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Meta-Analysis
. 2017 Nov 28;11(11):CD011432.
doi: 10.1002/14651858.CD011432.pub2.

Interventions to increase tuberculosis case detection at primary healthcare or community-level services

Francis A Mhimbira  1 , Luis E Cuevas, Russell Dacombe, Abdallah Mkopi, David Sinclair
Affiliations
Meta-Analysis

Interventions to increase tuberculosis case detection at primary healthcare or community-level services

Francis A Mhimbira et al. Cochrane Database Syst Rev. .

Abstract

Background: Pulmonary tuberculosis is usually diagnosed when symptomatic individuals seek care at healthcare facilities, and healthcare workers have a minimal role in promoting the health-seeking behaviour. However, some policy specialists believe the healthcare system could be more active in tuberculosis diagnosis to increase tuberculosis case detection.

Objectives: To evaluate the effectiveness of different strategies to increase tuberculosis case detection through improving access (geographical, financial, educational) to tuberculosis diagnosis at primary healthcare or community-level services.

Search methods: We searched the following databases for relevant studies up to 19 December 2016: the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library, Issue 12, 2016; MEDLINE; Embase; Science Citation Index Expanded, Social Sciences Citation Index; BIOSIS Previews; and Scopus. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) for ongoing trials.

Selection criteria: Randomized and non-randomized controlled studies comparing any intervention that aims to improve access to a tuberculosis diagnosis, with no intervention or an alternative intervention.

Data collection and analysis: Two review authors independently assessed trials for eligibility and risk of bias, and extracted data. We compared interventions using risk ratios (RR) and 95% confidence intervals (CI). We assessed the certainty of the evidence using the GRADE approach.

Main results: We included nine cluster-randomized trials, one individual randomized trial, and seven non-randomized controlled studies. Nine studies were conducted in sub-Saharan Africa (Ethiopia, Nigeria, South Africa, Zambia, and Zimbabwe), six in Asia (Bangladesh, Cambodia, India, Nepal, and Pakistan), and two in South America (Brazil and Colombia); which are all high tuberculosis prevalence areas.Tuberculosis outreach screening, using house-to-house visits, sometimes combined with printed information about going to clinic, may increase tuberculosis case detection (RR 1.24, 95% CI 0.86 to 1.79; 4 trials, 6,458,591 participants in 297 clusters, low-certainty evidence); and probably increases case detection in areas with tuberculosis prevalence of 5% or more (RR 1.52, 95% CI 1.10 to 2.09; 3 trials, 155,918 participants, moderate-certainty evidence; prespecified stratified analysis). These interventions may lower the early default (prior to starting treatment) or default during treatment (RR 0.67, 95% CI 0.47 to 0.96; 3 trials, 849 participants, low-certainty evidence). However, this intervention may have may have little or no effect on treatment success (RR 1.07, 95% CI 1.00 to 1.15; 3 trials, 849 participants, low-certainty evidence), and we do not know if there is an effect on treatment failure or mortality. One study investigated long-term prevalence in the community, but with no clear effect due to imprecision and differences in care between the two groups (RR 1.14, 95% CI 0.65 to 2.00; 1 trial, 556,836 participants, very low-certainty evidence).Four studies examined health promotion activities to encourage people to attend for screening, including mass media strategies and more locally organized activities. There was some increase, but this could have been related to temporal trends, with no corresponding increase in case notifications, and no evidence of an effect on long-term tuberculosis prevalence. Two studies examined the effects of two to six nurse practitioner educational sessions in tuberculosis diagnosis, with no clear effect on tuberculosis cases detected. One trial compared mobile clinics every five days with house-to-house screening every six months, and showed an increase in tuberculosis cases.There was also insufficient evidence to determine if sustained improvements in case detection impact on long-term tuberculosis prevalence; this was evaluated in one study, which indicated little or no effect after four years of either contact tracing, extensive health promotion activities, or both (RR 1.31, 95% CI 0.75 to 2.30; 1 study, 405,788 participants in 12 clusters, very low-certainty evidence).

Authors' conclusions: The available evidence demonstrates that when used in appropriate settings, active case-finding approaches may result in increase in tuberculosis case detection in the short term. The effect of active case finding on treatment outcome needs to be further evaluated in sufficiently powered studies.

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Conflict of interest statement

Francis A Mhimbira has no conflicts of interest to declare. Professor Luis Cuevas has received seven awards from the TB REACH programme of the Stop TB Partnership. This programme aims to increase tuberculosis case detection in low‐income countries, which often includes community‐based interventions, which is the focus of the current review. Russell Dacombe was part‐funded by a European & Developing Countries Clinical Trials Partnership grant (TB‐NEAT, IP.2009.32040.009) which included support to the preparation of this review. Abdallah Mkopi has no conflicts of interest to declare David Sinclair: was supported as an author and editor with the Cochrane Infectious Diseases Group by the Effective Health Care Research Consortium.

Figures

1
1
Logic model showing the additional cases that would never present passively and long‐term impact on lowering tuberculosis prevalence and incidence.
2
2
Study flow diagram.
3
3
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included trial.
1.1
1.1. Analysis
Comparison 1 Outreach tuberculosis screening versus no intervention, Outcome 1 Tuberculosis cases detected (microbiologically confirmed).
1.2
1.2. Analysis
Comparison 1 Outreach tuberculosis screening versus no intervention, Outcome 2 Tuberculosis cases detected: subgrouped by tuberculosis prevalence.
1.3
1.3. Analysis
Comparison 1 Outreach tuberculosis screening versus no intervention, Outcome 3 Tuberculosis cases detected; subgrouped by intervention.
1.4
1.4. Analysis
Comparison 1 Outreach tuberculosis screening versus no intervention, Outcome 4 Tuberculosis cases detected (all forms).
1.5
1.5. Analysis
Comparison 1 Outreach tuberculosis screening versus no intervention, Outcome 5 Tuberculosis treatment default.
1.6
1.6. Analysis
Comparison 1 Outreach tuberculosis screening versus no intervention, Outcome 6 Tuberculosis treatment success.
1.7
1.7. Analysis
Comparison 1 Outreach tuberculosis screening versus no intervention, Outcome 7 Tuberculosis treatment failure.
1.8
1.8. Analysis
Comparison 1 Outreach tuberculosis screening versus no intervention, Outcome 8 Tuberculosis mortality.
1.9
1.9. Analysis
Comparison 1 Outreach tuberculosis screening versus no intervention, Outcome 9 Long‐term tuberculosis prevalence.
2.1
2.1. Analysis
Comparison 2 Health promotion activities compared to no intervention, Outcome 1 Long‐term tuberculosis prevalence.
3.1
3.1. Analysis
Comparison 3 Training interventions compared to intervention, Outcome 1 Tuberculosis cases detected (microbiologically confirmed).
4.1
4.1. Analysis
Comparison 4 Outreach tuberculosis services versus health promotion, Outcome 1 Tuberculosis cases detected (microbiologically confirmed).
5.1
5.1. Analysis
Comparison 5 Outreach clinic versus house‐to‐house screening, Outcome 1 Tuberculosis cases detected (microbiologically confirmed).
6.1
6.1. Analysis
Comparison 6 Active case‐finding interventions versus no intervention, Outcome 1 Tuberculosis cases detected (microbiologically confirmed).
6.2
6.2. Analysis
Comparison 6 Active case‐finding interventions versus no intervention, Outcome 2 Tuberculosis cases detected: subgrouped by tuberculosis prevalence.
6.3
6.3. Analysis
Comparison 6 Active case‐finding interventions versus no intervention, Outcome 3 Tuberculosis cases detected; subgrouped by intervention.
6.4
6.4. Analysis
Comparison 6 Active case‐finding interventions versus no intervention, Outcome 4 Long‐term tuberculosis prevalence: subgrouped by intervention.
6.5
6.5. Analysis
Comparison 6 Active case‐finding interventions versus no intervention, Outcome 5 Tuberculosis treatment success.
6.6
6.6. Analysis
Comparison 6 Active case‐finding interventions versus no intervention, Outcome 6 Tuberculosis treatment default.
6.7
6.7. Analysis
Comparison 6 Active case‐finding interventions versus no intervention, Outcome 7 Tuberculosis treatment failure.
6.8
6.8. Analysis
Comparison 6 Active case‐finding interventions versus no intervention, Outcome 8 Tuberculosis mortality.
6.9
6.9. Analysis
Comparison 6 Active case‐finding interventions versus no intervention, Outcome 9 People with tuberculosis detected.
7.1
7.1. Analysis
Comparison 7 Outreach tuberculosis services versus no intervention (sensitivity analyses), Outcome 1 Tuberculosis cases detected (microbiologically confirmed).
7.2
7.2. Analysis
Comparison 7 Outreach tuberculosis services versus no intervention (sensitivity analyses), Outcome 2 Tuberculosis cases detected: subgrouped by tuberculosis prevalence.
7.3
7.3. Analysis
Comparison 7 Outreach tuberculosis services versus no intervention (sensitivity analyses), Outcome 3 Tuberculosis cases detected; subgrouped by intervention.
7.4
7.4. Analysis
Comparison 7 Outreach tuberculosis services versus no intervention (sensitivity analyses), Outcome 4 Tuberculosis cases detected (all forms).
7.5
7.5. Analysis
Comparison 7 Outreach tuberculosis services versus no intervention (sensitivity analyses), Outcome 5 Tuberculosis treatment default.
7.6
7.6. Analysis
Comparison 7 Outreach tuberculosis services versus no intervention (sensitivity analyses), Outcome 6 Tuberculosis treatment success.
7.7
7.7. Analysis
Comparison 7 Outreach tuberculosis services versus no intervention (sensitivity analyses), Outcome 7 Tuberculosis treatment failure.
7.8
7.8. Analysis
Comparison 7 Outreach tuberculosis services versus no intervention (sensitivity analyses), Outcome 8 Tuberculosis mortality.
7.9
7.9. Analysis
Comparison 7 Outreach tuberculosis services versus no intervention (sensitivity analyses), Outcome 9 Long‐term tuberculosis prevalence.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD011432

References

References to studies included in this review

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Abdurrahman 2017 {published data only}
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Ade 2016 {published data only}
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Dholakia 2016 {published data only}
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Dobler 2016 {published data only}
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Elden 2011 {published data only}
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Fatima 2016 {published data only}
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Gounder 2011 {published data only}
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Hermans 2012 {published data only}
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Kaboru 2013 {published data only}
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Kakinda 2016 {published data only}
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Khan 2007 {published data only}
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Kuznetsov 2014 {published data only}
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Lebina 2016 {published data only}
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Ntinginya 2012 {published data only}
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Oshi 2016 {published data only}
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Prasad 2016 {published data only}
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Pronyk 2001 {published data only}
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Ruutel 2011 {published data only}
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Sanaie 2016 {published data only}
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Sekandi 2009 {published data only}
    1. Sekandi JN, Neuhauser D, Smyth K, Whalen CC. Active case finding of undetected tuberculosis among chronic coughers in a slum setting in Kampala, Uganda. International Journal of Tuberculosis and Lung Disease 2009;13(4):508‐13. - PMC - PubMed
Sekandi 2014 {published data only}
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Shapiro 2012 {published data only}
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Shrivastava 2012 {published data only}
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Soares 2013 {published data only}
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Ssemmondo 2016 {published data only}
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Story 2012 {published data only}
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Szkwarko 2016 {published data only}
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Yimer 2009a {published data only}
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Yimer 2009b {published data only}
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References to studies awaiting assessment

Chen 1990 {published data only}
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Duanmu 2005 {published data only}
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Gadala 2015 {published data only}
    1. Gadala S, Valsangkar S, Prasad B, Galli C, Dasgupta B, Thomas T. Enhanced case finding in tuberculosis: implementation in marginalized and vulnerable populations in a lower middle income country. American Journal of Respiratory and Critical Care Medicine 2015;191:A3716.
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Jensen 2015 {published data only}
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Nadu 2004 {published data only}
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Poliakova 2015 {published data only}
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References to other published versions of this review

Mhimbira 2015
    1. Mhimbira FA, Cuevas LE, Dacombe R, Mkopi A, Sinclair D. Interventions to increase tuberculosis case detection at primary healthcare or community level services. Cochrane Database of Systematic Reviews 2015, Issue 1. [DOI: 10.1002/14651858.CD011432] - DOI - PMC - PubMed

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