Tuberculosis screening among pregnant women attending a tertiary care hospital in Puducherry, South India: is it worth the effort?

Abstract

Background: The national tuberculosis (TB) programme in India recommends screening all pregnant women for TB, but this is rarely implemented. We carried out systematic TB screening among women attending the antenatal clinic of a tertiary care hospital in Puducherry, South India, during February to April 2018. Objective: To assess the number screened and number (proportion) with presumptive and active TB, and understand potential implementation from the healthcare providers' perspective. Methods: We conducted a mixed-methods study. The quantitative phase was a cross-sectional study including 4203 pregnant women. Data were captured using a structured proforma. Any of the following symptoms constituted 'presumptive TB': any cough, haemoptysis, fever, weight loss, night sweats, neck swellings, joint pains, neck stiffness and disorientation. Those screening positive were referred for investigations and evaluation by a chest physician. The qualitative phase involved seven one-to-one interviews with healthcare providers. Manual thematic analysis was performed to generate themes. Results: Among 4203 women (two HIV-positive) screened, 77 (1.8%) had presumptive TB. Cough was the predominant symptom (n = 75). Only 12 women could produce a sputum sample, of whom one (0.02%) was diagnosed with active TB by the Xpert MTB/RIF assay. Challenges cited by healthcare providers were lack of awareness among clients and providers, high case load, lack of dedicated staff, perception that TB screening is a low-yield, low-priority activity and losses in the referral process. Suggested solutions were providing dedicated staff and space for screening, educating women to self-report using posters and videos, and creating a one-stop care provision. Conclusions: The TB yield among pregnant women was very low, calling into question the value of systematic screening in a low-HIV setting. However, the findings may not be generalizable. Evidence is urgently needed from primary and secondary care facilities. The challenges and solutions identified may help in optimizing the screening process.

Integrating tuberculosis screening into antenatal visits to improve tuberculosis diagnosis and care: Results from a pilot project in Pakistan

“…This analysis found 2.6% of pregnant women with TB symptoms on initial verbal screening during routine ANC visits, which is higher than the rate of 1.8% reported from South India (Vijayageetha et al, 2019) but lower than the rate of 5.0% reported in western Kenya (Kosgei et al, 2013). This study found a prevalence of TB of 0.9% among the screen-positive women with sputum tested on Xpert MTB/RIF.…”

A systematic review and meta-analysis of active case finding for tuberculosis in India

“… 18 , 19 , 20 , 21 , 22 , 23 One study conducted in 4 states did not report the location details. 22 Amongst 58 study sites in 44 studies, 26 were in South India (14 in Tamil Nadu, 18 , 19 , 20 , 21 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 6 in Karnataka, 18 , 19 , 23 , 34 , 35 , 36 4 in Andhra Pradesh, 20 , 37 , 38 , 39 1 in Telangana, 40 and 1 in Pondicherry 41 ), and 10 in Western India (8 in Maharashtra, 18 , 19 , 42 , 43 , 44 , 45 , 46 , 47 2 in Gujarat 18 , 19 ).

Figure 2 Geographical distribution of active case finding implementations in India.

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“…Of the 45 studies, 40 were conducted in a public sector setting, 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 43 , 44 , 45 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 3 in private sector, 32 , 42 , 61 and 2 were public-private mix. 31 , 46 Ten studies were in urban populations, 25 , 29 , 30 , 31 , 33 , 41 , 42 , 46 , 55 , 58 9 in rural, 21 , 24 , 26 , 27 , 36 , 48 , 49 , 53 …”

“… 31 , 46 Ten studies were in urban populations, 25 , 29 , 30 , 31 , 33 , 41 , 42 , 46 , 55 , 58 9 in rural, 21 , 24 , 26 , 27 , 36 , 48 , 49 , 53 , 59 21 in both rural and urban populations 18 , 19 , 20 , 22 , 23 , 32 , 34 , 35 , 38 , 43 , 44 , 45 , 47 , 50 , 51 , 52 , 54 , 56 , 57 , 60 , 61 ; the composition was unclear in 5 studies. 17 , 28 , 37 , 39 , 40 The level of health system for TB care varied: 23 at primary level, 17 , 21 , 24 , 25 , 26 , 27 , 29 , 30 , 31 , 33 , 35 , 36 , ...…”

“…22 , 28 , 37 A total of 33 studies diagnosed only pulmonary TB, 18 , 19 , 20 , 21 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 43 , 44 , 45 , 47 , 48 , 49 , 50 , 51 , 53 , 54 , 55 , 57 , 58 , 60 and 12 diagnosed both pulmonary and extra-pulmonary TB. 17 , 22 , 23 , 32 , 33 , 41 , 42 , 46 , 52 , 56 , 59 , 61 ( Table 1 , Supplementary File 3)…”