Provider initiated tuberculosis case finding in outpatient departments of health care facilities in Ghana: yield by screening strategy and target group

Abstract

BackgroundMeticulous 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 approaches of varying cough duration were used to screen and test for TB among general outpatients, PLHIV, diabetics and contacts in Accra, Ghana.MethodsThis study was a retrospective analysis comparing the yield of TB cases using two different screening approaches, allocated to selected public health facilities. In the first approach, the conventional 2 weeks cough duration with or without other TB suggestive symptoms was the criterion to test for TB in attendants of 7 general OPDs. In the second approach the screening criteria cough of >24 hours, as well as a history of at least one of the following symptoms: fever, weight loss and drenching night sweats were used to screen and test for TB among attendants of 3 general OPDs, 7 HIV clinics and 2 diabetes clinics. Contact investigation was initiated for index TB patients. The facilities documented the number of patients verbally screened, with presumptive TB, tested using smear microscopy and those diagnosed with TB in order to calculate the yield and number needed to screen (NNS) to find one TB case. Case notification trends in Accra were compared to those of a control area.ResultsIn the approach using >24-hour cough, significantly more presumptive TB cases were identified among outpatients (0.82% versus 0.63%), more were tested (90.1% versus 86.7%), but less smear positive patients were identified among those tested (8.0% versus 9.4%). Overall, all forms of TB cases identified per 100,000 screened were significantly higher in the >24-hour cough approach at OPD (92.7 for cough >24 hour versus 82.7 for cough >2 weeks ), and even higher in diabetics (364), among contacts (693) and PLHIV (995). NNS (95% Confidence Interval) varied from 100 (93-109) for PLHIV, 144 (112-202) for contacts, 275 (197-451) for diabetics and 1144 (1101-1190) for OPD attendants. About 80% of the TB cases were detected in general OPDs. Despite the intervention, notifications trends were similar in the intervention and control areas.ConclusionThe >24-hour cough approach yielded more TB cases though required TB testing for a larger number of patients. The yield of TB cases per 100,000 population screened was highest among PLHIV, contacts, and diabetics, but the majority of cases were detected in general OPDs. The intervention had no discernible impact on general case notification.

Trends of tuberculosis case detection, mortality and co-infection with HIV in Ghana: A retrospective cohort study

“…Other countries, such as India focuses on systematic screening in high-risk populations such as people living in urban slums [22]. Ohene and colleagues [23] however argue that, when considering a TB screening program, it is essential to simultaneously look at the overall health system functions and enhance capacity to facilitate early detection. Patient delay for seeking TB care may arise from various factors, including barriers in access to care such as costs of seeking care or stigma [24].…”

Barriers and facilitators to bidirectional screening of TB-DM in Ghana: Healthcare workers’ perspectives

“…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].…”

Presumptive pulmonary tuberculosis and its associated factors among adult patients availing out-patient services in a tertiary care center, Puducherry, South India

“…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.…”

“…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.…”