Breakthrough research presented at The Union World Conference on Lung Health demonstrates the importance of community-based active case finding in slowing the progression of TB
- Mobile chest X-ray screening revealed to be a crucial tool in community active case finding programme across Indonesia
- Leading research from Vietnam demonstrates role of active case finding in increasing TB treatment among ethnic minority and remote communities
- Person-centred active case finding for tuberculosis in the Philippines found to break down barriers to healthcare access for vulnerable populations
Bali, Indonesia; November 12, 2024: Tuberculosis (TB) experts have revealed the latest research demonstrating the value of active case finding (ACF) for improving detection of the disease across communities in South-East Asia.
Researchers presented new findings from TB community-based ACF and screening programmes from Vietnam, Indonesia, and the Philippines at the International Union Against TB and Lung Disease’s World Conference on Lung Health this week.
In Indonesia, researchers from Consortium Penabulu-STPI – backed by the Global Fund – used mobile chest X-ray screening to identify people with TB across four of the nation’s provinces.
Of the 29,251 people who attended the mobile CXR screening, 7,928 (27%) were presumptive of TB, and 3,859 (49%) were tested with a rapid molecular test. As a result, 570 (1.9%) people were identified to have TB.
Participation in the screening programme was encouraged by local leaders who promoted the project, which was conducted on weekends with transport provided for people with disabilities and prizes given to participants.
The researchers found that community-based ACF which involved local stakeholders and community cadres added value to the TB case finding programme, but stressed that optimal implementation requires TB service readiness and logistical planning.
Lead researcher Betty Nababan said: “Increasing community-based active case finding is a key way of empowering the community to end TB in Indonesia”.
Separate research undertaken in Vietnam by Friends for International TB Relief also demonstrated the value of ACF testing across communities – particularly among ethnic minority and remote communities where individuals may experience additional barriers to accessing healthcare, delaying or restricting their ability to receive a TB diagnosis.
Over 140 ACF events for TB were organised across five provinces of Vietnam, where community members were screened using chest X-rays. Those with suspected TB were then tested further and provided with treatment if diagnosed.
These ACF events resulted in a 37% increase in actual TB treatment at the district TB units compared to trend expectations.
The research, supported by the U.S. Centers for Disease Control and Prevention (CDC), demonstrated the value of community-based ACF, due to its ability to improve TB detection and linkage to treatment across Vietnam – particularly among ethnic minority and remote settings.
Thuc Doan Ngo and Andrew Codlin from Friends for International TB Relief said: “Community chest X-ray screening for TB among ethnic minority communities is more than just a health intervention—it's a vital step toward equity. By bringing screening services directly to these communities, we not only detected previously missed TB but also ensured that everyone, regardless of their location or background, had access to the care they needed.
“This proactive approach will ultimately save lives, reduce transmission, and strengthen the resilience of these communities.”
Researchers from the Philippines presented findings on the importance of person-centred ACF for supporting vulnerable populations across the country, such as those living in geographically isolated and disadvantaged areas who may experience barriers (e.g. social isolation, stigma, physical and financial) to accessing screening, diagnosis, and care.
The researchers screened 100,553 vulnerable people across 733 communities as part of a poverty alleviation programme, which empowered community members to participate and take a leading role. The underlying trust in community leaders facilitated the acceptability of the programme and allowed tuberculosis screening, diagnosis, treatment, and prevention to be integrated. This resulted in 3,529 previously unreached persons to be identified with tuberculosis and enrolled into treatment.
Despite identifying and enrolling people with TB at six times the Philippines national incidence, the researchers acknowledged the need for multisectoral partnerships to overcome remaining challenges to access to care at all levels of the health system.
Lead researcher Dr Melinda Kelly Mijares said: “We learned a great deal from the families about the barriers they face in the entire cascade of care. Our focus was at the community level and their entry into primary healthcare, but we recognise the need for collaboration at all levels of the health system.
“We look forward to our partnerships in 2025 to further improve access and the experience for our vulnerable population.”
Speaking from her experiences as a TB survivor, Eloise Zepeda Tang, President of TBPeople Philippines, said: “Throughout the Philippines, our understanding of TB within communities is still an issue. If we do not understand the systems, then we cannot help people.
“There is an urgent need to educate healthcare providers about the experiences of communities, in order to ensure care that is both effective and supportive for all.”
Speaking at The Union World Conference on Lung Health in Bali, Professor Guy B. Marks, President, International Union Against Tuberculosis and Lung Disease (The Union) said: “We know that active case finding for TB is one of the most effective ways of breaking the chain of transmission of disease – which is crucial to ending the spread of TB.
“This research is further evidence that governments should be prioritising active case finding as a primary method for eliminating the disease, and to ensure sustainable funding and support for such evidence-based interventions in all high-burden countries, as we look to take meaningful action in creating a world free of TB.”
Note: Full abstracts below
ENDS
Notes to editors:
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ANNEX – Abstract Summaries
Community-based active case finding tuberculosis using chest X-rays: lessons learned and challenges in Indonesia
Background and challenges to implementation: In 2022, the Indonesian National TB Program recommended implementing community-based active case finding for Tuberculosis (ACF TB) using mobile chest X-ray (CXR) screening to identify people with TB rather than standard case detection. Consortium Penabulu-STPI, funded by the Global Fund, conducted community-based ACF using CXR in a selected province in Indonesia.
Intervention or response: The community-based ACF TB was conducted in four provinces in Indonesia from May to December 2023 in collaboration with primary health care centres under the coordination of provincial and district health offices. Activities include identifying the ACF targets based on index cases, selecting the CXR provider, preparing the logistics, meeting with stakeholders to get support, training local community cadres and monitoring the implementation process. A dedicated staff was appointed to manage the implementation process.
Results/Impact: Of the 36,607 target participants referred to ACF, 29,251 (79,9%) attended the mobile CXR screening. Of the CXR screened participants, 7,928 (27%) were presumptive of TB, and 3859 were tested with the Rapid Molecular Test (RMT). As a result, 570 (1.9%) TB cases were identified. Factors supporting ACF TB attendance include the involvement of local leaders in promoting the ACF and local cadres in distributing invitations, revisiting target participants, and accompanying them to attend the mobile CXR. The ACF was conducted on weekends, with transport provided for people with disabilities and door prizes for participants. Absence participants were due to feeling unwell and fear of discrimination if diagnosed with TB. Limited cartridge availability, causing only half of the eligible participants tested with RMT, and doctor’s capacity to diagnose clinical TB remains a challenge in optimizing the TB case finding.
Conclusions: Implementing community-based ACF TB by involving local stakeholders and community cadres adds value to TB case findings. However, optimal implementation requires ensuring TB service readiness and attentive logistical planning.
Evaluating the yield and impact of an active case finding intervention for TB in ethnic minority and remote communities in Vietnam
Background: Ethnic minority communities and people living in remote areas of Vietnam often face barriers when trying to access healthcare, resulting in delayed and/or missed TB diagnoses. These barriers were intensified by social distancing restrictions during the COVID-19 pandemic.
Design/Methods: 146 active case finding (ACF) events for TB were organized across five provinces of Vietnam between December 2021 and March 2023. Community members were screened using chest X-rays (CXRs), which were interpreted by an on-site radiologist. Participants with abnormal CXRs were tested with the Xpert MTB/RIF Ultra or Truenat MTB Plus assay, and those diagnosed with TB were linked to care. TB treatment initiation data were collected from the intervention District TB Units (DTUs) for 12 quarters before ACF and were used to establish a linear trend regression, with 95% confidence intervals, which estimated the expected levels of TB treatment post-ACF. Actual treatment data during the post-intervention period were compared against the trend-expected estimates to assess improvements in TB treatment coverage.
Results: A total of 40,513 people were screened by CXR, resulting in the detection of 2,463 (6.1%) participants with an abnormal CXR result. 2,357 (95.7%) participants were then tested and 287 (12.2%) had an MTB-positive result. An additional 85 participants were clinically diagnosed with TB after the ACF events, bringing the total number of those diagnosed with all forms of TB to 372 (detection rate = 918 per 100,000 screened); 346 (93.0%) people with TB were linked to appropriate treatment. These ACF events resulted in a 36.5% increase in actual TB treatment at the intervention DTUs compared to trend expectations.
Conclusions: Community-based ACF can improve TB detection and linkage to treatment in ethnic minority and remote settings in Vietnam. Further studies may consider assessing TB treatment success rates for people detected at ACF events and the cost effectiveness of this intervention.
A view from ground level: the journey of 100,000 Philippine families screened for tuberculosis
Background and challenges to implementation: Vulnerable populations such as those living in geographically isolated and disadvantaged areas (GIDA) experience structural and multifactorial barriers to screening, diagnosis, and care. Patient-centered active case finding (ACF) for tuberculosis (TB) has proved a valuable service for these vulnerable groups, but thousands of communities in the Philippines remain unreached due to social isolation, stigma, physical and financial barriers.
Intervention or response: Working through community leaders in GIDA in the Visayas, Mindanao, and Palawan, 100,553 vulnerable persons were screened with ACF in 733 communities. ACF was performed within a community-based poverty alleviation program which empowered community members to participate and lead.
Weekly program activities enabled follow up of persons with presumed TB. Transportation and nutritional support were also provided as needed.
Results/Impact: Of 100,553 vulnerable persons screened, 3,527 (3.5%) were identified with TB and 3,345 (95%) enrolled. The highest incidence was found in Negros Occidental (7.5%) and Sarangani (6.1%).
Conclusions: Households were amenable to participating in ACF activities when embedded in a poverty reduction program with engaged community leaders, rather than a one-off event led by outsiders. An underlying level of trust was built, which facilitates further care. The collaboration between a range of stakeholders was instrumental in providing screening that was accepted by GIDA communities.
Several challenges remain. Among vulnerable communities receiving the poverty reduction program, 12% were unreachable by ACF van. These communities could benefit from backpack X-ray units which are not yet FDA approved in the Philippines except under research protocol. Same day reading remains scarcely available in the Visayas and Mindanao, which would significantly reduce the number of patients lost to follow up. Distance to facilities for enrollment and follow-up is a physical and financial barrier. Even with transportation subsidized, the opportunity loss and additional expenses have consequences. Reaching marginalized households with ACF requires strategies that considers these needs to complete care.