The detection of active pulmonary tuberculosis in participants within their homes, who reside in a high risk tuberculosis community confronted with minority ethnic groups, language and social barriers, high prevalence and incidence of HIV infections, high prevalence of abuse against women, high prevalence of teenage pregnancies, high prevalence of substance abuse and a high prevalence of poverty and illiteracy.

1. 1
Systematic home screening for active pulmonary
tuberculosis in the San community of
Platfontein, an historically disadvantaged ethnic
minority group within the Francis Baard District
of the Northern Cape, South Africa.
Researcher : Dr. Dalton Glynn Malambo
Definitions
Active pulmonary tuberculosis
Active tuberculosis refers to disease that occurs in someone infected with Mycobacterium
tuberculosis. It is characterized by signs and/or symptoms of active disease.1
Systematic home screening for active pulmonary tuberculosis
Systematic home screening for active pulmonary tuberculosis is a provider-initiated pathway,
and is defined as the systematic identification of people with suspected active pulmonary
tuberculosis, within their homes, in a predetermined target group, using tests, examinations or
procedures that can be applied rapidly.1
Passive pulmonary tuberculosis case-finding
Passive pulmonary tuberculosis case finding is a patient-initiated pathway for diagnosing
pulmonary tuberculosis , whereby a person with active TB, who experiences symptoms,
recognizes these symptoms as serious, seeks healthcare by spontaneously presenting to an
appropriate health facility.1
Risk group for TB
A risk group for TB is any group of people within which the prevalence or
incidence of TB is significantly higher than in the general population.1

2. 2
Aim
To detect people with undiagnosed active pulmonary tuberculosis at their homes, within a high
TB risk community, using validated WHO screening tools.
Introduction
Tuberculosis is a major global health problem, causing both high morbidity and mortality rates,
especially within high-burden countries. After adjusting for population size, South Africa has the
highest incidence and prevalence of tuberculosis among all the high-burden countries in the
world.2
It is estimated that 80% of the South African population is infected with the TB bacillus, however
not everyone who is infected will progress to active TB disease. Certain populations are at
higher risk of TB infection and re-infection, including: health care workers, miners, prisoners,
prison officers and household contacts of confirmed TB patients. In addition, certain groups are
particularly vulnerable to progressing from TB infection to TB disease. These include children,
people living with HIV, diabetics, smokers, alcohol and substance users, people who are
malnourished or have silicosis, mobile, migrant and refugee populations and people living and
working in poorly ventilated environments. These groups are considered
‘key populations’ for TB.3
Estimates of TB burden in South Africa 2014 :
• Prevalence = 696 per 100000 population.
• Incidence = 834 per 100000 population.4
The WHO End TB Strategy, adopted by the World Health Assembly in May 2014, is a blueprint
for countries to end the TB epidemic by driving down TB deaths, incidence and eliminating
catastrophic costs. It outlines global impact targets to reduce TB deaths by 90% and to cut new
cases by 80% between 2015 and 2030, and to ensure that no family is burdened with
catastrophic costs due to TB.
Ending the TB epidemic by 2030 is among the health targets of the newly adopted Sustainable
Development Goals. WHO has gone one step further and set a 2035 target of 95% reduction in
deaths and a 90% decline in TB incidence - similar to current levels in low TB incidence countries
today.
The success of the strategy will depend on countries respecting the following 4 key principles as
they implement the interventions outlined in each pillar:
• government stewardship and accountability, with monitoring and evaluation
• strong coalition with civil society organizations and communities
• protection and promotion of human rights, ethics and
• equity adaptation of the strategy and targets at country level, with global collaboration.5

3. 3
The National Strategic Plan on HIV, STIs and TB (2012- 2016) is an initiative implemented by the
South African Department of Health, to address the dual epidemics of HIV and TB.
The NSP 2012–2016 has adapted a 20 year vision for the country with respect to the HIV and TB
epidemics.
It has adapted the Three Zeros advocated by UNAIDS to suit the local context.
The South African vision is:
• Zero new HIV and TB infections;
• Zero new infections due to vertical transmission;
• Zero preventable deaths associated with HIV and TB;
• Zero discrimination associated with HIV, STIs and TB.
In line with this 20-year vision, the NSP 2012-2016 has the following broad goals:
• Reduce new HIV infections by at least 50% using combination prevention approaches;
• Initiate at least 80% of eligible patients on antiretroviral treatment (ART), with 70% alive
and on treatment five years after initiation;
• Reduce the number of new TB infections as well as deaths from TB by 50%;
• Ensure an enabling and accessible legal framework that protects and promotes human
rights in order to support implementation of the NSP; and
• Reduce self-reported stigma related to HIV and TB by at least 50%.3
The central pillars of TB control in order to avoid deaths and transmission include:
1) finding
2) treating and
3) preventing 6
The focus of research in this article addresses the important pillar of “finding TB” in people who
remain undiagnosed within communities at risk.
National TB prevalence surveys have demonstrated that a large pool of undetected prevalent
cases exist. Many people with TB therefore remain undiagnosed or are diagnosed only after
long delays. This high burden of undiagnosed TB causes much suffering, economic hardship and
sustained transmission.
In 1974, the ninth report by WHO Expert Committee on Tuberculosis recommended that
indiscriminate tuberculosis case-finding by mobile mass radiography should be abandoned. This
was supported by the inefficiency of mass screening, mostly based on the assessment of
populations with low prevalence TB and good access to high–quality health services. Community
screening in low–income settings was deemed as inappropriate due to basic diagnostic and
treatment services not being widely available.
Systematic screening for active TB, is a tool adopted by the WHO, of which it’s primary objective
is to ensure that active TB is detected early, therefore reducing the risk of poor disease
outcomes and the adverse social and economic consequences of the disease, as well as help
reduce TB transmission. It is defined as the systematic identification of people with suspected
active TB, in a predetermined target group, using tests, examinations or procedures that can be
applied rapidly.
Recent years has seen the resurgence of active case finding for tuberculosis as a complimentary
method to conventional passive case finding in communities with a high burden of TB.1
The WHO developed guidelines on screening for active TB screening. If done the right way and
targeting the right people, may reduce suffering and death. However, the benefits against risks
and costs of screening should be balanced.

4. 4
Key principles for systematic screening for active TB
1. Before screening is initiated high quality TB diagnosis, treatment, care, management and
support for patients should be in place and baseline analysis should be completed,
demonstrating that the potential benefits of screening clearly outweigh the risks of doing harm.
2. Indiscriminate mass screening should be avoided. The prioritization of risk group for screening
should be based on assessments made for each risk group.
3. The choice of screening and diagnosis should be based on the accuracy of the algorithm.
4. The screening should follow established ethical principles for screening for infectious diseases
5. The TB screening approach is implemented in such a way as to optimize the delivery of other
health and social services.
6. TB screening strategy should be continuously monitored and assessed.
WHO recommendations for risk groups to screen
Strong recommendations:
1. Household contacts and other close contacts
2. People living with HIV
3. Current and former workers in workplaces with silica exposure.
Conditional recommendations:
4. In prisons and other penitentiary institutions
5. People with an untreated fibrotic chest X-ray lesion
6. In settings where the TB prevalence in the general population is 100/ 100 000 population or
higher
7. In geographically defined subpopulations with extremely high levels of undetected TB (1%)
prevalence or higher.
8. Sub-populations that have very poor access to health care such as people living in urban
slums, homeless people, people living in remote areas with poor access to health and other
vulnerable or marginalized groups including indigenous populations, migrants and refugees.1

5. 5
Literature review
The WHO estimates that 3 million people with tuberculosis are “missed” each year by health
systems, leading to the persistence of infectious cases and the airborne disease’s
transmission within families and communities. A crucial step to stopping the transmission of
PTB is by finding people who have the disease, and using an effective strategy such as
targeted active case-finding to screen individuals at risk of having the disease, so that they
can be diagnosed early, and through correct treatment, rendered non-infectious. Targeted
or systematic screening is a fundamental strategy for disease control that has been used to
stop many life-threatening epidemics including smallpox, and the Ebola virus. It has been
recognized as crucial component of the epidemic-control response to tuberculosis since the
1930s.
Most tuberculosis programs in low-income and middle-income countries with high burdens
of the tuberculosis have adopted policies that rely on passive case-finding which depend on
the sick to seek care if they able. This strategy is driven by the concerns over costs and
prioritizes treatment success among passively detected cases and considers case detection
to be of secondary importance. However, by the time sick individuals seek treatment for
their symptoms, they have been infectious for some time, and transmission in the family
and within the community has already occurred.
The reliance on passive case-finding for tuberculosis has contributed to the present failure
to prevent transmission at the level required, to turn the tide of the tuberculosis epidemic.
By focusing on populations at a high risk for tuberculosis, targeted case-finding strategies
detect substantially more cases per number of people assessed than would be detected by
screening in the general population. When a tuberculosis case is identified, further
transmission from that individual can be stopped almost immediately by initiating
appropriate, effective treatment.
Increased rates in the identification and treating more people with tuberculosis may have
the following projected effect. An increase in case detection by 25% can achieve a 40-44%
reduction in tuberculosis-associated mortality, a 22-27% reduction in incidence and a 30-
33% reduction in prevalence in 10 years.
Stopping anepidemic requires stopping transmission. For an airborne disease without an
effective vaccine, stopping transmission requires finding all cases promptly and rendering
them non-infectious through treatment. The only way to accomplish this is to actively
search for cases, use effective diagnostic methods and algorithms, initiate patients promptly
on the correct therapy, and support them through to cure. The knowledge necessary to do
these activities exists and successes have been documented across a range of settings.7

6. 6
National TB prevalence surveys have demonstrated that a large pool of undetected
prevalent cases exists, even in settings with well-functioning TB programs. Many of these
prevalent cases would have been difficult to reach with passive case finding.
A systematic review done by Kranzer, K. et al in 2013 addressed four specific questions
regarding the benefits of systematic screening for active TB:
1. Does screening for TB increase the number of TB cases detected compared to
passive case finding?
A moderate evidence suggests that screening increases the number of cases found in
the short term. In many settings, more than half the prevalent TB cases in the
community are undiagnosed. Targeting some high-risk groups, or a combination of
risk groups, can contribute a high proportion of cases.
2. Does screening for TB disease identify cases at an earlier stage of TB disease than
passive case finding?
There is a moderate evidence suggesting screening found cases earlier and with less
severe disease.
3. Is there a difference in treatment outcomes between TB cases found by screening
and those found through passive case finding?
Treatment outcomes for those identified through screening or passively were very
similar in all studies.
4. Does the addition of screening for TB disease to PCF affect TB incidence or
prevalence in the community?
The impact on TB epidemiology of screening in addition to PCF suggested weak
evidence.8
A cross-sectional study was conducted in the Arkhangelsk region of Russia between 1 March
2012 and 5 February 2013 among new smear-positive PTB patients. The aim of the study
was to describe the main differences in symptoms and diagnostic delay between patients
who engaged with local TB services through passive case-finding and active case-finding
strategies. The researchers concluded that patients diagnosed through active case-finding
tended to under report their TB symptoms and showed little attention to their own health.
Active case-finding allowed TB patients to be revealed earlier than passive case-finding. In
risk groups, active case-finding is more effective than passive case-finding. It was therefore
recommended that passive case-finding systems should be supplemented with active case-
finding strategies for risk groups.9
A retrospective study for active TB case finding, was performed in Tshwane, a district in the
Gauteng Province of South Africa, between October 2011 and September 2013 by Ward

7. 7
Based Outreach Teams. A total population of 36802 consenting candidates, 15 years of age
or older were screened for TB. 1579(4,3%) were diagnosed with TB and 35223(95.7%) were
not diagnosed with TB. Only half of the people affected by TB were in contact with the
health system.10
ZAMSTAR was a large collaborated randomised control trial conducted in Zambia and the
Western Cape province of South Africa between August 2006 and December 2010. The
objectives of this study were to establish whether either community enhanced TB case-
finding or household intervention reduced the prevalence of tuberculosis and the incidence
of tuberculosis infection at the community level.
The study demonstrated that community intervention had no impact on the prevalence on
the incidence of TB infection. Household intervention was associated with a reduction in the
burden of TB in the community, recording a 22% lower prevalence of active TB and a 55%
lower incidence of TB infection. Despite the reductions in both prevalence and incidence of
tuberculosis within these communities, these figures were not statistically significant.1,11
DetecTB was a randomised community-based trial conducted in Zimbabwe between January
2006 and November 2008 and involved over 100000 participants. Door-to-door active case
finding was compared to mobile van active case-finding within communities.
The prevalence of TB was reduced by 40% over the 3 year period in both interventional
strategies of the study. Mobile van active case-finding produced a higher cumulative yield of
cases compared to the door-to-door active case-finding intervention.1,12
In a cohort study done by S. Moyo et al in the Cape Winelands District of South Africa
between 2007 and 2008, household TB screening combined with record surveillance
detected significantly more TB cases at a younger age than record surveillance alone.13
The Sihanouk Hospital Center of Hope conducted a door-to-door survey for TB in deprived
communities of Phnom Penh, Cambodia between 09 February 2012 and 31 March 2013. TB
workers and community health volunteers performed symptom screening, collected sputa,
and facilitated specimen transport to the laboratories. 315874 individuals were screened of
which 12201 aged 15 years or older were identified with symptoms suggestive of TB. 783
individuals were diagnosed with active pulmonary tuberculosis using smear microscopy and
GeneXpert assays. This study demonstrated that symptom screening followed by smear
microscopy and targeted GeneXpert assays, contributed to improved case detection of drug
susceptible and drug resistant TB, therefore shortening the diagnostic delay and successfully
bringing patients into care.14

8. 8
Method
Study site and setting
The township of Platfontein is situated about 15km southwest of Kimberley, and located within
the Francis Baard District of the Northern Cape province of South Africa.
The most recent national census in 2011 recorded the Platfontein population as 5185
inhabitants, who occupy 1277 households.
The San community of Platfontein forms part of a sub-continental regional society of former
hunting, foraging and pastoral Africans who have been subjected to intense waves of complex
socio economic and political changes. Residents are respectively members of !Xun and Khwe
ethnic communities, and speak two different San dialects namely !Xunthali and Khwedam
respectively. The medium of instruction at the local school is Afrikaans.
The local water supply and sanitation infrastructure is in a bad state. People reside in early
restructuring and development program houses, which since being handed over by the
Department of Housing, have not all been provided with proper water, sanitation and
electricity.15,16
Platfontein Clinic provides primary health care to all the inhabitants of Platfontein. Kimberley
Hospital is Platfontein Clinic’s referral hospital and inhabitants of Platfontein also gain direct
access to Kimberley Hospital after hours and over weekends, when the local clinic is closed.
The community remains poorly resourced and underserved, and experiences a high incidence of
TB and a high prevalence of HIV.
Intensified Case Finding (ICF) campaigns in the Northern Cape is one of the key strategies in
improving TB Case Detection in realising targets as set out in the joint TB/HIV strategic plan
(2012-2016) to fight the scourge of TB/HIV and to create awareness.17
Systematic active case-finding, as a strategy to improve TB case detection, has not been
implemented in Platfontein to date.
This community is a high-risk TB community for several reasons:
1. High prevalence of HIV.
2. High prevalence of TB.
3. High poverty levels.
4. High prevalence of alcohol abuse.
5. Marginalized ethnic minority group.
6. Poor sanitation.
7. Overcrowded houses.

9. 9
Study design
A cross-sectional study conducting active TB case-finding in consenting occupants aged ten and
older, from 300 randomized households, within the high-risk TB community of Platfontein.
Randomisation of households was achieved by screening the occupants of every third
household.
Study population and sample size
The population of Platfontein according to the national census in 2011 was 5185 occupying
1277 households. It is unknown how many inhabitants of Platfontein are currently on
appropriate treatment for tuberculosis.
The sample size needed in this study, to be representative of the number of households, was
calculated as 296 households, with a 95% confidence interval, and a margin of error being 3%.
Inclusion criteria
Consenting individuals (written consent on behalf of minors,) ten years of age or older.
Exclusion criteria
Patients currently on treatment for tuberculosis.
Screening
The screening method consists of a validated measuring tool, endorsed by the WHO, in the form
of a step-wise algorithm.(Annexure A.)
Screening is divided into two components:
1. Screening for symptoms in the form of a questionnaire. (Primary screen.)
2. Sputum collection for the detection of Mycobacterium tuberculosis using GeneXpert
analysis. (Secondary screen.)
Community health workers performed door-to-door visits to conduct a primary screen on all
available and consenting household members aged ten years or older, for any symptoms
suggestive of TB. Written consent was acquired by individuals who wished to participate in the
study, and written consent on behalf of children younger than 12 years old, was obtained from
their parents or guardians. These symptoms were defined as any cough, unintentional loss of
weight, loss of appetite, fever, night sweats or haemoptysis, for any duration. This primary
screen was performed by using a standardized questionnaire completed by the community
health worker, who interviewed each household occupant. If an individual had any positive TB
symptom, a secondary screen was conducted.
The secondary screen was performed by testing the sputum from these individuals, for
pulmonary TB, using the GeneXpert analysis. Sputum was collected outside the homes of these
participants, who were instructed on how to produce a good quality sputum specimen,
following a standard operating procedure.
Sputa was batched on a daily bases and sent to the National Health Laboratory Service at
Kimberley Hospital, for GeneXpert analysis.

10. 10
Patient management and follow-up.
The results of the GeneXpert analysis were printed out by the laboratory and confidentially
reported and explained to each participant. Those participants whose GeneXpert tested positive
for Mycobacterium tuberculosis, received additional counseling and were notified as per
protocol, for the notification of new TB cases, as required by The Department of Health of South
Africa. These participants were then assisted with voluntary presentation to Platfontein Clinic
for the commencement of appropriate tuberculosis management and voluntary counselling and
testing for HIV.
Statistical analysis
Results
Discussion
Limitations

11. 11
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