Increased Case Finding among high risk groups by Mobilizing Frontline Health workforces in Kathmandu Valley

Among garbage collectors, people living with TB symptoms, street children and contacts with Tuberculosis Patients...

grammes in the South East Asia Region, which thereby contribute greatly to global case detection. India alone notifies nearly 25% of all cases in the world. According to WHO estimates, TB prevalence, incidence and mortality in the region have declined steadily since 1990. However, these efforts will not suffice to achieve the TB targets set under Millennium Development Goal 6, which are to halve TB prevalence and mortality and reverse TB incidence by 2015 [6].
Globally, in 2014, 9.6 million people fell ill with TB and 1.5 million died from the disease TB occurs in every part of the world.

Objective
To evaluate the increase in case notification of smear-positive TB by active case finding at community-based microscopic camps by engaging the private providers, Community Health Workers and NGO's Volunteer.

Study Location
We evaluated an active case detection intervention in three urban districts of Kathmandu Valley of Nepal.

Study Design
A cross-sectional study of TB case detection associated with a project using door-to-door visit and Microscopic camps.

Study Population
The study was conducted in Kathmandu Valley (Lalitpur, Bhaktapur and Kathamdnu), and sample population were garbage collector, school children garbage collectors, people living with TB symptoms, street children and contacts with Tuberculosis Patients.

Screening and Enrollment of Target Population
The survey design is cross-sectional and conducted in

Sputum Examination and Diagnostic of TB
Two sputum samples including one early morning and one the spot specimen was collected in same day and examine sputum in line with international standard and protocol of TB diagnosis.
Diagnostic testing includes sputum AFB microscopic test.

Lessons Learnt
Household-level screening for prolonged cough was effective to assess and identify people living with TB symptoms. Intensive Volunteer mobilization for door-to-door visit and for identification of presumptive TB is obviously, efficient and effective model, however, educational level and age factor of Volunteer is challenging issues. In inception phase of the study, private health care providers and private pharmacy were reluctant to involve, however, after series of meeting with them, they involved and their involvement helps to identify the people living with TB sign and symptoms, who are visits to private pharmacy for early sputum examination.
Without accurate data, early detection of rising tuberculosis rates is challenging; so, mapping and situation analysis should be done to collect basic information in terms of target group, risk group's habitants, stakeholders etc. Door-to-door visit, Microscopic Camp and contact tracing of TB patient contacted person are the effective and efficient model for the active case finding, however, due to cause of funding gap, continuation of program is challenging issues.    (8%) were found to be smear-positive. major challenge [10]. Figure   2 revealed that 83.2 % identified people living with TB sign and symptom were participated on the sputum examination process.

Screening and Sputum Examination
Comparison with the sputum collection number is high, due to causes of door to door visit and local volunteer mobilization. On other hand positivity rate is quite higher in Indian experience (8%) rather than Nepali context (1.04). Risk factors associated with risk groups, accessibility of service and geographic variation might be factors associated with the positivity rate.
According study conducted by Global Fund-supported Project Axshya, in India, of 350047 presumptive pulmonary TB cases identified, 187 586 (54%) underwent sputum smear examination and 14 447 (8%) were found to be smear-positive [11]. In terms of positive rate and sputum collection rate is substantially different between Indian and Nepali context, there may have contextual differences, however risk and vulnerability factors, and methodology is another factor which gave different results.
Fifty (29.6%) pharmacies reported that they had referred 125 clients to public sector clinics during the previous 3 months. In total, 164 (96.5%) pharmacies reported that they always referred all TB symptomatic clients to DOTS (directly observed treatment, short course) clinics (Referral of tuberculosis symptomatic clients from private pharmacies to public sector clinics for diagnosis and treatment in Cambodia, 2105) [12]. Figure 4, reveals that, out to total people living with TB symptom, 284 were diagnosed tuberculosis, among them 193 (68%) were referred from the private sector.
Finding of the both surveys, approved the contribution of private pharmacy especially in establishing referral mechanism and referring people living with TB symptom for early TB diagnosis. Of these, 12.8% (4780/37417) were considered eligible for sputum examination. At least one sputum specimen was provided by 96.5% (4612/4780) of those eligible. A total of 114 (2.5%) subjects were smear-positive; 222 were smear-negative but culture-positive [13].
Based on the findings of Cambodian survey the positivity rate is quite high (2.5%) comparison to survey results of Nepal (1.04%).
Ironically, degree of positive rate is highly depending on people living with TB identification tools and technique. In addition, there a gap between no first sputum sample and second sample collection, due to multiple reason; low motivation of suspect person, stigma and discrimination, some sort of panic in terms of disease status and misconception about TB. Challenges gap of NTP unusual distribution of health staff, inadequate laboratory facilities, and weak procurement, supply chains, lack of effective and efficient monitoring, supportive supervision, and funding gap and surveillance systems. These challenges need to be effectively addressed. Doing so would help national TB programmed to depend less on the vertical systems that they established to overcome these constraints, while expanding DOTS programmed, over a decade ago [14][15][16].