New operational research finds TB patients diagnosed through active case finding suffer less diagnosis delay

A new study led by researchers from the International Union Against Tuberculosis and Lung Disease (The Union) has found that proactive outreach into communities to screen for tuberculosis (TB) among marginalised and vulnerable populations in India reduces the delay in diagnosis of smear-positive pulmonary TB, when compared to individuals diagnosed when patients with TB symptoms visit public health services on their own for diagnosis.

The research findings, published in PLOS ONE open access journal, show that when a patient is diagnosed through Passive Case Finding (PCF) having visited a health service unprompted rather than being screened as part of Active Case Finding (ACF) in the community, patients undergo significant delays in TB diagnosis. The research studied delays starting from when a patient first has symptoms and visits a health care provider (could be unqualified or qualified private health care providers or providers in public health system), through to actual diagnosis in TB programme, and then the initiation of treatment. Measuring these delays especially during diagnosis is important because it is the most uncertain period during illness.

When compared with patients diagnosed through PCF, ACF patients among marginalised and vulnerable populations in India had a significantly lower health-system level diagnosis delay – which relates to delays occurring between the first visit to a health care provider and diagnosis.  The median delay was five days for ACF patients, and 19 days for patients diagnosed through PCF.

Further analysis, after adjusting for baseline differences among ACF and PCF groups, also confirmed these findings. Adjusted analysis also showed that patients diagnosed through ACF had a 23 percent lower chance of having a total diagnosis delay (which relates to delays occurring between symptoms and diagnosis) of more than 50 days, when compared to PCF. This reduction could be due to the fact that patients in the ACF group visited fewer different healthcare providers to obtain their diagnoses than those in the PCF group. It is thought that ACF patients are more likely to be referred to the appropriate facility for diagnosis than PCF patients, and so reach a diagnosis more quickly. 

It is important to note that although ACF lowered the delay in diagnosis, it did not significantly reduce patient level delay - which relates to delays occurring between symptoms and the first visit to a health care provider. In fact, more than half of the patients in the ACF group had already visited a health care provider before the ACF activity. The missed opportunity for TB diagnosis before ACF activity particularly suggests the need for effective engagement of the private sector to improve diagnosis of patients from their first visit to the health care provider.

Another key finding from the study was that ACF did not also result in a reduction in the total delay - which relates to delays occurring between symptoms and treatment initiation in TB programme.

The study, led by Dr Hemant Deepak Shewade, Senior Operational Research (OR) Fellow at The Union, is part of a series of studies exploring if The Union’s active case finding strategy under project Axshya (Axshya means ‘free of TB’) is effective in reducing TB diagnosis delays; costs due to TB diagnosis; and unfavourable TB treatment outcomes. The findings on costs due to TB diagnosis were published last year (2018) in Global Health Action open access journal. When compared with patients diagnosed through PCF, ACF resulted in lower total costs and lower prevalence of catastrophic costs due to TB diagnoses.

In 2016-17, as part of Project Axshya, operating in 285 districts spread across 19 states in India, trained community volunteers visited households in marginalised and vulnerable areas. They educated members of the household on TB and screened them for symptoms. People with symptoms were then referred to public health facilities for TB diagnosis and treatment. Project Axshya is funded by The Global Fund against AIDS, TB and Malaria.

The Centre for Operational Research of The Union supported project Axshya in the design, planning and implementation of the study. Dr Hemant Deepak Shewade is supported under the Global Operational Fellowship programme by The Department for International Development of The United Kingdom (DFID).

This is the first study from India that has used nationally representative data and looked at the effect of ACF among marginalised and vulnerable populations on TB diagnosis delays. The significant reduction in diagnosis delay supports the recommendation of the Revised National Tuberculosis Control Programme (RNTCP) in its national strategic plan to eliminate TB, 2017-25, regarding the implementation of ACF among clinically, socially and occupationally vulnerable populations over and above the existing PCF strategies.