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  • Screening For Tuberculosis Disease

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    Screening for active tuberculosis (TB) a process to filter out people who are less likely to have TB, from a group. Screened positive people are likely to have TB and are confirmed subsequently using a TB diagnostic test. This will allow finite diagnostic testing resources to be used on the remaining.

    Screening in TB may be performed ​using simple field tools (4 Symptom complex) and tests such as Chest X-ray, or a combination of both. ​Combination of both is the most effective, but is often not applied due to the practical difficulties in making a chest X-ray conveniently available.

    Screening is an integral part of any general case finding effort. It is also applied systematically in specific situations.

    1. At health care facilities (intensified case finding): Here those visiting are screened using the 4 symptom complex, often at the point of entry to the facility. Those screened positive may be fast-tracked to TB Diagnostic testing.
    2. In vulnerable populations in active case finding efforts: Here the entire population identified for active case finding are screened using the pre-decided protocols by going door to door. 

    Resources

  • Universal Drug-susceptibility Testing for TB

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    Drug Susceptibility Testing (DST) refers to in-vitro testing using either of the phenotypic methods to determine susceptibility. Drug Resistance Testing (DRT) refers to in-vitro testing using genotypic methods (molecular techniques) to determine resistance.    

     

    • Universal Drug Susceptibility Testing (UDST) refers to universal access to rapid DST for at least Rifampicin (R), and further DST for at least Fluoroquinolones (FQs) among all TB patients with rifampicin-resistance.
    • UDST is essential to identify patients who can be initiated on Drug-resistant TB (DR-TB) treatment instead of Drug-sensitive TB (DS-TB) treatment, especially in a situation where the drug-resistance level is high.
    • It should be done preferably before initiation of treatment to a maximum within 15 days of diagnosis.
    • UDST is a part of national policy under the National TB Elimination Programme (NTEP).
    • NTEP has undertaken decentralization of quality assured diagnostics for scale up of UDST across the country which has helped in early detection of DR-TB treatment and reducing associated morbidity and mortality. 

     

    Resources​
     

     

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  • Approaches to TB Case Finding

    Content

    People who have been exposed to patients with infectious TB are known as TB contacts; they constitute a high-risk group for TB. Case finding investigation contributes to the early detection of TB cases, and results in identifying a significant number of additional patients.

    Figure: Approaches to Tuberculosis Case Finding

     

    Active case-finding requires systematic screening and clinical evaluation of populations who are at high risk of developing TB, such as people living in slums, tribal areas, congregate settings, persons who are household contacts of TB cases

     

    Resources:

     

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  • Active Case Finding

    Content

    Systematic screening of all individuals of a defined population is known as active case finding.  It is applied outside of health facilities at the community level by the health system.

    Objective of ACF is to:

    1. identify cases early, initiate prompt treatment, reduce risk of poor treatment outcomes and reduce risk of further transmission of TB
    2. to provide access to diagnosis services to populations that would have been otherwise unreached

    It is effort intensive and is recommended only in population groups where there is estimated high case load. In NTEP, ACF is recommended only to be performed in Key / vulnerable population.

    ACF can also be clubbed with suitable ACSM campaigns to create awareness about the signs and symptoms and about TB in the target population/ community. It can also be combined with other health activities/ campaigns (such as Pulse Polio/ Leprosy screening/ population based screening for NCDs) for increased efficiency.

    Resources

    1. Training Modules for Programme Managers and Medical Officers.
    2. Active TB Case Finding, Guidance Document.
    3. WHO recommendations for Systematic Screening for Active Tuberculosis

     

    Assessment

    Question Answer 1 Answer 2 Answer 3 Answer 4 Correct answer Correct explanation Page id Part of Pre-test Part of Post-test
    Which of the following is not a primary objective of ACF? Increase TB notification Early identification of cases. Reduce the risk of transmission of TB. Reduce the risk of poor treatment outcomes. 1 Notification is not a primary objective of ACF.   Yes Yes

  • Passive Case Finding

    Content

    Passive case finding is essentially where the patient self reports to the health care provider with symptoms. This requires that affected individuals are aware of their symptoms, have access to health facilities, and are evaluated by health workers or volunteers who recognise the symptoms of TB and link those individuals for TB testing services.

    This approach to case finding has the least effort and cost and is a minimum expectation. In a Peripheral Health Institution (PHI), it is estimated that about 2-3% of new adult outpatients are symptomatic that require referral for TB diagnosis (presumptive TB cases).

    Passive case finding may miss TB patients if :

    1. The disease is mild/ transient.
    2. Access to healthcare is poor.
    3. Health providers do not have an adequate index of suspicion and are unable to reliably link respiratory symptoms to TB. 

    Resources

    1. Training Modules for Programme Managers and Medical Officers.

     

    Assessment

    Question Answer 1 Answer 2 Answer 3 Answer 4 Correct answer Correct explanation Page id Part of Pre-test Part of Post-test
    Which of the following can be considered a passive case finding?  TB case finding for all patients attending an HIV clinic. TB case finding in all inmates of an elderly home. Patients attending a PHC with symptoms are referred for testing by the doctor. TB case finding among household contacts of a TB case. 3 All other examples except those attending PHC referred for TB testing are cases of active or intensified case finding effort.   Yes Yes
    What may cause a passive case finding to miss cases? Healthcare providers fail to notify the case. Healthcare providers do not refer cases for TB testing. There are no health facilities in the area. Both 2 and 3 4 Healthcare providers failing to notify cases is missing notification and not related to passive case finding.   Yes Yes

     

  • Intensified Case Finding

    Content

    Intensified Case Finding (ICF) is a case finding approach between Active and Passive approaches. Here individuals coming in contact with the health system through any activity are screened actively for symptoms of TB and referred for testing.

    This approach brings the benefit of active case finding approach by active screening for TB symptoms, but does limit the extensive effort required by restricting to only those people who has some or the other healthcare problem. This approach is considered for people attending a healthcare facility.

    Some examples of ICF are screening for TB symptoms and referral for testing in:

    • all cases attending an HIV clinic.
    • among children with malnourishment who attend a nutrition clinic.
    • all mothers attending the antenatal clinics

    Resources

    1. Technical and Operational Guidelines.
    2. Assessing TB Case Finding.

    Assessment

    Question Answer 1 Answer 2 Answer 3 Answer 4 Correct answer Correct explanation Page id Part of Pre-test Part of Post-test

    Which of the following is an example of an intensified case finding?

     

    		 Systematic screening for TB of all contacts of TB cases. Screening all cases attending an OPD with respiratory symptoms for TB testing. Referring cases that report more than 2 weeks of cough from an OPD for TB testing. Screening all people belonging to a slum for TB symptoms. 2

    Systematic screening of TB contacts and those belonging to a slum population are examples of active case finding.

    Referring to cases that report TB symptoms is a passive case finding.

    		   Yes Yes

  • Bidirectional Screening

    Content

    Bidirectional screening is a method to identify cases in diseases which have predisposition to each other or has a significant influence on each other. For example TB and HIV, where having HIV increases risk of developing TB and cases with TB would have poor outcomes if co-infected with HIV.

    Screening for TB is done through four-symptoms complex based screening or through Chest X-ray. Screening for the linked disease is carried out as per the policies of the corresponding health program.

    Bi-directional screening policies are implemented by various disease control programs. For example, with NTEP the following disease control efforts implement a bidirectional screening policy:

    1. HIV through NACO 
    2. COVID19 
    3. Diabetes Mellitus (DM) through NPCDCS
    4. Tobacco  through National Tobacco Control Program

    Both programs monitor bidirectional screening, referral and testing as per their own policies.

    Resources

    1. National Strategic Plan for TB Elimination.

    Assessment

    Question Answer 1 Answer 2 Answer 3 Answer 4 Correct answer Correct explanation Page id Part of Pre-test Part of Post-test
    Bidirectional screening for TB is not done in which of the following conditions? Diabetes Tobacco abuse/ addiction Pregnancy COVID-19 3 Although pregnant mothers may be screened for TB as a part of intensified case finding, all TB cases are not actively/ routinely screened for pregnancy.   Yes Yes