STS: Active Case Finding Campaign

Active Case Finding (ACF) is a provider-initiated activity with the primary objective of detecting TB cases early by active case finding in targeted groups and to initiate treatment promptly.

• It can target people who anyway would have sought health care with or without symptoms or signs of TB and also people who do not seek care.
• Increased coverage can be achieved by focusing on clinically, socially and occupationally vulnerable populations.
• ACF activities in a campaign mode will create mass awareness about the signs and symptoms in general population

Objective of ACF campaign activities- Reaching the unreached in a campaign mode to enhance TB case finding

Figure 1: Objectives of active case finding

Beyond TB disease, screening can also identify individuals who are eligible for and would benefit from TB preventive treatment (TPT) once TB disease is ruled out, thus further averting future incident TB.

General process is as below:

Figure 2: ACF campaign general process

Resources

1. WHO consolidated guidelines on tuberculosis: Module 2: Screening, Systematic screening for TB disease;WHO 2021
2. India TB Report 2022, Central TB Division, MoHFW 2022
3. Active TB Case Finding- Guidance document, Central TB Division & DGHS, MoHFW 2017

Assessment:

Mapping of vulnerable population is a pre-requisite for conducting an efficient ACF campaign. It involves understanding the population characteristics, identifying and enumerating and mapping the target population. 

Guidelines for mapping

• Identify & map high risk/ vulnerable populations in the local area with the following guidance. If additional information is available locally, it can be used for the prioritisation of target groups.

Figure 1: Schematic map for house to house survey of identified vulnerable population

• Without proper mapping, there is a high chance of missing cases. The success of the active TB case finding campaign relies on how good the mapping is.

Resources

• Active TB Case Finding - Guidance Document, Central TB Division & DGHS, MoHFW, 2017.

Assessment

Active case-finding (ACF) approaches bring essential TB services closer to the community. It has high potential for improving TB case detection and reach people with TB currently missed by the health system. To maximize gains from ACF, it is important that the interventions are planned in advance. 

Planning for ACF includes identifying the right target population/area, designing the intervention, finding the right implementing partners, training of workforce, microplanning for daily activities, logistics, ensuring that the complete pathway of care is followed, reporting and recording.

Steps involved in planning for ACF

1. Identification of population based on:

a. increased risk for TB eg: prisoners, miners, urban slums, co-morbidities like HIV, diabetes etc.

b. those with limited access to health services eg: migrants, homeless, tribal, live in hard to reach areas etc.

2. Identification of stakeholders including district and sub-district TB program staff, non-government organizations, community based organizations, community health workers to support with ACF activities

3. Strengthening the health system e.g. training of staff, ensuring sufficient lab supply and lab technicians. Staff trainings should be done to eliminate gaps in knowledge about TB, cough hygiene, infection control measures, conducting screening, collecting quality sputum, transporting sputum or referring people with presumptive TB to the health facility/laboratory, TB testing, data collection, data entry 

4. Microplanning for ACF includes:

a. when and where to conduct ACF-day, time, duration, methodology-camp, door-to-door, community gatherings, home visits, place of work etc

b. availability of trained manpower, team composition, logistics and consumables

c. screening and diagnostic algorithm to be used

d. number of screenings and tests done per day

e. accessibility and linkage with TB testing laboratories, use of mobile van with CXR, CBNAAT/Truenat 

f. laboratory workload to accommodate additional testing due to ACF

g. laboratory turn around time, availability of test reports for clinical management 

h. advocacy on ACF activities with the target population, pre-sensitization meetings, addressing perceived risks of TB screening and diagnosis (e.g. job loss, loss of income)

i. data collection tools (paper based, smartphones, tablets etc.), TB notification, recording and reporting

Resources

1. Systematic screening for active tuberculosis: an operational guide (http://www.who.int/tb/publications/ systematic_screening/en/)

2. Experience of active tuberculosis case finding in nearly 5 million households in India (Prasad BM, Satyanarayana S, Chadha SS, Das A, Thapa B, Mohanty S, et al. Public Health Action. 2016;6(1):15–8. doi:10.5588/pha/15/0035)

3. Community-wide screening for tuberculosis in a high-prevalence setting (Marks GB, Nguyen NV, Nguyen PTB, et al. N Engl J Med 2019; 381: 1347-57)

Assessment

A targeted approach is considered as an appropriate public health response to identify the hidden cases of TB in the communities. In this regard the National TB Elimination Programme (NTEP) expects that 110,000 per million vulnerable population (11%) should be mapped for community-based screening and >90% of the mapped target vulnerable population should be screened for symptoms of TB.

Mapping of target population from the identified vulnerable population helps the programme to screen out the persons into: 1) those who are at high risk of progression to active TB disease; 2) those who are eligible for TB preventive treatment 3) Enhance the cost-effectiveness of the programme

Following are various methods for identifying and mapping the target population from the vulnerable population:

• Tuberculosis symptom screening

• Sputum testing

• Chest X-ray

Various modalities used to conduct mapping of target population from the identified vulnerable population under the ACF campaign are:

a) House-to-house TB symptom interviews through community volunteers

• Relatively minimal costs

• Needs community awareness session as a pre requisite before conducting ACF

• May be affected by self and perceived stigma

• Community volunteers may require monetary/ no monetary incentives.

b) Door-to-door Sputum collection / sputum drop-off clinics

• Has the potential for higher yield of TB cases

• Involvement of Trained TB staff is required for appropriate collection of sputum

• The sputum has to be non-contaminated in order to avoid compromising the results.

c) Conducting Camps in prisons, migrant localities, old age homes and other such institutional settings

• Accessible to the population who are at high risk but otherwise have limited access to TB testing services

• Essential to detect TB early and stop the spread of infection in such institutional settings.

• Requires skilled TB staff in such settings

d) Mobile vans equipped with X-ray units and Truenat machines

• Feasible yet resource-intensive modality

• Requires skilled staff to handle the testing

• Requires resources - electricity, internet, computer/ tablet etc.

Image

Resource 

• Optimizing active case finding for tuberculosis, Implementation lessons from South-East Asia, World Health Organization,2021.

• Burugina Nagaraja, S.; Thekkur, P.; Satyanarayana, S.; Tharyan, P.; Sagili, K.D.; Tonsing, J.; Rao, R.; Sachdeva, K.S. Active Case Finding for Tuberculosis in India: A Syntheses of Activities and Outcomes Reported by the National Tuberculosis Elimination Programme. Trop. Med. Infect. Dis. 2021, 6, 206. https://doi.org/10.3390/ tropicalmed6040206

Assessment

A good screening algorithm should have the following characteristics:

• High specificity (to reduce the number of false positives, ideally around 70%)
• High sensitivity (to reduce the number of false negatives, ideally around 90%)
• Low Number Needed to Screen (NNS)
• Low cost
• Rapid and simple to apply
• High client acceptability

The algorithm should be optimised so that the maximum number of cases can be detected with available resources.

Usually verbal screening using  symptom complex (4S) are used. However ACF campaigns targeting high risk populations (household contacts, elderly homes etc.)can consider using X ray also as a screening tool. Chest X ray helps in picking up sub-clinical TB cases also which will be usually missed through verbal screening of symptoms.   

A more sensitive test like NAAT is preferred over sputum microscopy in ACF campaigns as the cases will be in early stage and may be missed by testing using Microscopy.

References

• Optimising Active Case Finding – Implementation Lessons from South-East Asia. WHO SEAR, 2021.
• WHO Consolidated Guidelines on Tuberculosis – Module 2: Screening, WHO, 2021.
• High-priority Target Product Profiles for New Tuberculosis Diagnostics: Report of a Consensus Meeting, 28–29 April 2014, Geneva, Switzerland. Geneva: World Health Organisation, 2014.

Assessment

1. Financial Resources

• Financial resources for ACF may be procured from the Centre/State or through local Private Provider Support Agencies (PPSA). When the funds for ACF are procured from the centre, it should be included under a separate budget head (DSTB Pool) under PIP. 
• Each team would be eligible for an incentive of INR 500 for every new case of TB diagnosed and put on treatment under this activity OR as per approvals in the Programme Implementation Plan (PIP) in the National Programme Coordination Committee (NPCC) of the respective state or as approved by the state National Health Mission (NHM). 
• Each state should ensure that local travel arrangements from the general health system are made available for the field visits by the team, supervisory visits, etc.
• Allowances to ensure Travel Allowance (TA)/ Dearness Allowance (DA) and refreshments as per entitlement are to be made from the respective source of salary for the field teams and supervisory teams.

2. Consumables

Logistics for an ACF campaign include:

a. IEC materials: Appropriate IEC materials are to be designed and printed in the local language. A prototype of the same will be shared with states from the CTD. IEC material printing/ distribution should be completed by two weeks before the start of field activities.

b. Additional logistics for testing:

• Additional slides, laboratory reagents, sample transport boxes, X-ray films, CBNAAT cartridges,  falcon tubes (minimum 1000 per 1 lakh population) should be procured and supplied to health staff for collecting sputum samples from the eligible symptomatic at least two weeks before the start of field activities. Boxes for sputum sample transport should be provided to the health staff for carrying samples to DMCs.
• Additional sputum examination request forms needed – 500 per 1 lakh population

c. Recording and reporting forms: All recording and reporting formats requirement assessment is to be done by DTOs three weeks before the start of field activities

3. Human resource

Human resource for ACF is required for the following:

a. Field activities: House-to-house visits, symptom screening, sputum collection and transport to the Designated Microscopy Centre (DMC).

• One field visit team will comprise two members - one health worker from National TB Elimination Programme (Senior Treatment Supervisor (STS)/ Senior TB Lab Supervisor (STLS)/ TB Health Volunteer (TB-HV)) or a partner organisation (NGO outreach worker) or general health services (Auxiliary Nurse Midwife (ANM)/ Multipurpose Worker (MPW)/ Multipurpose Healthcare Supporters (MPHS) and one Accredited Social Health Activist (ASHA) or community volunteer. The states should decide on the team composition based on available resources and the population to be covered (as obtained from vulnerability mapping).
• House-to-house visits by health workers should involve community leaders, panchayat members particularly the women members, religious leaders and other local influencers like medical practitioners, local moneylenders, grocery shop owners, popular teachers, prominent youth, etc.
• Local community members/ influencers must accompany search teams during house-to-house visits in such areas, especially during revisit to houses.

b. Testing additional sputum samples for Mycobacterium tuberculosis (MTB): Laboratory technicians of the linked DMC and Cartridge-based Nucleic Acid Amplification Test (CBNAAT) labs should be well-informed about the increase in workload and recording of information during ACF activities. 

c. Supervision and Monitoring of ACF activities: Supervision and monitoring of the campaign are done at various levels under the leadership of designated officers. It is  required during the preparatory phase as well as the implementation phase of the campaign.The list of observers along with the districts/ blocks/ urban areas allotted must be shared with Central TB Division (CTD).

• Village level - Medical Officer of Primary Health Centre (PHC)/ Community Health Centre (CHC)/ Urban Health Centre (UHC)
• Block level - Block Medical Officer (BMO)/ Block Health Officer (BHO)
• District level - District TB Officer (DTO)
• State level - State TB Officer (STO)
• Regional level – Regional Directors of the Regional Office of Health and Family Welfare (ROH&FW) will be in charge of supervising activities in their respective states.
• National level - One national level officer for each state will be nominated by CTD to supervise and monitor activities including field visits to the states prior to and during the campaign.

References

• Active TB Case Finding Guidance Document, Central TB Division, Ministry of Health and Family Welfare, 2017.

Assessment

Microplanning for ACF Campaign

A microplan is a detailed plan of action in terms of human resources, materials, money and time. A good microplan ensures that the health intervention reaches each individual beneficiary and is crucial to the success of the activity. For Active Case Finding (ACF), microplanning is performed at the health facility level and collated at the block, district and state levels. Training for the same is given to concerned personnel during state, district and block level meetings prior to the campaign. Microplan at PHI, Block, District and State levels should be ready at least 15 days prior to the initiation of field activities.

Microplanning is done with respect to:

I. Advocacy, Communication and Social Mobilization (ACSM)

 A comprehensive IEC plan should be made with communication material for mass media, mid-media and print media to reach out up to the remotest village in advance.

II. Logistics

• Microplan should include planning additional consumables required for the campaign
• It includes additional slides, laboratory reagents, sputum cups, falcon tubes, sample transport boxes, X-ray films, Cartridge-based Nucleic Acid Amplification Test (CBNAAT) cartridges, etc. Additional sputum containers (minimum 1000 per lakh population) will be procured and supplied to health staff for collecting sputum sample from the eligible symptomatic two weeks before the start of field activities
• Linkages of Peripheral Health Institute (PHI) areas with Designated Microscopy Centre (DMC), X-ray facilities, CBNAAT lab, Extra Pulmonary (EP) sample collection and EP testing should be included in the planning up-front. 
• Laboratory technicians of the linked DMC and CBNAAT labs should be well informed about the increase in workload and recording of information during ACF activities.

III. Field activities including human resources

• Maps prepared for other campaigns like Pulse Polio, Leprosy Case Detection Campaign (LCDC), etc. must be used while planning. If maps are not available with local bodies, search team members and supervisors should be sent to the area before the ACF campaign, in order to become familiar with the area and develop maps. 
• The number of houses to be covered each day should be mentioned in the microplan. This number may vary from day to day depending upon the geographical situation of the area planned to be covered by the team on a particular day. 
• Teams of two persons each should go house-to-house. Out of the two members in each team, one should be a local volunteer (including Accredited Social Health Activist (ASHA)).
• Each team should be allocated clear-cut, well-demarcated areas clearly mentioning the starting and ending points, identifiable with landmarks; for each day of House to House (h-t-h) activity.
• In special areas, one additional person from the local community, where the team will be working, should accompany the team. 
• Human resources required for covering the mapped vulnerable population during field activities should be calculated and recorded.
• For planning and implementation purposes, urban areas should be divided into smaller planning units based on municipal wards or assemblies, or by roads or prominent landmarks. Each such unit should be put under the charge of a medical officer or nodal officer.
• Involvement of the local community, leaders, health officials, municipal bodies and their staff is essential in planning.
• Local staff is familiar with the layout of the urban areas and their inputs are vital for planning and supervision of house-to-house activities.

Execution of Microplan

The ACF campaign is executed as per the microplan and supervision is done with reference to the microplan

The House to House (h-t-h) survey is done for 2 weeks

A survey team consisting of 2 persons - one NTEP staff/ partner organization staff/ General Health services staff and one local volunteer / ASHA worker. They go from house to house in the mapped vulnerable areas/ key population groups and screen individuals for symptoms of TB. After screening, the eligible population for sputum examination includes: Persistent cough for ≥2 weeks, Fever for ≥2 weeks, Significant weight loss (>5% weight loss over last 3 months), Presence of blood in sputum any time during the last 6 months, Chest pain in the last one month, History of Anti-TB Treatment (previous/ current). If any one of these is present, a sputum cup or falcon tube is given to them and a sputum sample is collected. Sputum samples thus collected are transported to a designated lab using the sample transport system existing in the area. testing using smear microscopy/CBNAAT will be done for all symptomatic persons as per the state policy. Those who are microbiologically confirmed to be positive should be initiated on treatment within 2 days. Additionally, the team will look for other symptoms/diseases also. If person is having any symptoms or other ill health, s/he will be referred for evaluation by a Medical Officer for further management, if needed. Field Activity Report will be submitted by each health staff on a daily basis to the Medical Officer of the Peripheral Health Institution

Resources

• Active TB Case Finding – Guidance Document, 2017, Central TB Division, MoHWF, New Delhi.
• Active Case Finding for Tuberculosis in India: A Syntheses of Activities and Outcomes Reported by the National Tuberculosis Elimination Programme, Burugina Nagaraja S et al, Trop Med Infect Dis., 2021.

Assessment

Vulnerability mapping and Microplanning are 2 important activities of Active Case Finding which precede field activities. Vulnerable populations should be mapped and recorded in prescribed formats from health facility level onwards. Mapping data from PHI are consolidated at Block level, those at Block level are consolidated at district level and those at district level are consolidated at state level. Data from mapping formats is used for microplanning. Microplanning forms the basis of field activities. Microplans are also consolidated at subsequent levels. During supervision and monitoring, it is important to assess the activities with respect to the microplan. 

The recording formats for ACF include:

1. Formats for mapping - Health Facility Level, Block Level, District Level and State Level                     

2. Formats for microplanning - Manpower, Logistics, Field Activity

FORMATS FOR MAPPING

Mapping details should also be entered in Ni-kshay under the section shown below:

Image

Fig: Ni-kshay section for reporting various ACF activities

FORMATS FOR MICROPLANNING

Based on the requirement obtained from the mapping exercise, microplanning is done with respect to human resource, logistics and field activities

Human Resource Planning Form

Field activities are captured in Form 1 & 2 of the ACF. The data from field activities are compiled at the PHI level and submitted to the District and State using google sheets at present. Although there is no specific mechanism to demarcate the presumptive TB patients and the confirmed (clinical and microbiological) TB cases in Ni-kshay, States follow different mechanism including marking in the Laboratory register as ACF testing and sending a separate sheet to the district in paper format.

Reference: 

1. Active TB Case Finding - Guidance Document, Central TB Division & DGHS, MoHFW, 2017 

Assessment:

Field supervision of Active Case Finding (ACF) is needed during both the preparatory phase and the implementation phase. Supervisory teams should be formed at the National, State, District, Block and Peripheral Health Institute (PHI) levels.

Field supervision during the preparatory phase: 

The Field Supervisors should: 

• Attend District and Block Coordination Committee meetings.
• Review the micro plan and check whether all components are present. 
  • All geographical areas have been included. 
  • Team composition is appropriate – all house-to-house teams have at least one Accredited Social Health Activist (ASHA) and at least one Non-government Organisation (NGO) worker and at least one National TB Elimination Programme (NTEP) field staff. 
  • Sensitisation training to detect the cases has been planned for all ASHAs and field staff. 
  • Workload of teams in terms of houses to be covered/ day has been rationalised.  
  • Areas requiring special attention have been identified and plans developed.
  • Information, Education and Communication (IEC)/ social mobilisation plans have been developed and documented. 

Field supervision during the implementation phase: 

• All officers should again visit their allotted districts/ blocks/ urban areas during the implementation phase to assess the quality as well as the completeness of coverage of the area through house-to-house visits. 
• Field Activity Report will be submitted by each health staff on a daily basis to the Medical Officer of PHI. The Field Activity reports from all health staff will be analysed and appropriate action will be taken by the Medical Officer of PHI and these reports will be combined and a report will be prepared and submitted to Block Medical Officer (BMO) on daily basis. 
• Ensure a mechanism of daily feedback from the observers to the block and district control rooms to facilitate immediate corrective action at all levels. Tracking the cascade of care is a useful tool for assessing quality. (Cascade of care: Track No. of people targeted, no. of people screened out of targeted, no. of presumptive TB identified out of screened, no. of presumptive TB patients examined out of identified, no. of presumptive TB completely evaluated {like smear-negative patients examined with chest X-ray and Cartridge-based Nucleic Acid Amplification Test (CBNAAT), no. of TB patients diagnosed out of examined, no. of TB patients put on treatment out of those diagnosed.})
• Qualitative and quantitative assessment of the ACF campaign activity from observers should be utilised for long-term corrective actions like problems faced by ASHAs & Frontline Workers (FLWs) during the campaign, review of micro-plans etc. or immediate corrective actions like repeating the activity in an area where a significant number of uncovered houses are found after completion of the activity. 

The Progress indicators and quality indicators for ACF should be monitored by the supervisory team while on field visit.

Resources

• Active TB Case Finding Guidance Document, CTD, DGHS, MoHFW, 2017.

Assessment

Monitoring should be an integral part of the Active Case Finding (ACF) interventions. It is accomplished by a strong data collection system enacted through a programme-based ACF data and recording in Nikshay.

Monitoring activities for ACF interventions broadly cover the number screened, number of presumptive TB cases based on symptoms or chest X-ray findings, samples collected for testing, samples transported for testing, samples tested, microbiologically and clinically diagnosed TB cases, TB notification and treatment initiation.

Monitoring Against the ACF Plan

1. Monitor the Number Needed to Screen (NNS), i.e., the number needed to be screened based on current TB symptoms, past history of TB, comorbidities, other socio-economic factors, etc. 

2. Monitor the Number Needed to Test (NNT) which helps understand the efficiency of diagnostic testing and the efficiency of screening for presumptive TB.

3. Monitor the yield of ACF activities, i.e., TB cases found and compare the yield of different screening and testing methods (X-ray, smear, Nucleic Acid Amplification Test (NAAT)).

4. Monitor whether there was an additional increase in TB notification of bacteriologically confirmed TB cases compared to the previous year (or in comparison to a control district).

• Monitor notification trends, treatment outcomes and mortality (TB prevalence should decrease over years based on repeated ACF in the same population).

5. Monitor engagement of National TB Elimination Programme (NTEP) staff, non-governmental organisations, community volunteers and the private sector in ACF activities.

Monitoring Against the Cascade of Care

1. Monitor the proportion of people with presumptive TB who provide sputum.

2. Monitor linkage to health facilities, sample collection, transportation and tests done.

3. Monitor drop-outs between screening and diagnosis, dropouts between diagnosis and treatment.

4. Monitor public health action provided to notified TB cases.

Resources

• Optimizing Active Case Finding for Tuberculosis, 2021. 
• Training Module (1-4) for Programme Managers and Medical Officers, NTEP, MoHFW, 2020.

Assessment

The ACF campaign has to be reported for documentation, monitoring and evaluating the performance of the activity and guiding the policy decisions. 

The various formats used for reporting of performance of Active Case Finding (ACF) activities are as follows:

1. Field activity daily report

• Submitted by each health staff on a daily basis to the Medical Officer of Primary Health Centre (PHC)/ Community Health Centre (CHC)/ Urban Health Centre (UHC).

Table 1: Format for field activity daily report

2. ACF activity reporting by Health Facility

• The Field Activity reports from all health staff will be analysed and appropriate action will be taken by Medical Officer of PHC/ CHC/ UHC.
• These reports are combined and a report will be prepared as per the following format and submitted to Block Medical Officer (BMO)/ Block Health Officer (BHO) on daily basis.

Table 2: Format for ACF activity by health facility

At the block level reports from all the reporting units will be compiled in the below format and sent to the District on a daily basis.

3. ACF activity reporting by Block/ Town/ City

Table 3: Format for ACF activity reporting by block/ town/ city

And at the district level, reports from all blocks are to be compiled in the format below, and the consolidated report should be sent to the State.

4. ACF activity reporting by District

Table 4: Format for ACF activity reporting by district

5. ACF activity reporting by State

Table 5: Format for ACF activity reporting by state

• State TB Officer (STO) would be responsible for the overall coordination and implementation of campaign activities and reporting in the State/ UT.
• Data entry of district-level reports in electronic format will be ensured by District TB Officer (DTO) on a daily basis after the field activity is completed. Nikshay has a section on active case finding where the mapping of target population and reporting of various activities can be done.

Fig 1: Nikshay section for reporting various ACF activities

Resources

• Active TB Case Finding - Guidance Document, Central TB Division & DGHS, MoHFW, 2017.

Assessment