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Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field

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A special issue of Tropical Medicine and Infectious Disease (ISSN 2414-6366). This special issue belongs to the section "Infectious Diseases".

Deadline for manuscript submissions: closed (1 January 2022) | Viewed by 47315

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Special Issue Editors

Dr. Tapash Roy

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Guest Editor

1. Country Director, IRD Global, Bangladesh Country Office, Gulshan 1, Dhaka 1212, Bangladesh
2. Adjuct Faculty, BRAC James P Grant School of Public Health, BRAC University, Dhaka 1212, Bangladesh
Interests: tuberculosis; child TB; drug-resistant TB; contact investigation; TB preventive treatment; NCDs; maternal and child health; mental health; diabetes and depression; sexual and reproductive health; HIV/AIDS; COVID-19
Special Issues, Collections and Topics in MDPI journals

Dr. Amyn A. Malik

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Guest Editor

1. IRD Global, Singapore 238884, Singapore
2. Analysis Group Inc., Boston, MA 02199, USA
Interests: tuberculosis; drug-resistant TB; pediatric TB; TB preventive treatment; COVID-19; vaccine acceptance and hesitancy
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Abu Naser Zafar Ullah

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Guest Editor

1. Deparment of Public Health, Daffodil International University, Daffodil Smart City, Ashulia, Dhaka 1341, Bangladesh
2. KIT Royal Tropical Institute, 64 Mauritskade, Amsterdam 1092 AD, The Netherlands
Interests: TB; TB PPM, HIV/AIDS; COVID 19; NCD; tobacco; maternal health; family planning; gender; refugee health
Special Issues, Collections and Topics in MDPI journals

Dr. Sourya Shrestha

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Guest Editor

Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205, USA
Interests: TB; co-infections; mathematical modeling
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Although it is mostly preventable and curable, approximately 10 million people develop tuberculosis disease, resulting in a million deaths every year globally. Most of this burden falls on low-resource settings and the most vulnerable and marginalized populations. While there has been progress toward reducing TB burden in recent years, the rates of decline we have achieved in TB incidence and mortality have lagged behind the Sustainable Development Goal (SDG) targets of 90% reduction in TB deaths and 80% reduction in TB incidence. Furthermore, the massive disruption caused by the current COVID-19 pandemic could ultimately reverse much of the recent gains we have made so far in reducing TB burden. This has resulted in sharp reductions in TB diagnosis, and it is estimated that an additional 6.3 million TB patients and 1.4 million TB deaths will be reported between 2020 and 2025. TB is currently the second largest infectious source of deaths globally, only behind the novel SARS coronavirus, and as such, much needs to be done on all fronts to flight TB.

However, there is much to feel hopeful for as well. For the first time in several decades, we are on the brink of having a shorter treatment regimen for the treatment of drug-sensitive TB (DS-TB) and a novel TB vaccine that would prevent TB disease in adults. The availability of several novel diagnostics tools, portable digital X-ray devices, novel short-course preventive therapy regimen, and novel preventive treatment for drug-resistant-TB adds further to this optimism.

As we look forward to TB elimination and meeting TB goals, evidence-based approaches would be the key. This Special Issue on “Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field” invites submissions on evidence-based approaches to ending TB, including active case-finding approaches, TB preventive treatment, and a holistic biosocial approach to TB elimination with global relevance. A broad range of research methodologies will be accepted, including qualitative, epidemiology, operational, implementation, and policy research, as well as other relevant approaches.

Dr. Tapash Roy
Dr. Amyn A. Malik
Prof. Dr. Abu Naser Zafar Ullah
Dr. Sourya Shrestha
Guest Editors

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Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Tropical Medicine and Infectious Disease is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2700 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

tuberculosis
epidemiology
TB elimination
TB case detection
contact investigation
TB preventive treatment
childhood TB
MDR-TB
urban TB
disparities in TB burden
TB in a high-risk population

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Published Papers (11 papers)

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Editorial

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3 pages, 172 KiB

Open AccessEditorial

Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field

by Abu Naser Zafar Ullah, Sourya Shrestha, Amyn A. Malik and Tapash Roy

Trop. Med. Infect. Dis. 2022, 7(3), 36; https://doi.org/10.3390/tropicalmed7030036 - 25 Feb 2022

Cited by 1 | Viewed by 2666

Abstract

The global fight against tuberculosis (TB) has gained momentum since the adoption of the ‘End TB Strategy’ in 2014 [...] Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

Research

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9 pages, 235 KiB

Open AccessEditor’s ChoiceArticle

Telehealth Reduces Missed Appointments in Pediatric Patients with Tuberculosis Infection

by Angela Zhao, Nirali Butala, Casey Morgan Luc, Richard Feinn and Thomas S. Murray

Trop. Med. Infect. Dis. 2022, 7(2), 26; https://doi.org/10.3390/tropicalmed7020026 - 14 Feb 2022

Cited by 4 | Viewed by 3586

Abstract

Pediatric patients with untreated tuberculosis infection (TBI), also called latent TBI, are at risk of progression to active TB disease. The primary aim of this study was to identify factors associated with higher rates of missed appointments and failure to complete therapy for pediatric patients with TBI. A secondary aim was to determine the impact of the COVID-19 pandemic and the rise of telehealth on TBI missed appointment rates. We first performed a retrospective chart review of 129 pediatric patients referred to the free Yale Pediatric Winchester Chest Tuberculosis Clinic from 2016–2019. Associations between demographic/clinical variables and missed appointments/failure to complete therapy were analyzed using univariate and bivariate chi-square tests. Language, lack of primary provider, and distance to clinic were the main contributors to missed appointments and poor treatment adherence. There was an association between the number of missed appointments and failure to complete treatment (p = 0.050). A second cohort of 29 patients was analyzed from January–December 2021 when telehealth was offered for follow-up appointments. Of these follow-up visits, 54% were conducted via telehealth, and the clinic’s missed appointment rate dropped significantly from 16.9% to 5.8% during this time frame (p = 0.037). These data demonstrate that telehealth is accepted as an alternative by patients for follow-up TBI visits. Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

12 pages, 612 KiB

Open AccessArticle

Implementing a Substance-Use Screening and Intervention Program for People Living with Rifampicin-Resistant Tuberculosis: Pragmatic Experience from Khayelitsha, South Africa

by Anja Reuter, Buci Beko, Boniwe Memani, Jennifer Furin, Johnny Daniels, Erickmar Rodriguez, Hermann Reuter, Lize Weich, Petros Isaakidis, Erin von der Heyden, Yulene Kock and Erika Mohr-Holland

Trop. Med. Infect. Dis. 2022, 7(2), 21; https://doi.org/10.3390/tropicalmed7020021 - 31 Jan 2022

Cited by 4 | Viewed by 3319

Abstract

Substance use (SU) is associated with poor rifampicin-resistant tuberculosis (RR-TB) treatment outcomes. In 2017, a SBIRT (SU screening-brief intervention-referral to treatment) was integrated into routine RR-TB care in Khayelitsha, South Africa. This was a retrospective study of persons with RR-TB who were screened for SU between 1 July 2018 and 30 September 2020 using the ASSIST (Alcohol, Smoking and Substance Involvement Screening Test). Here we describe outcomes from this program. Persons scoring moderate/high risk received a brief intervention and referral to treatment. Overall, 333 persons were initiated on RR-TB treatment; 38% (n = 128) were screened for SU. Of those, 88% (n = 113/128) reported SU; 65% (n = 83/128) had moderate/high risk SU. Eighty percent (n = 103/128) reported alcohol use, of whom 52% (n = 54/103) reported moderate/high risk alcohol use. Seventy-seven persons were screened for SU within ≤2 months of RR-TB treatment initiation, of whom 69%, 12%, and 12% had outcomes of treatment success, loss to follow-up and death, respectively. Outcomes did not differ between persons with no/low risk and moderate/high risk SU or based on the receipt of naltrexone (p > 0.05). SU was common among persons with RR-TB; there is a need for interventions to address this co-morbidity as part of “person-centered care”. Integrated, holistic care is needed at the community level to address unique challenges of persons with RR-TB and SU. Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

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8 pages, 1254 KiB

Open AccessEditor’s ChoiceArticle

Integrated Tuberculosis and COVID-19 Activities in Karachi and Tuberculosis Case Notifications

by Amyn A. Malik, Hamidah Hussain, Rabia Maniar, Nauman Safdar, Amal Mohiuddin, Najam Riaz, Aneeta Pasha, Salman Khan, Syed Saleem Hasan Kazmi, Ershad Kazmi and Saira Khowaja

Trop. Med. Infect. Dis. 2022, 7(1), 12; https://doi.org/10.3390/tropicalmed7010012 - 15 Jan 2022

Cited by 16 | Viewed by 4111 | Correction

Abstract

As the COVID-19 pandemic surged, lockdowns led to the cancellation of essential health services. As part of our Zero TB activities in Karachi, we adapted our approach to integrate activities for TB and COVID-19 to decrease the impact on diagnosis and linkage to care for TB treatment. We implemented the following: (1) integrated COVID-19 screening and testing within existing TB program activities, along with the use of an artificial intelligence (AI) software reader on digital chest X-rays; (2) home delivery of medication; (3) use of telehealth and mental health counseling; (4) provision of PPE; (5) burnout monitoring of health workers; and (6) patient safety and disinfectant protocol. We used programmatic data for six districts of Karachi from January 2018 to March 2021 to explore the time trends in case notifications, the impact of the COVID-19 pandemic, and service adaptations in the city. The case notifications in all six districts in Karachi were over 80% of the trend-adjusted expected notifications with three districts having over 90% of the expected case notifications. Overall, Karachi reached 90% of the expected case notifications during the COVID-19 pandemic. The collaborative efforts by the provincial TB program and private sector partners facilitated this reduced loss in case notifications. Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

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11 pages, 1860 KiB

Open AccessArticle

Screening for Parasitic Infection and Tuberculosis in Immunosuppressed and Pre-Immunosuppressed Patients: An Observational Study

by Luisa Carnino, Jean-Marc Schwob, Dionysios Neofytos, Maria Lazo-Porras, François Chappuis and Gilles Eperon

Trop. Med. Infect. Dis. 2021, 6(3), 170; https://doi.org/10.3390/tropicalmed6030170 - 21 Sep 2021

Cited by 4 | Viewed by 3055

Abstract

Reactivation of latent tuberculosis infection (LTBI) or latent parasitic infection (LPI) during drug-induced immunosuppression can have serious consequences. The Division of tropical and humanitarian medicine of the Geneva University Hospitals runs a specific consultation for parasitic screening of immunosuppressed or pre-immunosuppressed patients. We sought to determine the seroprevalence of LTBI and LPI in such patients and explore its relationship with country of origin or previous travel in a retrospective, single-centre observational study from 2016 to 2019. Demographic data, travel history, ongoing treatments and results of the parasitological (Strongyloides stercoralis, Trypanosoma cruzi, Echinococcus multilocularis, Entamoeba histolytica and Leishmania spp.) and TB screening were collected to calculate LPI or LTBI prevalence. Risk factors for LTBI and strongyloidiasis were analysed using Poisson regression with robust variance. Among 406 eligible patients, 24/353 (6.8%) had LTBI, 8/368 (2.2%) were positive for Strongyloides stercoralis infection, 1/32 (3.1%) was positive for Entamoeba histolytica and 1/299 (0.3%) was positive for Leishmaniasis. No cases of Trypanosoma cruzi (0/274) or Echinococcus multilocularis (0/56) infection were detected. Previous travel to or originating from high-prevalence countries was a risk factor for LTBI (PR = 3.4, CI 95%: 1.4–8.2 and 4.0, CI 95%: 1.8–8.9, respectively). The prevalence of serological Strongyloidiasis in immunosuppressed patients is lower in comparison to those without immunosuppression (PR = 0.1, CI 95%: 0.01–0.8). In conclusion, screening before immunosuppression needs to be individualized, and LTBI and LPI need to be ruled out in patients who originate from or have travelled to high-prevalence countries. The sensitivity of strongyloidiasis serology is reduced following immunosuppression, so an algorithm combining different tests or presumptive treatment should be considered. Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

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14 pages, 1480 KiB

Open AccessArticle

Challenges Perceived by Health Care Providers for Implementation of Contact Screening and Isoniazid Chemoprophylaxis in Karnataka, India

by Kiran Chawla, Sharath Burugina Nagaraja, Nayana Siddalingaiah, Chidananda Sanju, Vishnu Prasad Shenoy, Uday Kumar, Arundathi Das, Druti Hazra, Suresh Shastri, Anil Singarajipur and Ramesh Chandra Reddy

Trop. Med. Infect. Dis. 2021, 6(3), 167; https://doi.org/10.3390/tropicalmed6030167 - 14 Sep 2021

Cited by 3 | Viewed by 4308

Abstract

Background: In India, challenges in pediatric TB contact screening and chemoprophylaxis initiation are still underexplored. Elucidating these challenges will help in better implementation of the programme at the grass-roots level thereby helping in early detection of pediatric cases and timely initiation of preventive therapy. This study aimed at exploring the challenges faced by the health care provider in contact screening and chemoprophylaxis initiation implementation of the pediatric household contacts. Methods: A qualitative study was conducted in the districts of Bengaluru and Udupi and in-depth interviews of key participants were adopted to explore the challenges. Qualitative data analysis was done after developing transcripts by generating themes and codes. Results: The key challenges were identified as stigma towards the disease, migrant patients with changing address, difficulty in sample collection, anxiety among parents due to long duration of the prophylactic treatment and adherence to IPT is not well documented, inadequate transportation from rural areas, and the ongoing COVID-19 pandemic. Conclusions: It is important for the National TB programme to address these challenges efficiently and effectively. Innovative solutions, feasible engagements, and massive efforts are to be taken by the programme to improve contact screening and isoniazid chemoprophylaxis implementation. Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

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13 pages, 495 KiB

Open AccessArticle

Is It Feasible to Conduct Post-Tuberculosis Assessments at the End of Tuberculosis Treatment under Routine Programmatic Conditions in China?

by Yan Lin, Yuqin Liu, Guanghui Zhang, Qinghe Cai, Weihua Hu, Lixin Xiao, Pruthu Thekkur, Jonathan E. Golub and Anthony D. Harries

Trop. Med. Infect. Dis. 2021, 6(3), 164; https://doi.org/10.3390/tropicalmed6030164 - 10 Sep 2021

Cited by 10 | Viewed by 3098

Abstract

There is growing evidence that a substantial proportion of people who complete anti-tuberculosis treatment experience significant morbidity and mortality which can negatively affect their quality of life. It is suggested that national tuberculosis programs conduct end-of-treatment assessments, but whether this is feasible is currently not known. We therefore assessed whether tuberculosis program staff could assess functional and general health status of patients at the end of treatment in five TB clinics in four provinces in China. There were 115 patients, aged 14–82 years, who completed anti-tuberculosis treatment and a post-TB assessment. There were 54 (47%) patients who continued to have symptoms, the commonest being cough, dyspnea and fatigue. Symptom continuation was significantly more common in the 22 patients with diabetes (p = 0.027) and the 12 patients previously treated for TB (p = 0.008). There were 12 (10%) current smokers, an abnormal chest X-ray was found in 106 (92%) patients and distance walked in the 6-min walking test (6MWT) ranged from 30–750 m (mean 452 ± 120); 24 (21%) patients walked less than 400 m. Time taken to perform the post-TB assessment, including the 6MWT, ranged from 8–45 min (mean 21 ± 8 min). In 98% of the completed questionnaires, health workers stated that conducting post-TB assessments was feasible and useful. This study shows that post-TB assessments can be conducted under routine programmatic conditions and that there is significant morbidity that needs to be addressed. Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

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13 pages, 1196 KiB

Open AccessEditor’s ChoiceArticle

Implementation of an Effective Decentralised Programme for Detection, Treatment and Prevention of Tuberculosis in Children

by John Paul Dongo, Stephen M. Graham, Joseph Nsonga, Fred Wabwire-Mangen, Elizabeth Maleche-Obimbo, Ezekiel Mupere, Rodrigo Nyinoburyo, Jane Nakawesi, Gerald Sentongo, Pauline Amuge, Anne Detjen, Frank Mugabe, Stavia Turyahabwe, Moorine P. Sekadde and Stella Zawedde-Muyanja

Trop. Med. Infect. Dis. 2021, 6(3), 131; https://doi.org/10.3390/tropicalmed6030131 - 14 Jul 2021

Cited by 14 | Viewed by 5260

Abstract

Childhood tuberculosis (TB) is consistently under-detected in most high-burden countries, including Uganda, especially in young children at high risk for severe disease and mortality. TB preventive treatment (TPT) for high-risk child contacts is also poorly implemented. The centralised concentration of services for child TB at the referral level is a major challenge in the prevention, detection and treatment of TB in children. In 2015, the DETECT Child TB Project was implemented in two districts of Uganda and involved decentralisation of healthcare services for child TB from tertiary to primary healthcare facilities, along with establishing linkages to support community-based household contact screening and management. The intervention resulted in improved case finding of child and adult TB cases, improved treatment outcomes for child TB and high uptake and completion of TPT for eligible child contacts. A detailed description of the development and implementation of this project is provided, along with findings from an external evaluation. The ongoing mentorship and practical support for health workers to deliver optimal services in this context were critical to complement the use of training and training tools. A summary of the project’s outcomes is provided along with the key challenges identified and the lessons learnt. Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

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11 pages, 929 KiB

Open AccessEditor’s ChoiceArticle

Measuring Catastrophic Costs Due to Tuberculosis in Myanmar

by Si Thu Aung, Aung Thu, Htin Lin Aung and Min Thu

Trop. Med. Infect. Dis. 2021, 6(3), 130; https://doi.org/10.3390/tropicalmed6030130 - 14 Jul 2021

Cited by 15 | Viewed by 5224

Abstract

Background: This is the first survey to use the World Health Organization (WHO) methodology to document the magnitude and main drivers of tuberculosis (TB) patient costs in order to guide policies on cost mitigation and to produce a baseline measure for the percentage of TB-affected households experiencing catastrophic costs in Myanmar. Methods: A nationally representative cross-sectional survey was administered to 1000 TB patients in health facilities from December 2015 to February 2016, focusing on costs of TB treatment (direct and indirect), household income, and coping strategies. A total cost was estimated for each household by extrapolating reported costs and comparing them to household income. If the proportion of total costs exceeded 20% of the annual household income, a TB-affected household was deemed to have faced catastrophic costs. Results: 60% of TB-affected households faced catastrophic costs in Myanmar. On average, total costs were USD 759, and the largest proportion of this total was accounted for by patient time (USD 365), followed by food costs (USD 200), and medical expenses (USD 130). Low household wealth quintile and undergoing MDR-TB treatment were both significant predictors for households facing catastrophic costs. Conclusions: The high proportion of TB-affected households experiencing catastrophic costs suggests the need for TB-specific social protection programs in patient-centered healthcare. The survey findings have led the government and donors to increase support for MDR-TB patients. The significant proportion of total spending attributable to lost income and food or nutritional supplements suggests that income replacement programs and/or food packages may ameliorate the burdensome costs. Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

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Other

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1 pages, 162 KiB

Open AccessCorrection

Correction: Malik et al. Integrated Tuberculosis and COVID-19 Activities in Karachi and Tuberculosis Case Notifications. Trop. Med. Infect. Dis. 2022, 7, 12

Trop. Med. Infect. Dis. 2022, 7(5), 63; https://doi.org/10.3390/tropicalmed7050063 - 21 Apr 2022

Viewed by 1906

Abstract

The authors wish to revise the second citation of reference [26] to [27] in the original article main text [...] Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

22 pages, 1522 KiB

Open AccessSystematic Review

Active Case Finding for Tuberculosis in India: A Syntheses of Activities and Outcomes Reported by the National Tuberculosis Elimination Programme

by Sharath Burugina Nagaraja, Pruthu Thekkur, Srinath Satyanarayana, Prathap Tharyan, Karuna D. Sagili, Jamhoih Tonsing, Raghuram Rao and Kuldeep Singh Sachdeva

Trop. Med. Infect. Dis. 2021, 6(4), 206; https://doi.org/10.3390/tropicalmed6040206 - 30 Nov 2021

Cited by 15 | Viewed by 7390

Abstract

India launched a national community-based active TB case finding (ACF) campaign in 2017 as part of the strategic plan of the National Tuberculosis Elimination Programme (NTEP). This review evaluated the outcomes for the components of the ACF campaign against the NTEP’s minimum indicators and elicited the challenges faced in implementation. We supplemented data from completed pretested data proformas returned by ACF programme managers from nine states and two union territories (for 2017–2019) and five implementing partner agencies (2013–2020), with summary national data on the state-wise ACF outcomes for 2018–2020 published in annual reports by the NTEP. The data revealed variations in the strategies used to map and screen vulnerable populations and the diagnostic algorithms used across the states and union territories. National data were unavailable to assess whether the NTEP indicators for the minimum proportions identified with presumptive TB among those screened (5%), those with presumptive TB undergoing diagnostic tests (>95%), the minimum sputum smear positivity rate (2% to 3%), those with negative sputum smears tested with chest X-rays or CBNAAT (>95%) and those diagnosed through ACF initiated on anti-TB treatment (>95%) were fulfilled. Only 30% (10/33) of the states in 2018, 23% (7/31) in 2019 and 21% (7/34) in 2020 met the NTEP expectation that 5% of those tested through ACF would be diagnosed with TB (all forms). The number needed to screen to diagnose one person with TB (NNS) was not included among the NTEP’s programme indicators. This rough indicator of the efficiency of ACF varied considerably across the states and union territories. The median NNS in 2018 was 2080 (interquartile range or IQR 517–4068). In 2019, the NNS was 2468 (IQR 1050–7924), and in 2020, the NNS was 906 (IQR 108–6550). The data consistently revealed that the states that tested a greater proportion of those screened during ACF and used chest X-rays or CBNAAT (or both) to diagnose TB had a higher diagnostic yield with a lower NNS. Many implementation challenges, related to health systems, healthcare provision and difficulties experienced by patients, were elicited. We suggest a series of strategic interventions addressing the implementation challenges and the six gaps identified in ACF outcomes and the expected indicators that could potentially improve the efficacy and effectiveness of community-based ACF in India. Full article

(This article belongs to the Special Issue Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field)

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Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field

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