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Quarterly notification rates of all TB cases for Greater Accra and Ashanti Regions with linear-trend lines from 2008 to 2013. Q: Quarter, GAAT: Greater Accra all TB cases, AS-AT: Ashanti all TB cases. Baseline trend-refers to the linear-trend line drawn to project TB notification expected during the intervention period for both regions using quarterly historical TB notification data from Greater Accra and Ashanti Regions during the baseline period (first quarter of 2008 up to the second quarter of 2010) before the intervention started. Intervention trend-refers to the linear-trend line drawn through the actual TB notification data from Greater Accra Region during the intervention period (third quarter 2010 to fourth quarter 2013). Control trend-refers to the linear-trend line drawn through the actual TB notification data from Ashanti Region during the period (third quarter 2010 to fourth quarter 2013)
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Background
Meticulous identification and investigation of patients presenting with tuberculosis (TB) suggestive symptoms rarely happen in crowded outpatient departments (OPDs). Making health providers in OPDs diligently follow screening procedures may help increase TB case detection. From July 2010 to December 2013, two symptom based TB screening a...
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Citations
... Evidence suggests that the missed TB cases are not really missing as most of them are actively engaging with the health system which is failing to appropriately capture them [8]. This is due to various factors including low TB screening and testing capacity, poor understanding of the screening protocols, inadequate knowledge by the health providers to suspect TB, low diagnostic capacities and shortages of inputs [9][10][11]. Further, the growing interest in community-based active case finding (ACF) strategies especially in resource-constrained settings has shifted the attention from [12,13] facility-based intensified TB case finding even though it is more cost-effective and efficient [14,15]. ...
Background
Tuberculosis (TB) is the leading cause of death from a single infectious agent globally, killing about 1.5 million people annually, yet 3 million cases are missed every year. The World Health Organization recommends systematic screening of suspected active TB patients among those visiting the healthcare facilities. While many countries have scaled-up systematic screening of TB, there has been limited assessment of the extent of its integration into the health system. This study sought to explore factors that shape the integration of systematic screening of TB in outpatient departments of primary healthcare facilities in Kitwe district, Zambia.
Methods
This was a qualitative case study with health providers including district managers, TB focal point persons and laboratory personnel working in six purposively selected primary healthcare facilities. Data was collected through key informant ( n = 8) and in-depth ( n = 15) interviews. Data analysis was conducted using QDA Miner software and guided by Atun’s Integration framework.
Results
The facilitators to integration of systematic screening for TB into out patient departments of primary health facilities included the perceived high burden TB, compatibility of the systematic screening for TB program with healthcare workers training and working schedules, stakeholder knowledge of each others interest and values, regular performance management and integrated outreach of TB screening services. Constraining factors to integration of systematic screening for TB into outpatient departments included complexity of screening for TB in children, unbalanced incentivization mechanisms, ownership and legitimacy of the TB screening program, negative health worker attitudes, social cultural misconceptions of TB and societal stigma as well as the COVID-19 pandemic.
Conclusion
Systematic screening of TB is not fully integrated into the primary healthcare facilities in Zambia to capture all those suspected with active TB that make contact with the health system. Finding the missing TB cases will, therefore, require contextual adaptation of the systematic screening for TB program to local needs and capacities as well as strengthening the health system.
... Among target groups, we did screened a high number of PTB cases (95.5%) that were diagnosed among people who attended OPDs, which was higher than studies from Ghana (79.7%) (31) and Nigeria (80%) (16). These differences might be due to the study populations, screening and diagnosis methods used, and the settings of the screening. ...
Background: Tuberculosis (TB) remains a major cause of morbidity and mortality in sub-Saharan Africa. This high burden is mainly attributed to low case detection and delayed diagnosis. We aimed to determine the prevalence and predictors of TB among health care-seeking people screened for cough of any duration in Ethiopia.
Methods: In this multicenter cross-sectional study, we screened 195,713 (81.2%) for cough of any duration. We recruited a sample of 1,853 presumptive TB (PTB) cases and assigned them into three groups: group I with cough ≥2 weeks, group II with cough of <2 weeks, and group III pregnant women, patients on antiretroviral therapy, and patients with diabetes. The first two groups underwent chest radiograph (CXR) followed by sputum Xpert MTB/RIF assay or smear microscopy. The third group was exempted from CXR but underwent sputum Xpert MTB/RIF assay or smear microscopy. TB prevalence was calculated across the groups and TB predictors were analyzed using modified Poisson regression to compute adjusted prevalence ratio (aPR) with a 95% confidence interval (CI).
Results: The overall prevalence of PTB was 16.7% (309/1853). Of the positive cases, 81.2% (251/309) were in group I (cough ≥2 weeks), 14.2% (44/309) in group II (cough of <2), and 4.5% (14/309) in group III (CXR exempted). PTB predictors were age group of 25–34 [aPR = 2.0 (95% CI 1.3–2.8)], history of weight loss [aPR = 1.2 (95% CI 1.1–1.3)], and TB suggestive CXRs [aPR = 41.1 (95% CI 23.2–72.8)].
Conclusion: The prevalence of confirmed PTB among routine outpatients was high, and this included those with a low duration of cough who can serve as a source of infection. Screening all patients at outpatient departments who passively report any cough irrespective of duration is important to increase TB case finding and reduce TB transmission and mortality.
... Among target groups, we did screened a high number of PTB cases (95.5%) that were diagnosed among people who attended OPDs, which was higher than studies from Ghana (79.7%) (31) and Nigeria (80%) (16). These differences might be due to the study populations, screening and diagnosis methods used, and the settings of the screening. ...
Background
Tuberculosis (TB) remains a major cause of morbidity and mortality in sub-Saharan Africa. This high burden is mainly attributed to low case detection and delayed diagnosis. We aimed to determine the prevalence and predictors of TB among health care-seeking people screened for cough of any duration in Ethiopia.Methods
In this multicenter cross-sectional study, we screened 195,713 (81.2%) for cough of any duration. We recruited a sample of 1,853 presumptive TB (PTB) cases and assigned them into three groups: group I with cough ≥2 weeks, group II with cough of <2 weeks, and group III pregnant women, patients on antiretroviral therapy, and patients with diabetes. The first two groups underwent chest radiograph (CXR) followed by sputum Xpert MTB/RIF assay or smear microscopy. The third group was exempted from CXR but underwent sputum Xpert MTB/RIF assay or smear microscopy. TB prevalence was calculated across the groups and TB predictors were analyzed using modified Poisson regression to compute adjusted prevalence ratio (aPR) with a 95% confidence interval (CI).ResultsThe overall prevalence of PTB was 16.7% (309/1853). Of the positive cases, 81.2% (251/309) were in group I (cough ≥2 weeks), 14.2% (44/309) in group II (cough of <2), and 4.5% (14/309) in group III (CXR exempted). PTB predictors were age group of 25–34 [aPR = 2.0 (95% CI 1.3–2.8)], history of weight loss [aPR = 1.2 (95% CI 1.1–1.3)], and TB suggestive CXRs [aPR = 41.1 (95% CI 23.2–72.8)].Conclusion
The prevalence of confirmed PTB among routine outpatients was high, and this included those with a low duration of cough who can serve as a source of infection. Screening all patients at outpatient departments who passively report any cough irrespective of duration is important to increase TB case finding and reduce TB transmission and mortality.
... Evidence suggests that the missed TB cases are not really missing as most of them are actively engaging with the health system which is failing to appropriately capture them (8). This is due to various factors including low TB screening and testing capacity, poor understanding of the screening protocols, inadequate knowledge by the health providers to suspect TB, low diagnostic capacities and shortages of inputs (10)(11)(12). Further, the growing interest in community-based active case nding (ACF) strategies especially in resource-constrained settings has shifted the attention from (13,14) facility-based intensi ed TB case nding even though it is more cost-effective and e cient (15,16). ...
Background
Tuberculosis (TB) is the leading cause of death from a single infectious agent globally, yet 3 million cases are missed every year. The World Health Organization recommends systematic screening of suspected active TB patients among those visiting the healthcare facilities. While many countries have scaled-up systematic screening of TB, there has been limited assessment of the extent of its integration into the health system. This study sought to explore factors that shaped the integration of systematic screening of TB in outpatient departments of primary healthcare facilities in Kitwe district, Zambia.
Methods
This was a qualitative case study with health providers including district managers, TB focal point persons and laboratory personnel working in six purposively selected primary healthcare facilities. Data was collected through key informant (n=8) and in-depth (n=15) interviews. Data analysis was conducted using QDA Miner software and guided by Atun’s Integration framework.
Results
Integration was facilitated by perceptions of the magnitude of the TB burden, alignment of the intervention with national TB aspirations, knowledge of stakeholder interests, power and values, regular performance management and intra-facility collaboration. Constraining factors included external partners’ influence in the TB screening program, unbalanced incentivization mechanisms, donor-driven financing and social determinants of health such as gender and stigma including the COVID-19 pandemic.
Conclusion
Systematic screening of TB is not well integrated into the primary healthcare facilities to capture all those suspected with active TB that make contact with the health system. Finding the missing TB cases will, therefore, require contextual adaptation of the systematic screening for TB and strengthening the health system.
... Evidence suggests that the missed TB cases are not really missing as most of them are actively engaging with the health system which is failing to appropriately capture them (8). This is due to various factors including low TB screening and testing capacity, poor understanding of the screening protocols, inadequate knowledge by the health providers to suspect TB, low diagnostic capacities and shortages of inputs (10)(11)(12). Further, the growing interest in community-based active case nding (ACF) strategies especially in resource-constrained settings has shifted the attention from (13,14) facility-based intensi ed TB case nding even though it is more cost-effective and e cient (15,16). ...
Background: Tuberculosis (TB) is the leading cause of death from a single infectious agent globally, yet 3 million cases are missed every year. The World Health Organization recommends systematic screening of suspected active TB patients among those visiting the healthcare facilities. While many countries have scaled-up systematic screening of TB, there has been limited assessment of the extent of its integration into the health system. This study sought to explore factors that shaped the integration of systematic screening of TB in outpatient departments of primary healthcare facilities in Kitwe district, Zambia.
Methods: This was a qualitative case study with health providers including district managers, TB focal point persons and laboratory personnel working in six purposively selected primary healthcare facilities. Data was collected through key informant (n=8) and in-depth (n=15) interviews. Data analysis was conducted using QDA Miner software and guided by Atun’s Integration framework.
Results: Integration was facilitated by perceptions of the magnitude of the TB burden, alignment of the intervention with national TB aspirations, knowledge of stakeholder interests, power and values, regular performance management and intra-facility collaboration. Constraining factors included external partners’ influence in the TB screening program, unbalanced incentivization mechanisms, donor-driven financing and social determinants of health such as gender and stigma including the COVID-19 pandemic.
Conclusion: Systematic screening of TB is not well integrated into the primary healthcare facilities to capture all those suspected with active TB that make contact with the health system. Finding the missing TB cases will, therefore, require contextual adaptation of the systematic screening for TB and strengthening the health system.
... So they may never present to the health care facility, or present after a significant delay after continuing the chain of transmission as super spreaders. 9,10 Sometimes, because of overlapping of non specific symptoms of TB with other chronic co-morbidities, TB goes undiagnosed and untreated for long periods of time. Failure to conduct testing even if the patient comes forward after overcoming all the geographical and financial barriers needs to be taken seriously and properly addressed. ...
Case finding, an important parameter in fight against Tuberculosis (TB) has always remained a challenge despite advances in diagnostic modalities, access to health care and administrative commitment. We are still far from reaching the goals so set as per End TB Strategy and National Strategic Plan 2017–2025, and case finding is of paramount importance for achieving the said targets.
This article, after identifying the obstacles faced in case finding, explores the various case finding strategies in the perspective of diagnostics, feasibility, resource utilization and current recommendations. Need for prioritization of case finding in different settings with involvement and active participation of one and all has been discussed. Role of health education in an individual, general public and health care worker in the context of case finding has been highlighted. Research areas to strengthen case finding have been enumerated. The review concludes by bringing out the need for heightened efforts for case finding in TB as the resources are significantly diverted as the world is facing the corona virus disease 2019 (COVID-19) pandemic.
... This PPV is lower compared to the general situation in outpatient departments of health care facilities in Ghana where the percentage sputum smear positive cases among those tested was 8.6% and in Uganda where the percentage sputum smear positive cases among chronic coughers in a peri-urban setting was 18%. 13,21 The representativeness of the surveillance system for the municipality is also low. There is only one TB laboratory in the Ga West Municipality. ...
... This PPV is lower compared to the general situation in outpatient departments of health care facilities in Ghana where the percentage sputum smear positive cases among those tested was 8.6% and in Uganda where the percentage sputum smear positive cases among chronic coughers in a periurban setting was 18% . 13,21 The representativeness of the surveillance system for the municipality is also low. There is only one TB laboratory in the Ga West Municipality. ...
Background:
Evaluate the Tuberculosis (TB) surveillance system in the Ga West Municipality to determine if it is achieving its objectives, and to assess its attributes and usefulness.
Design:
Descriptive analysis of primary and secondary data.
Data source:
Stakeholder interviews and record reviews on the objectives and operation of the surveillance system at all levels of the system.
Intervention:
We evaluated the system's operation from 2011-2015 using the Centers for Disease Control and Prevention (CDC) updated guidelines for evaluating public health surveillance systems and the World Health Organisation (WHO) TB surveillance checklist for assessing the performance of national surveillance systems.
Results:
The TB surveillance system in the municipality was functional and operated at all levels for timely detection of cases, accurate diagnosis, and case management. The system improved management of TB/HIV co-infections. The average time taken to confirm a suspected TB case was one day. The registration of a confirmed case and subsequent treatment happen immediately after confirmation. The municipality detected 109 of 727 TB cases in 2015 (case detection rate=15%). The positive predictive value (PPV) was 6.4%. There was one diagnostic centre in the municipality. Private facilities involvement in TB surveillance activities was low (1/15).
Conclusion:
The Tuberculosis surveillance system in the Ga West Municipality is well structured but partially meeting its objectives. The system is timely, stable and acceptable by most stakeholders and useful at all levels. It has no major data quality issues. Private health facilities in the municipality should be well incorporated into TB surveillance.
Funding:
This work was supported by Ghana Field Epidemiology and Laboratory Training Program (GFELTP), University of Ghana through the support of the West Africa Health Organization (Ref.: Prog/A17IEpidemSurveillN° 57212014/mcrt) to B-YA.
... 18,22 However, a study conducted in the Greater Accra region of Ghana from 2010 to 2013 showed that more TB cases were identified when screening was done using the new diagnostic guidelines of a cough of any duration (>24 hours) and any other TB-related symptom compared to using just a cough >2 weeks. 23 This confirms that using longer duration of symptoms to investigate for TB could lead to missed opportunities for early diagnosis. This, however, has high cost implications for diagnosis. ...
Background:
We assessed coverage of symptom screening and sputum testing for tuberculosis (TB) in hospital outpatient clinics in Ghana.
Methods:
In a cross-sectional study, we enrolled adults (≥18 years) exiting the clinics reporting ≥1 TB symptom (cough, fever, night sweats or weight loss). Participants reporting a cough ≥2 weeks or a cough of any duration plus ≥2 other TB symptoms (per national criteria) and those self-reporting HIV-positive status were asked to give sputum for testing with Xpert MTB/RIF.
Results:
We enrolled 581 participants (median age 33 years [IQR: 24-48], 510/581 [87.8%] female). The most common symptoms were fever (348, 59.9%), chest pain (282, 48.5%) and cough (270, 46.5%). 386/581 participants (66.4%) reported symptoms to a healthcare worker, of which 157/386 (40.7%) were eligible for a sputum test per national criteria. Only 31/157 (19.7%) had a sputum test requested. Thirty-two additional participants gave sputum among 41 eligible based on positive HIV status. In multivariable analysis, symptom duration ≥2 weeks (adjusted odds ratio [aOR] 6.99, 95% confidence interval [CI] 2.08-23.51) and previous TB treatment (aOR: 6.25, 95% CI: 2.24-17.48) were the strongest predictors of having a sputum test requested. 6/189 (3.2%) sputum samples had a positive Xpert MTB/RIF result.
Conclusion:
Opportunities for early identification of people with TB are being missed in health facilities in Ghana.
... Ghana is an LMIC where TB is still a major contributor to morbidity and mortality. The national TB incidence is 148/100,000 population; though as many as 2/3 of the country's cases are estimated to be missed due to inadequate or misdiagnoses [10,11].TB prevalence is found to increase with age among the adult population [10]. The national prevalence of DM is also high-3.6% in adult population, and Ghana continues to face challenges relating to undiagnosed DM cases, which in turn leads to increased complications with assessing outcomes for DM-TB [12]. ...
... Since its launch in 2011, health systems of various countries, including Ghana, have adopted the collaborative framework and are at various stages of implementation [5]. Ghana's NTP begun the pilot phase of the Intensive Case Finding Initiative (ICF) between 2009-2013 and has since expanded it to all facilities offering TB care [11]. The objective of the pilot phase was to assess the feasibility of screening all patients who visit public health facilities for TB [11]. ...
... Ghana's NTP begun the pilot phase of the Intensive Case Finding Initiative (ICF) between 2009-2013 and has since expanded it to all facilities offering TB care [11]. The objective of the pilot phase was to assess the feasibility of screening all patients who visit public health facilities for TB [11]. However, beyond the pilot phase, there is a paucity of empirical evidence on the implementation of bidirectional screening in Ghana [11]. ...
Background
The tuberculosis (TB) and diabetes mellitus (DM) co-epidemic continues to increase globally. Low-and middle-income countries bear the highest burden of co-epidemic, and Ghana is no exception. In 2011, the World Health Organisation (WHO) responded to this global challenge by launching a collaborative framework with a view to guide countries in implementing their DM and TB care, prevention and control plans. Subsequently, several countries, including Ghana, adopted this framework and began implementing bidirectional screening of TB and DM patients. Almost a decade later since the launch of the framework, the implementation of bidirectional screening in Ghana has not been subjected to empirical research. This study explored the barriers and facilitators to bidirectional screening through the lenses of the implementing healthcare workers.
Methods
This was an exploratory qualitative study conducted in three public health facilities offering both TB and DM services in Northern Ghana. In-depth interviews, document review and observations, were used to generate data. In total twenty-three healthcare workers (doctors, nurses, prescriber, health managers and TB task- shifting officers delivering care in TB and DM clinics) were interviewed, using semi-structured interview guides. The interview questions solicited information on the screening process, including knowledge of the collaborative framework, comorbidity, collaboration and workload.
Results
Six themes emerged from the analysis, of which two (Increase in staff capacity, and Institutionalisation of bidirectional screening) were facilitators, and four (Delays in screening, Fear and stigmatization of TB, Poor collaboration between TB and DM units, and Skewed funding for screening) were barriers.
Conclusions
The implementation of bidirectional screening at public health facilities in Ghana was evident in this study and increased staff capacity, funding and institutionalisation enhanced the policy implementation process. However, the screening of TB patients for DM is yet to be prioritised, and emphasis should be put on the design for cost-effective screening approaches for low- and middle-income countries.
... Prevalence of PPTB reported by other studies varied across populations, a study from India reported the prevalence to be 8%, while two others from Ghana and Cameroon reported a prevalence of 1% and 55% respectively. [6][7][8] The difference in the study setting and the operational definition of presumptive TB used in the studies may have contributed to the difference in prevalence. We used 'cough of any duration' as one of the criteria which may partially explain the higher proportion of PPTB in our study. ...
... 11 Hence, screening for PPTB in an OPD setting can be recommended as there is an increased yield with the utilization of minimal resources. The use of "cough of any duration" as one of the symptoms for screening can be considered a strength as studies suggest screening regardless of the duration of cough or using a shorter duration of cough (>24 hours) instead of cough >2 weeks should accelerate early detection of TB. 7 A systematic review which looked into the sensitivity and specificity of different screening tools using culture-confirmed pulmonary TB as the gold standard, found the pooled sensitivity of "any cough" to be greater than "prolonged cough (lasting >2-3 weeks)", the latter, however, had a higher specificity. 12 According to the review, although, "prolonged cough" would limit the resource needs for confirmatory tests, it would leave a majority of the TB cases undetected. ...
Background: In line with WHO’s END TB strategy and Sustainable Development Goal’s vision, India has set a goal to eliminate tuberculosis by 2025. To meet this goal, intensified case finding is a strategy adopted by India’s national tuberculosis program. This study aimed to determine the proportion of presumptive pulmonary tuberculosis (PPTB) patients among outpatients of a tertiary care center and its association with socio-demographic and behavioral factors.Methods: A hospital based cross-sectional analytical study was done in a tertiary care center during November 2017 among outpatients aged 18 years or above. Known cases of tuberculosis (TB) were excluded. Information on socio-demographic characteristics and TB symptoms was collected using a structured questionnaire. A person with any symptom suggestive of TB, including, cough of any duration, subjective weight loss, and fever at present was considered to have PPTB. Presence of PPTB was reported as proportion with 95% confidence intervals. Association between variables and presumptive pulmonary TB was assessed using chi square test and prevalence ratio with 95% CI.Results: Among 2638 outpatients, 907 (34%) had PPTB. Cough was the most reported symptom (22.9%); followed by fever (10.0%), weight loss (13.9%) and hemoptysis (0.9%). PPTB was found to be significantly higher among males, smokers, alcohol users and patients having a history of contact with any TB patient.Conclusions: One-third of the outpatients had PPTB and this was high. A screening procedure could be incorporated within the hospital policy to identify outpatients with symptoms of TB.
