Improving TB case notification in northern Uganda: evidence of a quality improvement-guided active case finding intervention

Abstract

BackgroundStrategies to identify and treat undiagnosed prevalent cases that have not sought diagnostic services on their own, are necessary to treat TB in patients earlier and interrupt transmission. Late presentation for medical services of symptomatic patients require special efforts to detect early and notify TB in high risk populations. An intervention that combined quality improvement with facility-led active case finding (QI-ACF) was implemented in 10 districts of Northern Uganda with the highest TB burden to improve case notification among populations at highest risk of TB.MethodsUsing QI-ACF intervention approach in 48 facilities, we; 1) targeted key vulnerable populations, 2) engaged district and facility teams in TB systems strengthening, 3) conducted systematic screening and diagnosis in vulnerable groups (people living with HIV, fishing communities, and prisoners), and 4) trained health workers on national x-ray diagnosis guidelines for smear-negative patients. Facility-led QI-ACF meant that health care providers identified the target population, mobilized and massively screened suspects, and addressed gaps in documentation. Chest X-ray diagnosis was promoted for smear-negative TB among those suspects whose sputum examination was negative. The effect of the intervention on case notification was then assessed separately over the post intervention period.ResultsOver all TB case notification in the intervention districts increased from 171 to 223 per 100,000 population between the baseline months of October–December 2016 and end line month of April–June 2017. TB patient contacts had the majority of TB positive cases identified during active case finding (40, 6.1%). Fishing communities had the highest TB positivity rate at 6.8%. Prisoners accounted for the lowest number of TB positive cases at 34 (2.3%).ConclusionTargeting should be applied at all levels of TB intervention to improve yield: targeting districts and facilities with the lowest rates of case notification and targeting index patient contacts, HIV clients, and fishing communities. Screening tools are useful to guide health workers to identify presumptive cases. Efforts to improve availability of x-ray for TB diagnosis contributed to almost half of the new cases identified. Having all HIV patients who were eligible for viral load provide sputum for TB screening proved easy to implement.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3786-2) contains supplementary material, which is available to authorized users.

Tuberculosis active case-finding interventions and approaches for prisoners in sub-Saharan Africa: a systematic scoping review

“…Species identification and drug susceptibility testing performed with Genotype MTBDRplus Active TB Henostroza et al, 2013 [ 46 ] Zambia Cross-sectional study Lusaka Central Prison 2011 Digital X-ray/sputum smear microscopy, LED fluorescence, Lowenstein-Jensen Medium) culture. Active TB Kalonji et al, 2016 [ 47 ] Democratic Republic of the Congo Cross-sectional study Mbuji-Mayi Central Prison 2015 Clinical examination and bacteriological tests Active TB Karamagi et al, 2018 [ 48 ] Uganda Cross-sectional study 16 central and farm prisons (Names not specified) 2017 Combined quality improvement with facility-led active case finding (QI-ACF) Active TB Kayomo et al, 2018 [ 49 ] Democratic Republic of the Congo Cross-sectional study Mbuji-Mayi Central Prison 2015 Xpert MTB/RIF assay Active TB Kwabla et al, 2015 [ 50 ] Ghana Cross-sectional study Ho Prison 2014 Sputum smear microscopy Active TB Maggard et al, 2015 [ 51 ] Zambia Cross-sectional study Lusaka Central Prison, Livingstone Central Prison, Kabwe Prison Complex, 2011 Fluorescence microscopy, cultures, X-rays and physical examinations. Active TB Merid et al, 2018 [ 52 ] Ethiopia Cross-sectional study Hawassa prison 2016 Acid-fast bacilli, smear microscopy and molecular diagnostic testing (Xpert® MTB/RIF) Active TB Noeske et al, 2006 [ 53 ] Cameroon Cross-sectional study New Bell Central Prison of Douala 2004 Smear microscopy and/or culture Active TB Owokuhaisa et al, 2014 [ …”

“…All 31 articles scored between 57 and 86%. The majority (45.2%) of the included articles scored 71.4% (14/31) [ 36 , 39 , 40 , 42 , 45 , 46 , 49 , 50 , 53 – 56 , 60 , 61 ] and 10 (32.2%) scored 57.1% [ 35 , 37 , 38 , 41 , 43 , 44 , 47 , 48 , 52 , 57 ]. The remaining seven included articles scored the highest (85.7%) [ 32 – 34 , 51 , 58 , 59 , 62 ].…”

“…Of the 31 included studies 23 (74%) used only mass screening strategy [ 32 – 45 , 47 , 49 , 50 , 52 – 55 , 57 , 58 ], and two studies used both mass and entry screening [ 56 , 61 ]. One study each used the following strategies: Mass screening and routine screening by peer educators [ 62 ], mass screening and tuberculin skin testing [ 60 ], facility-led ACF [ 48 ], mass screening of inmates, community-based screening of adjacent encampments, and comprehensive entry and routine using inmates as peer educators [ 51 ], entry screening and screening of newly admitted prisoners, and use of inmates as peer educators [ 59 ], and mass screening of all inmates entering, residing, and exiting the prison, as well as in the surrounding community [ 46 ]. Figure 3 summarizes the ACF approaches used by the included studies.…”

“…Kayomo et al cross-sectional study aimed to report the outcomes of the outbreak of TB and Multidrug-Resistant TB in Mbuji-Mayi Central Prison further confirmed 170 TB cases out of 475 symptomatic TB cases [ 49 ]. In Uganda, Karamagi and colleagues combined quality improvement with facility-led active case finding confirmed 2.3% (34/1494) TB cases from 16 central and farm prisons in Northern Uganda [ 48 ]. Owokuhaisa et al ACF intervention in Mbarara Central prison of Uganda involving 248 prisoners confirmed five new TB cases [ 54 ].…”

Active TB case finding in a high burden setting; comparison of community and facility-based strategies in Lusaka, Zambia

“…Much as the term ACF is often used to imply systematic screening and diagnostic evaluation of TB risk groups that happens outside the health facility, it actually constitutes provider initiated screening both inside and outside the health facility [13]. There is evidence on effectiveness of ACF in the community [14][15][16][17][18][19], there is less evidence for the effectiveness of ACF at the health facility [7,20,21] and even less literature comparing the two active case finding strategies [21].…”