WCLH 2015: Community Care Workers Boost TB Case Finding Among Hard-to-Reach Adults


Active case finding by community care workers is an effective tool for increasing tuberculosis (TB) case detection, according to 2 studies presented at the 46th Union World Conference on Lung Health held in December in Cape Town. Finding and diagnosing TB is the essential first step to closing the global gap in stopping TB.

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Screening for signs and symptoms of HIV, TB, and diabetes by volunteer community care workers at the 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.

IN this study 37 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 2 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 were sick.

According to study presenter Derek Turner of the Umvoti AIDS Centre in 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 obtain access to TB record cards for recording treatment start dates and outcomes, and they also consistently fill in the screening tool.  

Of the 1665 people screened, a high percentage (39.8%) were male. Men are traditionally harder to reach than women and less likely to access health services. A total of 350 people showed signs and symptoms of TB and were referred to primary health clinics for TB testing, 247 of whom had either no prior visit to a health facility or an uncertain outcome reported by caregivers.

Of the 103 people who were successfully referred to a public health care facility, 36 started TB treatment (20 women and 16 men), and 17 have completed treatment to date.

There were 29 people who were already confirmed as having TB and on treatment, 5 of whom had been treated for more than 1 year. One of those on treatment for more than a year has been diagnosed with multidrug-resistant TB and has started second-line treatment. Also 2 people with known TB who had refused treatment were identified. In addition, 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," Turner said.

Case Finding Strategies in Malawi

Another study looked at patient characteristics and contribution to overall caseload from 3 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. The study showed that between January 2011 and August 2014, the vast majority of cases (90.9%, 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 8 lay workers who conducted door-to-door enquiries every 6 months for chronic cough, in which case 2 sputum samples were taken for auramine fluorescence microscopy. All results were reported in less than 5 days.

Although routine program 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 community worker active case finding were smear-positive compared to 57% of cases identified through passive case finding and 35% who received TB/HIV screening. 59% 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.

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

Early TB Detection in Pre-Trial Detention and Prison

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 for detainees awaiting trial in Ukraine between 2013 and 2015.

This project aimed to improve early TB diagnosis, increase the yield of bacteriologically confirmed TB cases, and reduce delays to starting treatment among pre-trial detainees and in prisoners, groups 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 3 detention centers (known as SIZOs in Ukraine) and 5 prisons across 3 regions.

In the first year, which focused on the 3 detention centers only, 8361 detainees were verbally screened; 3280 (39.2%) individuals showed signs and symptoms of TB, of which 120 were confirmed to have TB disease. This translated into a TB prevalence of 1435 patients per 100,000, which is more than 10-fold that of the Ukraine national prevalence estimate.

The second year also included 5 prisons. Of the prison and detainee population, 82% (n = 11,964 of 14,654) were screened and 37% (n = 4427) showed symptoms of TB, among whom 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 institutionalized in all penitentiary institutions in Ukraine and has improved the monitoring system of TB cases detection in trial detention centers.



D Turner, S Shenoi, R Brooks, et al. TB screening of hard-to-reach populations at household level with volunteer field workers in Umzinyathi, KwaZulu-Natal. 46th Union World Conference on Lung Health. Cape Town, December 2-6, 2015.Abstract OA-314-04.

P Macpherson, E Webb, A Choko, et al. Patient characteristics and contribution to overall caseload from three different TB case finding strategies in Blantyre, Malawi. 46th Union World Conference on Lung Health. Cape Town, December 2-6, 2015.Abstract OA-371-04.

S Leontyeva, K Gamazina, O Bogdanov, et al. Early case detection in pre-trial detention centres (SIZOs) in Ukraine. 46th Union World Conference on Lung Health. Cape Town, December 2-6, 2015.Abstract OA-315-04.