Supporting TB program in active contact tracing: a case study from Pakistan | Infectious diseases of poverty

Pulmonary tuberculosis is usually diagnosed when symptomatic people seek treatment at health facilities. Historically, community health workers have played a minimal role in promoting health-seeking behaviors for this stigmatized disease. However, some policy experts believe that the health system could be more active in tuberculosis (TB) diagnosis to increase TB case detection. [1]. Contact investigation, the systematic assessment of people in close contact with an infectious patient, is a key active case finding strategy for the global fight against TB. To curb the TB epidemic, behavioral change and earlier identification and treatment of infectious people and their close contacts are imperative.[2, 3]. Tuberculosis contact investigation, defined as the systematic assessment of people exposed (contacts) to people with potentially infectious tuberculosis (index cases), is a strategy to identify additional new cases of active and latent tuberculosis infection, eligible for preventive treatment. A contact investigation is initiated when a new case of TB is identified. An index case interview is conducted to obtain a list of all household and non-household contacts. Although procedures may vary, home visits for symptom screening are recommended for all contacts who have had a cough for more than two weeks, and those who screen positive are referred for clinical evaluation for active TB, while those who screen negative are eligible to start preventive treatment.[4]. Household contacts of patients with multidrug-resistant tuberculosis (MDR-TB) are at high risk of becoming infected with TB/MDR-TB, underscoring the importance of symptomatic or vulnerable individuals being detected and treated early [5]. Contacts of diagnosed TB patients may have a high prevalence of TB and can be easily detected by active contact tracing, but tests more sensitive than sputum smear are needed [6].

Tackling the burden of TB in Pakistan has been a challenge due to limited funding and bottlenecks in other systems such as shortage of skilled human resources and insufficient availability of drugs. Although it is a notifiable disease, its reporting is extremely low. Limited access to diagnostic and treatment facilities and the stigma attached to the disease remain deeply embedded in communities [7]. In the context of South and Southeast Asia, active contact tracing of TB cases has been used vigorously in most countries, with a few exceptions [8, 9]. Pakistan stands out in this regard due to weak community engagement and action. Nevertheless, small-scale research has shown that improved and active approaches to contact tracing can effectively identify additional TB patients among household contacts at relatively low cost. These active strategies can be added to passive contact investigation in a high-burden setting to find people with TB who are missed and achieve TB strategy goals. [10, 11].

Tuberculosis is managed by Provincial Tuberculosis Programs (PTPs) in each province of Pakistan. Despite the efforts of Sindh PTP Sindh and the support of the Global Fund, PTP detected 74,524 TB cases (59%) in 2018, out of 126,898 TB cases in the province. More importantly, 41% were hidden/unreported TB cases in Sindh. Currently, only 23% of index cases benefit from contact testing, whereas this should be 100% according to program standards. Similarly, in Khyber Pakhtunkhwa, the case detection rate increased from 57% in 2016 to 40% in 2020 [12]. While the case detection rate in the country remains at 48%, the target of the TB control program is to increase the case detection rate to 80% by 2023. [13]. It is estimated that one undiagnosed patient with active TB can transmit TB to at least 10 people in a year. Given the poverty, malnutrition and average household size in Pakistan, the risk of transmission of TB to other people increases many times, especially in rural areas. There is an urgent need to fill this gap by increasing testing in hotspots in vulnerable rural districts, especially testing of households and other close social contacts of index cases. More accurate and credible data from rural areas could provide insight into the true prevalence and current disease burden in the country. In addition to estimating the true burden of the disease, it is imperative to raise awareness of the symptoms, its mode of transmission, prevention, diagnosis and treatment, and above all, destigmatization of the disease through health education. at local level. [14, 15].

The Integrated Health System Strengthening and Service Delivery (IHSS-SD) activity is an initiative funded by the United States Agency for International Development (USAID) in Pakistan since 2018, working closely with the federal and provincial health authorities to reorient, reform and strengthen the health system. . The overall objective of this technical support was to help the provincial tuberculosis control programs in Sindh and Khyber Pakhtunkhwa to improve active contact tracing of bacteriologically positive tuberculosis cases and to decentralize the management of tuberculosis cases. drug-resistant tuberculosis. The ultimate objectives of this activity were to collect sufficient evidence to prove the effectiveness of active contact tracing and screening as an important strategy to improve the detection of bacteriologically positive cases of tuberculosis in communities, and to improve the testing capacity of provincial TB programs. . The TB support program was rolled out on January 1, 2021 and ended on September 30, 2021.