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Case finding, an important parameter in fight against Tuberculosis (TB) has always remained a challenge despite advances in diagnostic modalities, access to health care and administrative commitment. We are still far from reaching the goals so set as per End TB Strategy and National Strategic Plan 2017-2025, and case finding is of paramount importance for achieving the said targets. This article, after identifying the obstacles faced in case finding, explores the various case finding strategies in the perspective of diagnostics, feasibility, resource utilization and current recommendations. Need for prioritization of case finding in different settings with involvement and active participation of one and all has been discussed. Role of health education in an individual, general public and health care worker in the context of case finding has been highlighted. Research areas to strengthen case finding have been enumerated. The review concludes by bringing out the need for heightened efforts for case finding in TB as the resources are significantly diverted as the world is facing the corona virus disease 2019 (COVID-19) pandemic., Highlights • Early case finding and prompt treatment is of paramount importance for elimination of Tuberculosis but has always remained a challenge. • Ongoing passive case finding (PCF) needs to be strictly complemented with active case finding (ACF) especially in the vulnerable population till we are ready for mass screening. • Efforts for case finding in TB should not be neglected despite the present corona virus disease 2019 (COVID-19) pandemic.

Background Cambodia has made notable progress in the fight against tuberculosis (TB). However, these gains are impeded by a significant proportion of undiagnosed cases. To effectively reach people with TB, active case-finding (ACF) strategies have been adopted by countries affected by the epidemic, including Cambodia, alongside passive case finding (PCF). Despite increased efforts to improve case detection, approximately 40% of TB cases in Cambodia remained undiagnosed in 2018. In Cambodia, several community-based TB ACF modalities have been implemented, but their effectiveness has yet to be systematically assessed. Methods This pragmatic cluster randomized controlled trial will be conducted between December 2019 and June 2021. We will randomize eight operational districts (clusters) in seven provinces (Kampong Cham, Kampong Thom, Prey Veng, Thbong Khmum, Kampong Chhnang, Kandal, and Kampong Speu) to either the control group (PCF) or the intervention groups (ACF using a seed-and-recruit model, ACF targeting household and neighborhood contacts, and ACF targeting persons aged ≥ 55 years using mobile screening units). The primary endpoints will be TB case notification rates, additionality, and cumulative yield of TB cases. The secondary endpoints include treatment outcomes, the number needed to screen to find one TB case, and cost-effectiveness outcome measures. We will analyze the primary and secondary endpoints by intention to treat. We will compare cluster and individual-level characteristics using Student’s t test and hierarchical or mixed-effect models to estimate the ratio of these means. The incremental cost-effectiveness ratio per disability-adjusted life year averted will also be considered as a benchmark to determine whether the interventions are cost-effective. Discussion This study will build an evidence base to inform future scale-up, implementation, and sustainability of ACF strategies in Cambodia and other similar settings. Implementation of this study will also complement TB control strategies in Cambodia by conducting ACF in operational districts without active interventions to find TB cases currently. Those who are ill and might have TB will be promptly screened, diagnosed, and linked to care. Early diagnosis and treatment initiation will also benefit their community by interrupting transmission and prevent further infections. The experience gained from this project will inform future attempts in conducting pragmatic trials in low-resource settings. Trial registration ClinicalTrials.gov, NCT04094350. Registered on 18 September 2019.

This study aimed to estimate the costs and incremental cost-effectiveness of two community-based tuberculosis (TB) active case-finding (ACF) strategies in Cambodia. We also assessed the number needed to screen and test to find one TB case. Program and national TB notification data from a quasi-experimental study of a cohort of people with TB in 12 intervention operational districts (ODs) and 12 control ODs between November 2018 and December 2019 were analyzed. Two ACF interventions (ACF seed-and-recruit (ACF SAR) model and one-off roving (one-off) ACF) were implemented concurrently. The matched control sites included PCF only. We estimated costs using the program and published data in Cambodia. The primary outcome was disability-adjusted life years (DALY) averted over 14 months. We considered the gross domestic product per capita of Cambodia in 2018 as the cost-effectiveness threshold. ACF SAR needed to test 7.7 people with presumptive TB to identify one all-forms TB, while one-off ACF needed to test 22.4. The costs to diagnose one all-forms TB were USD 458 (ACF SAR) and USD 191 (one-off ACF). The incremental cost per DALY averted was USD 257 for ACF SAR and USD 204 for one-off ACF. Community-based ACF interventions that targeted key populations for TB in Cambodia were highly cost-effective.

There is a new paradigm that preventing tuberculosis (TB) and addressing the reservoir of latent TB infection in combination with curing all TB cases is essential to accelerate the decline of TB rates and ending TB by 2050. However, complacency and incremental change eludes radical policy transformation needed to meet global targets. This essay explores current attitudes, policy disparities between high and lower burden settings, and what changes are needed to remove the obstacles to progress.

Background: Chest x-ray is central in screening and diagnosis of tuberculosis. However, sputum culture remains gold standard for diagnosis. Aim: To establish the rate of normal chest x-rays in tuberculosis patients found by spot sputum culture screening, and compare them to a group identified through passive case finding. Method: Chest x-rays from 39 culture-positive patients, identified by spot sputum culture screening in Copenhagen from 2012 to 2014, were included in the study (spot sputum culture group(SSC)). 39 normal chest x-rays from persons screened by mobile x-ray, and 39 chest x-rays from tuberculosis-patients identified through passive case finding(PCF) were anonymised and randomised. Two respiratory physicians and two radiologists assessed the chest x-rays. Results: The normal chest x-ray rate was higher in the non-tuberculosis control group (median = 32 (82.1%), range = 74.4% – 100%), compared to the SSC group (median = 7 (17.9%), range = 10.3% – 33.3%), and the PCF controls (median = 3(7.7%), range = 2.6% – 15.4%). In the SSC group 14 (35.9%) were categorized as normal by at least one study participant. Conclusion: A substantial minority of patients diagnosed with tuberculosis by spot sputum culture screening, and through passive case finding would not have been identified with chest x-ray alone, highlighting that a normal chest x-ray does not exclude pulmonary tuberculosis. Keywords: Tuberculosis, Chest x-ray changes, Passive case finding, Active case finding, Chest x-ray assessment, Normal chest x-ray

Passive case finding remains the mainstay of tuberculosis (TB) control in several resource-limited countries. Although TB prevalence and mortality rates have declined in recent years, an estimated 3 million cases a year still go undetected and/or unreported, and delays in the diagnosis and treatment of TB continue to be widespread. It has been shown that identifying and treating individuals with latent TB infection (LTBI) prevents progression to active TB disease and is one of the key components of TB control strategies. However, neither systematic screening of LTBI nor a policy of isoniazid preventive therapy exists in several resource-limited countries for TB close contacts, leading to the vicious cycle of infection/reinfection in household. Moreover, no reliable data exist for TB contacts for efficient control measures to be set up. In recent years, many countries, especially developing countries, have witnessed an upsurge in the use of mobile phones. Should we want to achieve the post-2015TB elimination goal? For this purpose, it is necessary to formulate new strategies utilizing the widespread availability of new communication technologies (e.g., smartphone apps). This can provide an enhanced means to curb the disease, especially in resource-limited countries still lacking preventive measures and effective strategies to combat this old foe.

Background: Close contact investigation is the essential key in tuberculosis (TB) case finding and an effective strategy for TB control program within any society. Methods: In this prospective study, 1186 close family contacts of hospitalized TB patients (index) in a referral TB hospital in Tehran-Iran were passively studied. These people were studied to rollout TB infection and disease. Demographic characteristics, clinical and laboratory data of these individuals were reviewed and summarized for analysis. Results: A total of 886 (74.4%) close-family contacts completed their investigation. The index TB patients of these individuals were sputum smear negative for acid-fast bacilli in 137 cases (11.6%) and the rest were smear positive. A total of 610 (68.8%) close-family contact ruled out for TB infection or disease (Group I). A total of 244 cases (27.5%) had latent TB infection (Group II) and active TB (Group III) was confirmed in 32 cases (3.6%). A significant difference was shown for female gender, signs and symptoms, family size, and positive radiological finding between Group I and Group II. The study of index parameter including positive sputum smear/culture did not reveal any significant difference, but positive cavitary lesion significantly more has seen in active TB group (P = 0.004). Conclusions: This study emphasizes on sign and symptoms and radiological finding in TB contact investigation, where index parameters including positive smear/culture, does not implicate any priority. Although cavitary lesions in index patient have more accompanied by active TB, close contact study should include all of TB indexes. This investigation should include chest radiography for these individuals.

Background. Tuberculosis (TB) control is a public health priority with 3 million cases unrecognized by the public health system each year. We assessed the impact of improved TB diagnostics and on-site training on TB case detection and treatment outcomes in rural healthcare facilities. Methods. Fluorescence microscopy, Xpert MTB/RIF, and on-site training were introduced at 10 healthcare facilities. Using quasi-experimental methods, these 10 intervention healthcare facilities were compared with 2 controls and their own performance the previous year. Results. From January to October 2012, 186 357 and 32 886 outpatients were seen in the 10 intervention and 2 control facilities, respectively. The intervention facilities had a 52.04% higher proportion of presumptive TB cases with a sputum examination (odds ratio [OR] = 12.65; 95% confidence interval [CI], 5.60–28.55). After adjusting for age group and gender, the proportion of smear-positive patients initiated on treatment was 37.76% higher in the intervention than in the control facilities (adjusted OR [AOR], 7.59; 95% CI, 2.19–26.33). After adjusting for the factors above, as well as human immunodeficiency virus and TB retreatment status, the proportion of TB cases who completed treatment was 29.16% higher (AOR, 4.89; 95% CI, 2.24–10.67) and the proportion of TB cases who were lost to follow-up was 66.98% lower (AOR, 0.04; 95% CI, 0.01–0.09). When compared with baseline performance, the intervention facilities had a significantly higher proportion of presumptive TB cases with a sputum examination (64.70% vs 3.44%; OR, 23.95; 95% CI, 12.96–44.25), and these facilities started 56.25% more smear-positive TB cases on treatment during the project period (AOR, 15.36; 95% CI, 6.57–35.91). Conclusions. Optimizing the existing healthcare workforce through a bundled diagnostics and on-site training intervention for nonphysician healthcare workers will rapidly improve TB case detection and outcomes towards global targets.