TABLE 3.

Risks for TB active case-finding and options to manage them

Risk/challenge	Adaptations and precautions
Health workers will be in close contact with persons who may have COVID-19 and/or TB	Training on infection control, adaptation of existing infection control standard operating procedures to incorporate risk of exposure to both TB and SARS-CoV-2 Triage and management of persons with presumptive COVID-19 prior to TB screening Telehealth to conduct initial screening interviews Maintain physical distance when interviewing persons (preferably outdoors or in a well-ventilated area) Provide those presenting to services with cloth or surgical masks PPE when examining patients (standard, contact and airborne precautions) Additional PPE when conducting aerosol-generating procedures, including sputum collection and laboratory examination Regular COVID-19 testing of ACF staff Healthcare workers undertaking testing will need to have adequate knowledge of both diseases and the consequences of a positive test for either (or both) to provide consistent and adequate responses to questions from community members
Risk of increasing person-to-person transmission of SARS-CoV-2 and TB during case-finding (ACF can create large gatherings of people who come to be screened and wait in close quarters	Focus on conducting ACF with the household as the unit and locus of intervention: screening of household contacts or community screening by going door-to-door Conduct initial screening of contacts by phone Reduce throughput of screening – fewer persons attend at a time, enact physical distancing while waiting
Symptoms for TB and for COVID-19 are likely to overlap, meaning that screening for COVID-19 may expose people to the risk of TB patients and vice versa)	Maintain physical distancing between persons Disinfection of surfaces and equipment after each person seen Educate community about hand hygiene and provide surgical masks for persons to wear Environmental cleaning of waiting areas Adequate ventilation: natural or mechanical ventilation Triage, separation and management of patients with suspected COVID-19 prior to TB investigation
Risk of SARS-CoV-2 and TB transmission when taking CXR in vans	X-ray procedures and adequate staffing with clear defined roles and processes including appropriate cleaning Use portable CXR in well ventilated rooms Use protective barriers to prevent patients from touching X-ray machine and to separate staff from patients Manage queuing of those presenting for screening by using markings on the ground to indicate required physical distancing and provide cloth or surgical masks Consider alternative screening algorithms that reduce the need for CXR such as initial screening using GeneXpert for TB, although these will be more expensive
Risk of spills when transporting sputum samples	Procedures and training of staff on safe handling and transportation of specimens Implement safety procedures for handling and transportation of specimens – triple packaging; spill kits
Risk of transmission in laboratories due to specimen handling	Procedures and training of staff on safe handling and processing of specimens Implement safety procedures and infection control
Risks associated with facility-based models of TB care:	Support referral facilities if they have not yet implemented TB and COVID-19 triage and screening for all patients entering
Health facility-based transmission of SARS-CoV-2 for TB patients required to attend health facilities for diagnosis and care services	Implement home-based or community-based service models where possible (treatment initiation, treatment support, patient review) Provide TB patients with at least a month-long supply of treatment drugs so less frequent visits have to be made to the health centre for drug refills
Risk of missed diagnoses and loss to follow up if people are unwilling to travel to health facilities to access TB services	Use remote options to provide treatment support (phone calls, use of digital adherence tools) if in-person support is not possible Implement home-based or community-based service models where possible (treatment initiation, treatment support, patient review)
Patients may be unwilling or unable to use ACF services and other services	Community engagement and education Collect qualitative feedback from patients and communities and adapt service design accordingly
Insufficient supply of PPE to meet infection control needs	Extend the safe use of PPE items through cleaning, sterilisation and reuse Implement substitute methods where safe to do so: sterile booths, barriers, face shields over surgical masks
Unclear, inconsistent or incorrect messaging or information provided	Staff training as above Development of information, education and communication material (illustrated pamphlets) in local language

PPE = personal protective equipment; ACF = active case-finding; CXR = chest X-ray.