International Journal of Community Medicine and Public Health Burma SP et al. Int J Community Med Public Health. 2019 Aug;6(8):3314-3320 http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040 DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20193447 Original Research Article Active detection of tuberculosis: tackling the problem head on in the remote area of Andaman and Nicobar Islands Samarendra Prasanna Burma1, Gunda Jahnavi2*, Pappachen Lal3, Pandurang V. Thatkar2 1Department of TB and Chest, GB Pant Hospital, 2Department of Community Medicine, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, Union Territory, India 3District TB Officer, South Andaman, Port Blair, Union Territory, India Received: 30 May 2019 Revised: 16 July 2019 Accepted: 17 July 2019 *Correspondence: Dr. G. Jahnavi, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: Community based active case finding for tuberculosis (TB) is an essential step in the fight forward for eliminating TB. One of the steps in targeting TB intervention is early diagnosis and treatment of patients by reducing the reservoir of infection in the community. Active case finding (ACF) targeting the entire population by house to house survey was done in Nicobar district of these islands. Methods: A community-based, cross-sectional, descriptive study was conducted with the trained mobile teams from 17.07.2017 to 31.07.2017 in the Nicobar District. The algorithm of the case detection included screening patients by symptoms, then by sputum microscopy for confirmation. X-ray was done in patients who were symptomatic but sputum negative. If both smear and chest X-ray results were negative but still symptomatic, then cartridge-based nucleic acid amplification test (CBNAAT) was done. Results: A total population of 18526 was mapped of which 14784 (79.8) could be screened. A total of 209 people were identified by the mobile teams with symptoms who were examined by sputum microscopy. Among them 7 cases were identified to be sputum smear positive, 2 X-ray positive and 2 were diagnosed by CBNAAT. Conclusions: This study shows that the active case finding method is feasible and acceptable by the community. The results obtained are encouraging for the implementation of ACF through mobile team activity in all these islands in order to meet the target of WHO’s End TB Strategy. Keywords: Active case finding, Tuberculosis, Nicobar district INTRODUCTION headquarters for the Nicobar District and has a population of 36,842 according to 2011 census. Nicobarese families Andaman and Nicobar islands, one of the seven union are patriarchal and as a rule live in large joint families territories of India is archipelago of 572 islands in the called Tuhet. They live in circular shaped huts with a Bay of Bengal; comprises two island groups, the high thatched pent roof. The hut is raised on piles 5-7 feet Andaman Islands and the Nicobar Islands. These islands from the ground consisting of one large boarded floor, are a home for six primitive tribes which constitute about without divisions. The houses have no windows and there 10 of the population and also the immigrants from is only one single sleeping space for all the occupants of mainland India. Car Nicobar is the administrative the hut. International Journal of Community Medicine and Public Health | August 2019 | Vol 6 | Issue 8 Page 3314 Burma SP et al. Int J Community Med Public Health. 2019 Aug;6(8):3314-3320 The National Tuberculosis Control Programme started in through active case finding, characteristics of the patients these islands from 1962, and then in 1997 Revised detected and their treatment outcomes. National Tuberculosis Control Programme was implemented. The targets set by World Health METHODS Organization of detecting 70 of estimated cases and successfully treating 85 of the detected cases have been A community-based, cross-sectional, descriptive study achieved by the islands in 2005. Despite the success was conducted was conducted from 17.07.2017 to achieved over the past decade the notification rates have 31.07.2017 in the Nicobar District. A total of 10 teams stagnated. Though there is a lack of definitive evidence had performed house-to-house survey using the that systematic screening for TB leads to epidemiological structured proforma. Before conducting the survey, impact, screening persons at high risk for TB has detailed area map was prepared by individual team. The increasingly become a major global health priority, as it team consisted of Ashas, Anganwadi workers, multi- ensures that those with TB receive prompt treatment and purpose health workers of that area. They were trained may reduce ongoing transmission.1-4 A variety of active before the survey. Village selection for active case case-finding strategies for tuberculosis (TB) were tested finding was based on Hard to Reach and Vulnerable and proved to be effective over the past century.5 population. 7 villages were selected from Car Nicobar island, 4 from Campbell Bay, 6 from Nancowrie, 3 from Early diagnosis and treatment of TB remains the essential Katchal, 5 from Teressa. Thus a total of 25 villages were step in reducing the reservoir of infection in the chosen from 5 islands of the Nicobar district. A house to community. While the routine TB services are essential house screening was done to cover the entire population particularly for case management, it has proven of these villages. The algorithm followed was to screen inadequate to control TB because available services are for presence of Presumptive TB with any of the four not always accessible to poor and vulnerable populations symptoms suggestive of Pulmonary Tuberculosis – cough where TB often concentrates.6,7 In light of this challenge, or fever ≥ 2 weeks, history of hemoptysis anytime in last a renewed interest in active case finding (ACF) as a 6 months, significant weight loss, chest pain ≥ 1 month as complementary strategy to improve case detection has per RNTCP criteria.10 If any of these presumptive emerged.8,9,10 In a large study carried out in India using symptoms were present, they were motivated to undergo ACF resulted in the detection of a large number of sputum examination. They were educated to bring out presumptive pulmonary TB cases who were not accessed mucopurulent sputum and spot samples were collected by by the regular National TB programme with variation the survey team, the second container was given to across different states.11 collect early morning sputum and the same was collected by the survey team on the next day. Sputum examinations TB is the 9th leading cause of death worldwide and the were done of which even one positive is considered as leading infectious cause, ranking above HIV/AIDS.11 The confirmation of Tuberculosis and put on treatment. Chest World Health Organization’s End TB Strategy and also X-ray was advised for sputum negatives or if the Sustainable Development Goals envisage achieving 90 individual cannot expectorate and reviewed by the chest reduction in TB deaths and an 90 decrease in TB physician. If both smear and chest X-ray results were incidence by 2035 compared to 2015.12 Active case negative but still symptomatic, then cartridge-based finding was proposed under RNTCP to enhance the case nucleic acid amplification test (CBNAAT) was done. finding of the remaining 25 of the missed cases.13,14 Those who were diagnosed were started on treatment. Systematic screening of those at high risk for TB is a key Socio demographic data like age, sex, address also was component of the end TB strategy. Active case finding collected. (ACF) can help in early and efficient case detection among vulnerable population. Health Care pertaining to Tuberculosis in Andaman and Nicobar islands are that there are 9 TB units, 13 The incidence of Tuberculosis in the Nicobar district is Designated Microscopy Centers, 233 Dots Centers of 3.1 per 1000 polulation which is very high as compared which 3 TB units, 4 Designated Microscopy Centers and to the rest of the country 2.1 per 1000 population. (167 35 Dots Centers are in Nicobar District. cases in 2017 and 115 cases in 2018 total population 37000). As it is a hard to reach area and the incidence of The data collected was entered in MS excel and analysed Tuberculosis is very high and the living conditions which using SPSS statistical software IBM SPSS 20.0 favour the spread of Tb like sharing the same hall for (Chicago), after which it was tabulated, analysed and sleeping, overcrowding and ill ventilated houses, the interpreted using frequencies and percentages. ACF strategy has been undertaken in this district to start with. RESULTS The objective of this study was to detect the missed out The total population of these villages was 18526 of which cases from the vulnerable population of the Nicobar 14784 (79.80) could be screened for symptoms of district through mobile teams, contribution of patients Tuberculosis. In some of the villages that is Kalasi, International Journal of Community Medicine and Public Health | August 2019 | Vol 6 | Issue 8 Page 3315 Burma SP et al. Int J Community Med Public Health. 2019 Aug;6(8):3314-3320 Bengali Basthi and Alurong of Teressa island all the Tuberculosis cases detected by routine case finding and people could be screened as shown in Table 1. active case finding through mobile teams is depicted in Table 5. The age and sex distribution of the total number of people screened for symptoms of Tuberculosis is depicted in There is a wide range of variation in the contribution in Table 2.