The collaboration of ‘Active case finding campaign’ with the 'Leprosy case detection campaign': An important step towards tuberculosis elimination

Tuberculosis is a disease of ancient origin.1 The disease occurs due to an infection by the acid-fast bacillus Mycobacterium tuberculosis.2 It is a significant contributor to morbidity and mortality and is the leading cause of the same among all infectious diseases.3 This disease is highly prevalent in developing countries in Asia and Africa.2, 3 In India, the prevalence and incidence stand at 312 and 188 per one lakh population, respectively.4 Several countries have undertaken measures in the form of well-defined national programs for tuberculosis control.5 In India, this program is known as the National Tuberculosis Elimination Program (NTEP).6 It was started in 1962 as the National TB Programme (NTP), then changed to the Revised National Tuberculosis Control Programme (RNTCP) in 1997, and was renamed the NTEP in 2020.6 The NTEP is working on a mission mode to achieve the national target of tuberculosis elimination in India by 2025.7 It is an important part of the National Strategic Plan 2017-25 aimed at early diagnosis and timely initiation of treatment for all notified tuberculosis cases on an appropriate regimen. To achieve this ambitious goal of tuberculosis elimination by 2025, five years ahead of the global target, the involvement of all stakeholders at various levels plays a vital role.7

In the National Health Mission (NHM), one of the key strategies is having a Community Health Volunteer, i.e., Accredited Social Health Activist (ASHA) for every village with a population of 2000.8 The ASHA works at the grass-roots level and is the closest in contact with the community. The active involvement of ASHAs shall contribute to the effective implementation of the NTEP and will also create mass awareness about the signs and symptoms of tuberculosis in the general population. In the past, inclusion of ASHA has proven feasible and effective in various community-based prevention and control programs for chronic diseases.9, 10 Bhardwaj et al. reported that the inclusion of ASHA in tuberculosis control is highly cost-effective.11

As per the directions given by the Directorate General of the Health Services (DGHS) of Government NCT of Delhi during the Delhi State NTEP Review meeting held on 18^th of May 2023, NTEP Delhi collaborated its ‘Active Case Finding Campaign’ (ACF) with the 'Leprosy Case Detection Campaign' of the National Leprosy Eradication Programme (NLEP) Delhi, which was held from 5^th to 18^th June 2023. An ACF is defined as systematic screening for tuberculosis applied outside of health facilities.12 It was initiated in 2013 by the Global Fund-supported Project Axshya among the high-risk groups in 300 districts in India.13 It is a well-recognized tool to reach nearly three million cases that were missed in high-burden countries.13 While more target groups have been well defined by the NLEP, it is being done for tuberculosis as well, and reaching such target populations in a campaign mode was proposed. This joint effort also aimed to create mass awareness about the signs and symptoms of tuberculosis in the general population.

The details of the activity are as follows

The State Leprosy Cell, Delhi, had planned the ‘Leprosy Case Detection Campaign’ from 5^th to 18^th June 2023, in all eleven revenue districts of Delhi.

NTEP Delhi merged its ACF for tuberculosis campaign with the Leprosy Case Detection Campaign.

Target population determined by NLEP Delhi-1073328.

Estimated houses visited during the above campaign-1775647.

NTEP Delhi, in collaboration with NLEP Delhi, was given support from the general health services to utilize around 4008 ASHA workers across all 11 revenue districts of Delhi state.

District tuberculosis officers (DTO) were requested to coordinate with the concerned District Leprosy Officers (DLO), District ASHA coordinators of all 11 revenue districts, and the Medical Officer in Charge (MOIC) of the respective Delhi Government Dispensaries in retrieving all details of the area-wise target population and involving ASHA workers in a particular area or district.

The training sessions were scheduled under the supervision of the DLO or MOIC. The DTO was requested to coordinate with the respective DLO and MOIC to train ASHAs for the ACF campaign in the provided training slot.

The objectives of the training were capacity building for all ASHAs to identify suspected TB cases in the targeted population, collection and transportation of sputum samples, and recording and reporting of daily activities.

The orientation covered the operational as well as interpersonal communication aspects of the ACF campaign. The instruction sheet for the search team, recording and reporting tools, sputum collection and transportation methodologies, and kit on frequently asked questions were distributed and discussed during these orientations.

ACF reporting formats and requirement assessments were to be done by the DTO before the start of field activities. All DTO were requested to share the details of their catchment areas, retrieve the details of all the ASHA workers in their districts or local areas from the respective DLO/District ASHA Coordinators/MOIC, and provide all the necessary logistics to the team members: the required number of ACF Formats and a Flyer displaying the tuberculosis symptoms (as approved by the Central TB Division) for all ASHA workers involved in the ACF campaign in their respective district or local area.

Daily field reports were submitted by the team members to the Designated Microscopy Centers (DMC). Lab Technicians were requested to mention all details of ASHA in the referring facility column of the Lab register against the respective Presumptive TB patients they refer/bring to DMC so that they are eligible for the Informant Incentive– INR 500 to Informant for tuberculosis notification after notification of the respective tuberculosis patient.

All field reports had to be compiled at the chest clinic level. Data entry operators (DEO) had to enter ACF reports into the Nikshay portal. Regarding entry in the Nikshay portal, DEO had to first enter mapping details, only then would be able to enter activity reports in the Nikshay Portal.

DTOs were requested to ensure the availability of the additional sputum containers for collecting sputum samples from eligible symptomatic patients before the start of field activities. The arrangement of boxes for sputum sample transport for carrying sputum samples to the DMC was also DTO’s responsibility.

Workflow and incentives of ASHA

Case-finding efforts: By door-to-door screening during routine surveys and identifying individuals with symptoms suggestive of tuberculosis (four symptoms (4S) screening) during Active Case Finding (ACF) and other similar campaigns.

Other incentives

Expenditure: The budget for the aforementioned activities was provided through the various heads of budget allocation under NTEP.

To conclude, the joint efforts of NLEP and NTEP with the inclusion of ASHA for the ACF are commendable. In the past, ACF has resulted in early diagnosis and treatment initiation. Reports of such joint efforts are available from other parts of the country. 16 Presently, this step towards tuberculosis elimination is remarkable because a grassroots worker is directly involved in ACF. There is an urgent need for such innovative efforts to achieve the goal of tuberculosis elimination. Further, large-scale studies finding the outcomes of these joint efforts will help in modifying or making new guidelines.

Conflicts of Interest

None declared.

Source of Funding

None.

Acknowledgements

None.