TABLE 2.

Options for TB active case-finding during the COVID-19 pandemic

ACF option	Target	Description	Pros	Cons	Possible COVID-19 integration
High-risk community symptom screening by CHWs	Symptomatic and acutely unwell individuals in the community	CHWs (kader) routinely screen for symptomatic persons in their catchment areas and notify the ACF team to investigate any presumptive cases Questions: Should people with presumptive TB be referred to health facility for further investigation or should a team visit the patients in the community with Xpert and/or mobile CXR?	May help to detect symptomatic cases in communities and areas where/when other ACF activities are not being conducted Opportunity to engage community and transfer knowledge for COVID-19 and TB Opportunity to increase community testing for COVID-19 in symptomatic patients	Relies on an active network of CHWs with supervision and support Sensitivity and specificity of symptom screening could vary widely Potential high demand on clinical services but low yield of bacteriologically confirmed cases if symptom screening criteria are oriented towards high sensitivity Challenging to protect all CHWs from risk of SARS-CoV-2 and TB infection	Community education and awareness Screening for COVID-19 based on symptoms and history Monitoring and support of persons in home isolation
Contact investigation	Close contacts of notified TB cases	Investigation of household contacts and/or other close contacts by health workers using appropriate personal protective equipment and algorithms that enable physical distancing and reduced patient contact with health services Questions: Should TB infection testing (e.g., tuberculin skin test) be done to test for infection as it requires extra visits? Should TB preventive treatment be provided?	Feasible with small team and infection prevention and control Focuses on screening a high-risk group with a known exposure, so potential high yield Contact investigation already recommended in NTP guidelines Overlap in procedures, training with COVID-19 response	Limited throughput: contacts of different index cases may be dispersed geographically Limited number of index cases in some areas, especially if relying on passive case-finding that is disrupted by COVID-19 Possible risk of SARS-CoV-2 infection for staff if they encounter a person with COVID-19 inside a household (staff will be donning and doffing personal protective equipment frequently)	Community education and awareness Screening for COVID-19 Specimen collection for COVID-19 testing COVID-19 contact investigation
Community-based ACF with mobile CXR	Symptomatic and asymptomatic cases in target community populations	Using multiple methods of physical distancing and infection control to conduct ACF using a mobile screening service with CXR to set up temporary community-based ACF sites	Screening with CXR will aid in the detection of patients who may be asymptomatic Rationalises the use of Xpert testing Screen more people in one occasion Opportunity to expand testing for COVID-19 in symptomatic and asymptomatic cases	As above with COVID risks Possible low uptake if there are community concerns about ACF services and crowding at ACF sites	Community education and awareness Screening for COVID-19 Specimen collection for COVID-19 testing COVID-19 contact investigation
Community-based ACF using Xpert testing of sputum for all	Symptomatic and asymptomatic cases in the community	Small team conducts case-finding in the community by going door-to-door and collecting sputum samples from all individuals screened Samples could also be used for viral testing Sample collection can be done outdoors and with distancing	Decentralisation of TB diagnostic services Can be implemented with social distancing maintained Opportunity to strengthen infection control procedures? Opportunity to expand testing for COVID-19 in symptomatic and at-risk	Greater resources and time needed for the programme to screen door-to-door: reduced throughput Need adequate supplies Expense of more Xpert testing Potentially lower sensitivity and yield than CXR screening — will miss some Xpert-negative TB cases that X-ray will help diagnose In some settings, being diagnosed with TB is a potential disincentive for COVID testing due to stigma Possible risk of SARS-CoV-2 infection for staff if screening a person with COVID-19 Infection risks for TB and SARS-CoV-2 when collecting samples	Community education and awareness Screening for COVID-19 Specimen collection for COVID-19 testing COVID-19 contact investigation
Using ACF teams to identify high-risk patients and transfer them to a facility with X-ray	Symptomatic cases in the community	Screening in community by ACF teams with subsequent transport of high-risk patients to an X-ray facility	Assists patients in overcoming barriers in reaching care Avoids extensive modification that would be required for safe operation of mobile X-ray services	Requires regular cleaning of vehicle between each patient – depending on vehicle seat materials may not be able to easily clean for fomites Requires personal protective equipment and use of masks by patients and staff during transport in the vehicle Expensive due to the time required to transport relatively few patients	Community education and awareness Screening for COVID-19 Specimen collection for COVID-19 testing COVID-19 contact investigation

ACF = active case-finding; CHW = community health worker; NTP = National TB Programme; CXR = chest X-ray.