Active Case Finding for Tuberculosis through TOUCH Agents in Selected High TB Burden Wards of Kolkata, India: A Mixed-methods Study on Outcomes and Implementation Challenges

Background: Active case finding for TB was implemented in selected sixty high TB burden wards of Kolkata, India. Community volunteers called TOUCH agents (TAs) identified and referred presumptive TB patients (PTBPs) to health facilities for TB diagnosis and treatment. We aimed to describe the ‘care cascade’ of PTBPs identified during July to December, 2018 and to explore the reasons for attrition as perceived by TAs and PTBPs. Methods: An explanatory mixed methods study with quantitative phase of cohort study using routinely collected data followed by descriptive qualitative study with in-depth interviews was conducted. Results: Of the 3, 86,242 individuals enumerated, 1132 (0.3%) PTBPs were identified. Only 713 (63.0%) PTBPs visited referred facility for TB diagnosis. TB was diagnosed in 177 (24.8%) and the number needed to screen for one TB was 2,183 individuals. The potential reasons for low yield were stigma and apprehension about TB, distrust about TA, wage loss for attending health facilities and substance abuse among PTBPs. Conclusion: The yield of ACF was suboptimal with low PTBP identification rate and high attrition rate. Interviewing each individual for symptoms of TB and supporting PTBPs for diagnosis through sputum collection and transport can be adopted to improve the yield.