RNTCP services, in addition to passive case finding. Determining whether the yield was ‘additional’ would require further research comparing the number of cases who reached RNTCP services through ACF with those who reached the RNTCP without this activity. Fourth, as identification and referral only of PPPTB is unlikely to be helpful (only 22% reached microscopy centres in our study), ACF should be combined with SCT for it to be effective in this setting. The reasons for referrals not reaching a DMC need to be evaluated further, and appropriate measures need to be taken based on the findings. Fifth, pulmonary TB patients were diagnosed by Ziehl-Neelsen; additional cases could have been detected if more sensitive technologies, such as light-emitting diode (LED) fluorescence microscopy or Xpert^® MTB/RIF (Cepheid, Sunnyvale, CA, USA), were used.¹⁰ The number of SSP TB cases detected by ACF in this study is thus likely to be an underestimation. Finally, whether ACF results in a reduction in diagnostic delay due to early identification and/or reducing the number of health care providers visited prior to diagnosis, or a reduction in costs incurred by PPPTB and TB patients, needs further evaluation. These aspects of ACF present a rich area for operational research.

CONCLUSION

In India, ACF resulted in the detection of a large number of persons with presumptive pulmonary TB and TB patients with variations across different states. ACF can be conducted efficiently by CVs with adequate training and supervision. Ensuring that all identified persons undergo sputum smear examination was a major challenge; this could be partially overcome by sputum collection and transportation.