Background New, sensitive diagnostic tests facilitate identification and investigation of milder forms of tuberculosis (TB) disease. We used community-based TB testing with the Xpert MTB/RIF Ultra assay (“Ultra”) to characterize individuals with previously undiagnosed TB and compare them to those from the same community who were diagnosed with TB through routine care. Methods We offered community-based sputum Ultra testing to adult residents of a well-defined area (population 34 000 adults) in Kampala, Uganda, via door-to-door screening and venue-based testing, then used detailed interview and laboratory testing to characterize TB-positive individuals. We compared these individuals to residents diagnosed with pulmonary TB at local health facilities and a representative sample of residents without TB (controls). Results Of 12 032 residents with interpretable Ultra results, 113 (940 [95% confidence interval {CI}, 780–1130] per 100 000) tested positive, including 71 (63%) positive at the lowest (trace) level. A spectrum of TB disease was observed in terms of chronic cough (93% among health facility–diagnosed cases, 77% among residents with positive community-based Ultra results at levels above trace, 33% among trace-positive community participants, and 18% among TB-negative controls), TB symptom prevalence (99%, 87%, 60%, and 38%, respectively), and C-reactive protein (75th percentile: 101 mg/L, 28 mg/L, 6 mg/L, and 4 mg/L, respectively). Community-diagnosed cases were less likely than health facility–diagnosed cases to have human immunodeficiency virus coinfection or previous TB. The specificity of Ultra was 99.4% (95% CI, 99.2%–99.5%) relative to a single spot sputum culture. Conclusions People with undiagnosed prevalent TB in the community have different characteristics than those diagnosed with pulmonary TB in health facilities. Newer diagnostic tests may identify a group of people with early or very mild disease.

BackgroundSystematic screening is a potential tool for reducing the prevalence of tuberculosis and counteracting COVID-related disruptions in care. Repeated community-wide screening can also measure changes in the prevalence of tuberculosis over time.MethodsWe conducted serial, cross-sectional tuberculosis case-finding campaigns in one community in Kampala, Uganda, in 2019 and 2021. Both campaigns sought sputum for tuberculosis testing (Xpert MTB/RIF Ultra) from all adolescents and adults. We estimated the prevalence of tuberculosis among screening participants in each campaign and compared characteristics of people with tuberculosis across campaigns. We simultaneously enrolled and characterized community residents who were diagnosed with tuberculosis through routine care and assessed trends in facility-based diagnosis.ResultsWe successfully screened 12,033 community residents (35% of the estimated adult/adolescent population) in 2019 and 11,595 (33%) in 2021. In 2019, 0.94% (95% CI 0.77-1.13%) of participants tested Xpert-positive (including trace). This proportion fell to 0.52% (95%CI 0.40-0.67%) in 2021; the prevalence ratio was 0.55 [95%CI: 0.40-0.75]). There was no change in the age (median 26 vs 26), sex (56% vs 59% female), or prevalence of chronic cough (49% vs 54%) among those testing positive. By contrast, the rate of routine facility-based diagnosis remained steady in the eight months before each campaign (210 [95%CI 155-279] vs. 240 [95%CI 181-312] per 100,000 per year).ConclusionsFollowing an intensive initial case-finding campaign in an urban Ugandan community in 2019, the burden of prevalent tuberculosis as measured by systematic screening had decreased by 45% in 2021, despite the intervening COVID-19 pandemic.

BACKGROUND: Population-based active case-finding (ACF) identifies people with TB in communities but can be costly.METHODS: We conducted an empiric costing study within a door-to-door household ACF campaign in an urban community in Uganda, where all adults, regardless of symptoms, were screened by sputum Xpert Ultra testing. We used a combination of direct observation and self-reported logs to estimate staffing requirements. Study budgets were reviewed to collect costs of overheads, equipment, and consumables. Our primary outcome was the cost per person diagnosed with TB.RESULTS: Over a 28-week period, three teams of two people collected sputum from 11,341 adults, of whom 48 (0.4%) tested positive for TB. Screening 1,000 adults required 258 person-hours of effort at a cost of US$402,000, 70% of which was for GeneXpert cartridges. The estimated cost per person screened was $36 (95% uncertainty range [95% UR] 34–38), and the cost per person diagnosed with Xpert-positive TB was $8,400 (95% UR 8,000–8,900). The prevalence of TB in the underlying community was the primary modifiable determinant of the cost per person diagnosed.CONCLUSION: Door-to-door screening can be feasibly performed at scale, but will require effective triage and identification of high-prevalence populations to be affordable and cost-effective.

Dear Editor, Globally, epidemics of diabetes mellitus (DM) and tuberculosis (TB) are increasingly linked. 1,2 Diabetes is associated with TB infection and with a two-to-four-fold increase in the risk of active disease; 3 active TB may also increase the risk of diabetes. 4 In sub Saharan Africa, where the prevalence of diabetes in the general population is lower than in other regions, 5 the prevalence of diabetes among patients with TB has been estimated at 9%. 6 However, many studies that contributed to that estimate, including one in Uganda, 7 evaluated only hospitalized TB patients and may not be representative of the region's TB epidemic as a whole. There are few data from sub-Saharan African settings on the prevalence of DM among non-hospitalized TB patients or people with TB who have not yet sought treatment. Therefore, the extent to which diabetes detection or management should be integrated with TB care in this region remains unclear.We used a TB case-finding study as an opportunity to estimate the prevalence of diabetes among people with and without TB in a community of Kampala, Uganda. We recruited adult (>15 years) TB cases and TB-negative controls from health facilities and the community. The health facility component recruited patients who were diagnosed with TB by any method at four local facilities ("health-facility cases") and a representative sample of