Multidrug-resistant tuberculosis household contact screening and management by community healthcare workers in Mongolia: a prospective implementation study

Background: Mongolia is a high burden country for multidrug- or rifampicin-resistant tuberculosis (MDR/RR-TB). The implementation of systematic household TB contact investigation has been very limited despite policy recommendations. We implemented a community-based approach to MDR/RR-TB contact screening and management. Methods: We conducted a prospective implementation study in the nine districts of Ulaanbaatar and 10 other provinces. Community health workers (CHWs) were trained to identify and screen household contacts of patients with confirmed pulmonary MDR/RR-TB. Initial screening included symptom assessment for all with chest radiography for adult contacts or tuberculin skin test (TST) for child or young adolescent contacts (<15 years). Follow-up visits to households were conducted quarterly for 12 months. Six months of daily levofloxacin (6Lfx) was offered to eligible contacts, i.e. <15 years, TST-positive and without disease. Findings: Of 99 people with pulmonary MDR/RR-TB, 349 household contacts were identified and 347 (99.4%) were screened by CHWs at initial home-based visit. Contact screening coverage remained high (>98%) for each quarterly visit up to 12 months of follow-up. TB was diagnosed in 17 contacts (4.9%); ten from initial screen, seven from follow-up screen and 12 (71%) were children or adolescents. Four contacts were diagnosed with bacteriologically confirmed MDR/RR-TB and two died. 6Lfx was initiated in 15 (43%) of 35 eligible contacts who all completed therapy without interruption. Interpretation: A decentralized model for the screening and management of MDR/RR-TB contacts implemented by trained CHWs has wider potential for increasing TB detection and prevention in Mongolia and the region. Funding: John Burge Trust and National Health and Medical Research Council, Australia.