Community care workers boost TB case finding among hard-to-reach adults

Community care worker active case finding is an effective tool for increasing TB case detection, according to two studies presented at the 46th Union World Conference on Lung Health held in Cape Town from 2 to 6 December. Finding and diagnosing TB is the essential first step to closing the global gap in diagnosing TB.

Screening for signs and symptoms of HIV, TB and diabetes by volunteer community care workers at household level is an effective way to reach hard-to-reach populations, according to a study of active TB case finding conducted in Umzinyathi in KwaZulu-Natal, South Africa.

Thirty-seven semi-literate volunteer community care workers screened 1665 people in approximately 400 households for the signs and symptoms of TB and diabetes using an 11-question tick sheet comprising questions about close TB contacts within the last year, persistent cough for more than two weeks, night sweats, weight loss, excessive tiredness and standard HIV and diabetes questions. The community care workers were instructed to go to households where they knew people to be sick.

According to the study presenter Dr Derek Turner of the Umvoti AIDS Centre, Greytown, Kwazulu Natal, caregivers are able to convince community members to go to primary health care facilities when signs and symptoms of TB are present, get people to disclose previous TB and HIV statuses and get access to TB record cards for recording treatment start dates and outcomes and also consistently fill in the screening tool.  

Of the 1665 people screened, a high percentage (39.8%) were males. Men are traditionally harder to reach and less likely to access health services. Three hundred and fifty people showed signs and symptoms of TB and were referred to primary health clinics for TB testing, 247 of which had either no visit to a health facility or an uncertain outcome reported by care givers.

Of the 103 that were successfully referred to a public health care facility, 36 started TB treatment (20 females and 16 males) and 17 have completed treatment to date.

Twenty-nine people were already confirmed as having TB and on treatment, five of which had been on treatment for more than one year. One of the cases of those on treatment for more than a year has been diagnosed with multi-drug resistant TB and has started second-line treatment. Two people with known TB who had refused treatment were identified. 109 people had been in close contact with a person with TB in the last year.

“The simplicity and non-threatening nature of the intervention is instrumental in getting traditionally hard-to-reach people, particularly men, to answer questions and access care,” said Dr Turner.

A study of the patient characteristics and contribution to overall caseload from three different TB case finding strategies used in Blantyre, Malawi, namely passive case finding (passive self-presentation for case detection), TB/HIV screening and the implementation of community-wide active case finding showed that between January 2011 and August 2014, the vast majority of cases (90.97%, n = 9308 of 10,232) were identified through passive case finding, with 7.6% (n = 785) being identified through HIV/TB screening and 1.41% (n = 144) through community worker active case finding.

The active case finding team was made up of eight lay workers who conducted six-monthly door-to-door enquiries for chronic cough, in which case two sputum samples were taken for auramine fluorescence microscopy. All results were reported in less than five days.

Although routine programme case finding remained the dominant mode of TB detection, cases identified through community active case finding were significantly more likely to be HIV-negative and smear-positive, making it an important TB care and treatment intervention. 84% of the cases identified by the community worker active case finding were smear-positive compared to 57% of the cases identified through passive case finding and 35% who received TB/HIV screening (p < 0.001).

Fifty-nine per cent of TB cases identified through community worker active case finding were HIV positive, compared to 73% in the passive finding group and 86% in the HIV/TB screening group (p < 0.001).

It was recommended that combined case finding strategies are likely to have complementary benefits and improve access to diagnosis.

A significant increase in the number of TB cases detected and referred for immediate treatment was seen following the implementation of an early TB case detection algorithm using a verbal screening tool, among awaiting-trial detainees in Ukraine between 2013 and 2015.

The project aimed to improve early TB diagnosis, increase the yield of bacteriologically confirmed TB cases and to reduce delays to starting treatment among pre-trial detainees and in prisoners. Pre-trial detainees and prisoners are at high risk of developing TB.

A verbal screening tool for symptoms and risk factors of TB was developed and pre-tested among detainees and prisoners and implemented systematically, followed by sputum smear microscopy and further Xpert MTB/RIF, culture and drug-sensitivity testing, if indicated. The study was conducted in three detention centres (known as SIZOs in Ukraine) and five prisons across three regions.

In the first year, which focused on the three detention centres only, 8361 detainees were verbally screened; 3280 (39.2%) individuals showed signs and symptoms of TB, of which 120 people were confirmed with TB disease. This translated into a TB prevalence of 1435 patients per 100,000, which is more than tenfold that of the national prevalence estimate of Ukraine.

The second year also included five prisons. Of the prison and detainee population, 82% (n = 11,964 of 14,654) were screened, 37% (n = 4427) showed symptoms of TB, of which 68 cases of TB were diagnosed.

The detection and initiation of treatment of people with active TB disease will decrease TB transmission inside and outside the detention and prison settings. The screening algorithm has been institutionalised in all penitentiary institutions in Ukraine and has improved the monitoring system of TB cases detection in trial detention centres.

Macpherson P et al. Patient characteristics and contribution to overall caseload from three different TB case finding strategies in Blantyre, Malawi. OA: 371-04. 46th Union World Conference on Lung Health, Cape Town, 2015.

Leontyeva S et al. Early case detection in pre-trial detention centres (SIZOs) in Ukraine. OA: 315-04. 46th Union World Conference on Lung Health, Cape Town, 2015.

Turner D et al. TB screening of hard-to-reach populations at household level with volunteer field workers in Umzinyathi, KwaZulu-Natal. OA: 314-04. 46th Union World Conference on Lung Health, Cape Town, 2015.