Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) strategy for early diagnosis of TB in Nepal: An implementation research.

INTRODUCTION: Tuberculosis is one of the leading causes of death worldwide. Diagnosing TB in an early stage and initiating effective treatment is one of the best ways to reduce the burden of tuberculosis. Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) Strategy helps to improve the early diagnosis of tuberculosis cases among inpatient settings as well as out patient department patients and prevent TB transmission in hospital. This study aimed to assess the feasibility of the FAST strategy, organizational factors, technical factors, barriers and enablers for the proper implementation of the FAST strategy in Nepal.
METHODS: A qualitative study was conducted from April 2019 to August 2019. Data was collected by using focus group discussion, key informant interviews, and client exit interviews. A retrospective research was conducted in different hospitals in Nepal where FAST strategy was implemented. The patients, health care workers, province, district, and National level stakeholders were interviewed. Thematic analysis was used to assess the feasibility as well as barriers and enablers of the FAST strategy.
RESULTS: Study identified that the 'current setting' of implementation and service delivery arrangement at hospitals were not well arranged as per requirements. The research findings showed hospital ownership is crucial for mobilizing staff and proper space management inside hospitals. Study identified that unavailability of a separate room, limited capacity of GeneXpert machine, irregular supply of GeneXpert cartridge, and insufficient human resources for screening and counseling are the major barriers of FAST implementation in Nepal.
CONCLUSION: FAST strategy is feasible to implement in healthcare settings in Nepal although the technical and organizational factors should be managed to ensure effective function of the strategy as per the approach. Hospital ownership is essential to mobilize health workers, improve client flow system and proper space management for FAST services.

Introduction

Tuberculosis (TB) is one of the top ten leading causes of death worldwide and the leading cause of death from a single infectious agent [1, 2]. An estimated 10 million people were fell ill and 1.4 million peoples people died of TB in 2019 due to tuberculosis in 2019 [1, 2]. Globally, an estimated 54 million lives were saved through TB diagnosis and treatment services between 2000 and 2017 but there are still large and persistent gaps in the detection and treatment of tuberculosis [1].

Tuberculosis is a major public health problem in Nepal, as it is ranked as the sixth among the leading causes of death in the country [3]. Among the leading causes of death in the country, World Health Organization estimated that 44,000 people develop active TB every year in Nepal. As per the estimation made by WHO, Nepal is still missing around 20–25% i.e.12,000 to 13,000 people who become sick with TB [4, 5]. Early case detection is important to interrupt infection transmission chain within healthcare facilities and community, in addition to reduce suffering time of patient and to reduce the spread of infection from health facilities and untimately at community level.

To identify the missed cases of TB the National Tuberculosis Control Center commenced the FAST (Find cases Actively, Separate safely and Treat effectively) strategy [6]. FAST strategy is an active screening process for the early diagnosis to enable prompt initiation of effective treatment. In FAST approach, the health workers are mobilized to actively search and identify potentially infectious patient in health facilities and the presumptive TB cases are screened, examined and treated. This strategy focused on actively looking for unsuspected TB patients through organized cough surveillance in general medical settings (Fig 1) [7]. The FAST strategy can be used to reduce TB or Drug-resistant tuberculosis (DR-TB) transmission in outpatient and inpatient healthcare settings. A Study conducted in Bangladesh shows that FAST implementation revealed a high frequency of unsuspected TB in hospitalized patients [8]. Similarly, a study conducted in Nigeria shows that the integration of FAST into health care service delivery system improves early detection by reducing the average time of diagnosis [9]. The FAST strategy was initiated in October 2018, as implementation of the this strategy is in the early stage, it is important to understand the feasibility of intervention before scaling up all over the nation. There was no previous study conducted to assess the feasibility of FAST strategy for the diagnosis of TB and infection prevention in Nepal. In this context, this study aimed identify the feasibility of FAST strategy in health facility level and the result of this study aims to suggest National tuberculosis control program for the areas needed to improve. In order to suggest National Tuberculosis control program the areas which are crucial to be improved to strengthen the health facility-based diagnosis and prompt treatment of TB, we aimed to explore organizational, technical and financial factors needed to implement FAST activities in four hospitals.

Fig 1

Find cases Actively, Separate safely and Treat effectively (FAST) approach.

Materials and methods

Study design

This study was an implementation research that used qualitative study design. A total 14 key informant interviews (KII), one focus group discussion and eight clients exit interviews were conducted. A purposive sampling method was utilized to recruit study participants. Respondents were purposively selected from hospitals who were directly involved in the implementation of FAST activities and currently working on FAST activities. The patients who were screened for TB at hospitals were also selected purposively for client exit interviews. Those patients, who attended the out-patient department with chest symptomatic features and screened for TB were selected for the interview purpose. Similarly, district, province & national TB Program focal persons, provincial program manager were selected for KII. Participants for the focus group discussion (FGD) were also selected purposively from National TB Control Centre, implementing partners, & national level stakeholders to achieve the study objective. This study was conducted from April 2019 to August 2019. To ensure the completeness, methodology and reporting the results, the checklist of Standards for Reporting Implementation Studies (StaRI) guidelines was utilized by this research (S1 File) [10].

Study setting

The FAST is a global fund-supported activity, where various non-governmental organizations are providing technical support to the National TB Control Centre and hospitals to implement this program. The FAST strategy was prepared by the National Control TB Centre in consultation with national-level stakeholders and organizations to initiate this program. Major seventy-four hospitals were identified as a priority hospitals for FAST implementation however the program was initiated from Dhulikhel hospital and it was further implemented in fifteen different hospitals in Nepal. At the National level, principle recipient of Global Fund, Save the Children was providing technical support to NTC whereas local NGOs were supporting at the hospital level as a partner organization. As FAST approach consists of finding TB patients in outpatient and inpatient setting, health workers actively asked about TB symptoms, separated presumptive TB cases to collect sputum for GeneXpert and diagnosed patients were enrolled for the treatment [7]. The implementation research was conducted in three different settings in Nepal. 1) hospitals in different setting where FAST strategy was implemented, 2) Province and district level health authorities where planning, management, supply related activities are managed and 3) National Tuberculosis Control Centre. To understand the different contexts, data was collected from selected four different hospitals; government hospital, community hospital, teaching hospital and hospital owned by non-governmental organization. The Bir hospital was oldest government hospital in Nepal and the flow of patients is very high as this is major refferal hospital located in Kathmandu. Another study site, Dhulikhel hospital was a community supported hospital in which FAST approach was commenced first time in Nepal. Gandaki Medical College is one of the leading private institution in western region of Nepal and Bayalpata Hospital was located in the rural area of Nepal which was also renowned model hospital operated by NGO in public private partnership model in rural area of Nepal. The purposively selected TB focal person, district and province TB coordinators were interviewed who were primarily responsible to monitor, support and supervise the FAST activities at district and province level. FGD was conducted at the National TB center with National TB program managers and stakeholders who were working to plan, execute, manage, supervise and lead the overall FAST activities at national level.

Data collection and analysis

The data was collected by using qualitative research instruments. The face-to-face interview with key informants was conducted. The instruments consist of a semi-structured questionnaire and FGD guideline. The Consolidated Framework for Implementation Research (CFIR) domains; inner setting, individual involved, and implementation process were used to prepare the interview tools [11]. The interview guide was developed to determine organizational factors, human resources, availability of services and logistics management, capacity building and knowledge management, information, communication, policy, advocacy related factors for the feasibility of FAST strategy. PI collected data using FGD guideline and Key informant interviews (KII) tool. The KII was used to collect information from service providers, local managers, district and province level program managers and focal persons whereas FGD was conducted at National Tuberculosis Centre with central level program managers and stakeholders who were directly involved in planning, supervision and monitoring of the FASTactivities. The interview was taken with healthcare workers after completion of their regular screening process of patients at hospital. Similarly, client exit interview was taken among patients to explore the client’s perspective regarding the FAST approach. Those patients who were screened for TB at hospital by using FAST approach were interviewed after completion of their screening process at hospital. The information was audiotaped using a voice recorder. The recorded information obtained from FGD, KII, and client exit interviews were transcribed into the Nepali language and translated into English. Two research assistants were recruited to assist the principal investigator during data transcription and translation. All information obtained from transcripts, translated documents were re-read, and examined carefully for initial coding. The transcripts were coded, and codes were grouped into manageable categories and the categories were refined to identify the key theme. Inductive codes were used for writing narratives. To ensure the credibility of the data, the triangulation method was employed.

Ethics approval

The ethical approval for conducting this research study was obtained from Ethics Committee, Universitas Gadjah Mada, Yogyakarta, Indonesia (Ref. No.: KE/FK/0532/EC/2019) and Nepal Health Research Council (Ref. No. 3038) before starting this study. Approval from National Tuberculosis Centre and permission from hospital administration was taken before conducting study. Written informed consent was obtained prior to the interview by using informed consent form. Privacy and confidentiality of the respondents was well maintained. The participants were ensured that there were no risks of physical, financial and psychological burden. Research instruments and informed consent form was translated into Nepali language.

Results

Characteristics of respondents

There were total 27 participants, which included health care providers, hospital managers, district focal persons, provincial team leader, program coordinators and patients. We conducted one mini focused group discussion with national level stakeholders at the National Tuberculosis Centre. Patients were interviewed from four different hospitals (Bayalpata, Bir, Dhulikhel and Gandaki Medical College) to capture the client’s perspective regarding the FAST strategy. Key informants, FGD participants, and patients were selected. The characteristics of respondents can be found in Table 1. The responses from the KII and FGDs were grouped into the four major themes as i) implementation context, ii) identified factors for feasibility iii) barriers and enablers iv) way forward for the program implementation.

Table 1

Characteristics of respondents.

Character	Categories	KII (n = 14)	Mini FGD (n = 5)	Client exit interview (n = 8)
Gender	Male	6	5	4
	Female	8	0	4
Age	≥ 40	12	2	5
	< 40	2	3	3
Work experience (in year)	≥ 17	11	3	NA
	< 17	3	2	NA
Education	No Formal Education	0	0	1
	Secondary level	3	0	3
	Intermediate level	2	0	1
	Bachelor	2	5	1
	Master	6	0	2
	PhD	1	0	0
Ethnicity	Dalit	0	0	2
	Janajati	4	3	2
	Madeshi	2	0	0
	Brahmin/Chhetri	8	2	4
Respondent type	Health care provider	5	0	0
	Provincial and District level officer	5	0	0
	National TB Program managers	0	5	0
	Hospital manager and administrator	4	0	0
	Patients	0	0	8
Organization	National TB Centre	0	2	NA
	INGO/NGO	4	2	NA
	WHO	0	1	NA
	Hospital	9	0	NA
	District Health Office	1	0	NA
		14	5	8
Total		27

Implementation context

The FAST strategy in Nepal was introduced as an infection control measure in selected hospitals where the flow of patients is comparatively high. Respondents added that nowadays FAST also helps to increase case notification of TB at hospitals. National stakeholders described that FAST is implemented as a non-costed intervention as there is no financial implication for program implementation, where TB screening and treatment services are offered at different hospitals.

‘‘We take FAST as an infection control measure. When we practiced, it also did well with the case notification. [sic]” (National stakeholder, INGO, FGD)

National level program manager indicated that the approach of FAST was easily adopted and implemented at medical college, community hospitals and NGO operated hospitals whereas it was really difficult to initiate at government hospitals. They added that the building structure, service delivery room and waiting room of government hospital is congested and infection prevention measures are not implemented properly as in private hospitals.

‘‘The OPD has excessively crowded. In the case of Western Regional Hospital, when people come for treatment, it is like competing in a battlefield. [sic]” (TB leprosy officer, government)

It was also observed that the waiting room and flow of patients in government hospital was crowded whereas the flow of patient, client flow system and waiting room arrangement was properly managed in medical college, private hospital and community hospital.

‘‘It is difficult to work at the government setup. For example, Bharatpur hospital has a very congested and limited area to work. “Therefore, it is difficult to pick the patient, compared to the Teaching hospital and Achham hospital. [sic]” (National stakeholder, FGD)

Participants explained that the implementation setting was not readily structured as per the requirements, however they strongly argued that the hospital setting. Service operation process can be easily modified as per FAST guideline to implement the FAST approach and physical space can be managed inside the hospitals.

‘‘It’s all about the administrative arrangement, there was no such a special technical problem in implementing sites so we can easily implement if ownership can be taken by respective hospital. [sic]” (TB leprosy officer, government)

Based on their experiences, participants identified numerous benefits of the FAST strategy. They explained that the number of presumptive cases and case notification was increased in the selected hospitals. FAST increases a sensitization among healthcare providers for self-protection as well as symptomatic patients are prioritized to examine faster.

‘‘It has helped to lessen the transmission cycle and we noticed that case has been increased after the FAST strategy in comparison to before. [sic]” (hospital director, NGO operated hospital)

‘‘Sometimes the doctor could not identify the TB case in their routine screening process and the possibility of losing the case is high but now FAST can detect the case early. [sic]” (Nursing administrator, medical college)

Respondent indicated that the approach of the FAST strategy was not implemented as per the expectation at the initial stage of program implementation. The preliminary results show that the TB case identification was not as expected. Both national level program managers and hospital managers raised a common issue on staff mobilization and space management.

They added that screening of cases at the hospitals was performed per protocol, however the separation of suspected TB patients was not properly done because there was no adequate space to keep patient separately and there was no individual assigned for TB screening.

As the FAST approach consists of series of activities in the hospital setting, our study identified that the actively screening, counseling, and sputum examination was conducted as per the framework of FAST strategy. However separation of the patient from the queue and place them in the isolated or well-ventilated room was not followed as per the requirement of the program. It was found that the diagnosed cases were properly enrolled for DOTS. As per the FAST framework, the main problem was identified on the separation of patients. This study identified that the treatment of diagnosed TB cases was initiated timely and the patients were enrolled at DOTS therapy within hospitals.

Identified factors for the feasibility of FAST

Various factors are identified as an essential factor for the proper implementation of the FAST approach in hospital settings. Different organizational perspectives, such as ownership, separate room, and interdepartmental coordination were associated with perceived facilitating factors for FAST implementation. This study identified that the FAST strategy can be implemented undoubtedly if all these things are working and managed.

Hospital ownership

Participants repeatedly stressed that strong hospital ownership is a fundamental factor for staff mobilization, arrangement of the client flow system, registration desk, and waiting room. Similarly, hospital ownership is required for overall program implementation, monitoring, recording, reporting, and evaluation of the program. We identified that the hospital ownership was established in a community hospital and NGO-operated hospital to mobilize local resources for FAST whereas the government hospital didn’t realize it.

‘‘We thought it is the hospital’s responsibility. They should take ownership to control the infection and separate patients. [sic]” (National Stakeholder, FGD)

Room availability

From KII and Client’s exit interview, it was found that the availability of a separate room or confidential space impacted on the effectiveness of FAST services. Many health care providers at implementing hospital defined the importance of separate room for counseling and screening to maintain the privacy and confidentiality of patients. Respondents identified that separate waiting room is essential for patients, and it should be well ventilated to prevent infection transmission. Arrangement of FAST services in a limited space overcrowded with patients for screening was identified challenges in government hospital whereas it was separately arranged in community hospital and NGO operated hospital.

‘‘In reality, the density of patients is high in hospitals, and it is difficult to identify the case. The patients are roaming around the hospitals for their turn. Meanwhile, the TB patient is spreading the TB around. So, to prevent infection transmission separate waiting room is essential for suspected patient. [sic]” (TB leprosy officer, government)

Many participants argued that the arrangement of FAST desk or specific space for TB screening near the registration room at the hospital will facilitate to improve the screening process among all patients. One of the respondents expressed that separate booth for sputum collection is required to prevent the transmission of infection from patient to the environment and people around the hospital.

‘‘The client goes outside and starts coughing without caring for the people around them. If we have the particular sputum booth, then we will use that booth to produce and collect sputum only. [sic]” (District program coordinator, NGO)

Health service providers and patients talked about the arrangement of the FAST services; screening, sputum collection, counseling and treatment in the same floor in the hospital will make easier for patients. Our observation also suggests that services for screening, counseling, and sample collection all at one place makes easier for patients to receive a service timely. It was observed that all services for FAST process was arranged in same floor in NGO operated hospital whereas in other hospitals services were given from different floor. Many healthcare providers mentioned that use of FAST stamp helps to prioritize the patients in the hospital to provide quick services to the patients. Respondents argued that when OPD ticket is stamped on the spot for FAST examination, the patient is checked up more seriously and carefully after seeing the stamp. Some participants argued that implementation of FAST activities in a hospital setting is a collaborative task of administrative staff and healthcare providers, specially highlighted by health workers who are working in government hospital. They reported that only a few people and volunteers cannot complete all these activities, for that inter-departmental coordination between laboratory, wards as well as registration department is required. Majority of respondents also suggest that activities of FAST should be integrated to the existing committee on infection prevention to manage it properly as FAST approach is also working to prevent hospital-based infection prevention. They explained that the FAST activities and hospital infection prevention committee are not working jointly until now. Few respondents from NGO hospital highlighted the important role of patient navigator ‘‘birami sahayogi” to helps patients to move from one department to another department. Birami sahayogi is the administrative staff mobilized to support patients for searching service rooms inside hospitals. It was found that the NGO operate hospital initiated a novel concept of patient navigator whereas there were no such patient support staffs in other hospitals. The patient navigators are the support personnel mobilized at hospital to provide information to patients and guide them to move from one room to another room to get timely services.

‘‘Our hospital has a unique system of patient navigators, we say "birami sahayogi" which I think is necessary for other hospitals where the patient flow is high and to implement a FAST strategy to manage properly. [sic]” (Hospital director, NGO operated hospital)

It was found that, the hospital dress like using apron by NGO staff during their duty hour at hospital may facilitate for better communication with patients. Respondents emphasized that dedicated staff for screening and counseling of patients is necessary for proper management of FAST activities in hospitals.

‘‘We have hired two staffs in each 15 hospitals as a full-time employee. After that, the number of FAST case and presumptive has increased. [sic]” (National stakeholder, INGO, FGD)

Similarly, few respondents argued that the existing staff of the hospital should be mobilized for the sustainability of the program. Some respondents reported that there is no workload for healthcare providers to implement FAST activities in the hospital. However, some described that there is a workload for laboratory staff and patient’s navigator because the patient had to visit different rooms. Majority of respondents explained that there is a positive role of incentives to motivate healthcare providers. One responded added that the hazard allowance provided by the government for laboratory staff should be distributed on time to motivate them.

‘‘NRS. 50 per case was provided by the government as a hazard allowance for the laboratory staffs it motivates them. [sic]” (District program coordinator, NGO)

GeneXpert and DOTS service

GeneXpert service was identified as a key factor to implement the FAST approach at hospitals. Respondent highlighted that the GeneXpert should be prioritized to reduce the duration of diagnosis time. Respondents explained that the limited capacity of the GeneXpert machine is one of the challenges to test all samples and provide results in the same day. Respondents stated that they can only test maximum twelve samples in an office hour. So, if the number of TB suspected patients increased, the reporting time will be prolonged until the next day. The basic understanding of FAST is to provide a report and treatment to the patients within a day, however due to prolonged time on laboratory report, the service cannot provide in a same day when the patient’s flow is high. Respondents highlighted only two technicians were available at National TB Centre to machine maintenance and repairment all around the country, so it takes long time to maintenance, calibrate and repair machine. This study reveals that there should be well managed supply and storage of GeneXpert cartridge. Similarly, it was found that the cartridge is temperature sensitive and it should maintain 2–28 degrees Celsius for its proper storage.

Another identified issue was the availability of DOTS treatment center in the same health facility will be more beneficial to the FAST approach. Respondent argued that arrangement of all services; screening, diagnosis and treatment in the same hospital makes it easy for patients and it will help to prevent the chances of missing patients when the patient is referring from one hospital to the other institutions for DOTS treatment.

Capacity building

This study reveals that training and orientation were required for service providers and hospital administrative staffs. Similarly, National stakeholders also described that training and orientation is the key factor to FAST implementation and motivate hospital administrative staff to initiate FAST in the hospital. It was reported that the existing modular training on TB and infection prevention is sufficient to build the capacity of local health workers. It was identified that onsite coaching, supervision, monitoring and monthly review meeting plays a positive role in the capacity enhancement of healthcare providers.

Counseling tool

The results showed absence of uniformity on counseling counseling among chest symptomatic patients. This study identified that group counseling for patients will be beneficial during the waiting time of patients.

They [Health worker] told FAST. FAST but I don’t know what it is… ha ha ha.. [sic]” (Client exit interview, male, 32-year, bachelor level education)

Another identified issue was the counseling tool is important to provide complete and concise health information. Participants added that there is a no flex board, information booklet, wall chart, pamphlets and poster to convey adequate information to patients.

Advocacy

This study found that the advertisement of FAST activities plays an important role in the proper implementation of the program as well as the linkage of the FAST activities with community TB awareness program will be beneficial to increase the utilization of services.

‘‘This type of FAST services should be advertised, and every chest symptomatic patient should be screened. [sic]” (Client exit interview, female, 28-year, master level education)

Policy formulation

National level stakeholders stressed the importance of policy formulation. A lack of clear policy is the main challenge to convince hospital administration to implement activities inside the hospital. FGD Participants also pointed out to conduction of advocacy activities among hospital administrative to make a clear understanding of FAST and its importance.

‘‘It needs to be discussed at the policy level. If policy directs hospitals to segregate the coughing patients, it won’t bring a big challenge for proper implementation. [sic]” (National stakeholder, INGO, FGD)

Many respondents said that FAST is an administrative intervention that can easily adopted within the normal service delivery approach of hospitals and routine TB screening and treatment protocol. National TB Centre provides services free of cost to all peoples for Sputum Microscopic examination, GeneXpert and TB treatment services, so there is no financial burden to hospitals. So, this study found out that a separate budget for FAST activities is not required for diagnostic procedures and TB treatment. However, the logistics and equipment should be regularly supplied as well as proper incentives to the healthcare providers is required to motivate them.

Barriers and enablers

Unavailability of a separate room, limited capacity of GeneXpert machine were the commonly reported barriers. Similarly, lack of clear policy, irregular supply of cartridge for GeneXpert, insufficient human resources for screening and counseling in high OPD flow hospital, delay in laboratory result due to a high volume of samples are also identified barriers from service delivery side. Inadequate counseling, no distribution of Information, education and communication (IEC) materials such as booklets, wall charts, pamphlets and information sheet as well as no advertisement of the FAST approach were reported barriers from patient side. Similarly, few enabling factors were highlighted by participants. Free TB service and equipment supplies from government is one of the major enabling factors. Multi-stakeholder engagement and partnership between various organizations, regular supervision, monitoring, and onsite coaching help to create an enabling environment to implement FAST activities locally. Some hospital administrators and healthcare providers reported that dedicated staff for screening and counseling is also an enabler for better service. Provision of hazard allowance for laboratory staff, availability of DOTS service in the same hospital was also noticed as an enabling factor.

Way forward for program implementation

Participants specifically mentioned that the FAST strategy is feasible to implement in the context of Nepal however, they highlighted that the availability of laboratory facility, space management, hospital ownership and dedicated staff to screen and counsel the suspected patients should be ensured. Several participants suggested that the preliminary result of the FAST implementation is very good for infection prevention and to increase case notification.

“‘‘It is a very basic matter,…. Space management, a supportive laboratory staff, GeneXpert and one dedicated staff is enough to implement FAST. [sic]” (Hospital focal person, community hospital, KII)

They clearly emphasized that FAST should be implemented in every hospital. Healthcare providers from different hospitals explained that there is no complex procedure to implement FAST in the hospital setting. They added that FAST is easy adoptable however the enabling environment at implementing site is required. This research identified that administrative management is an important thing to make FAST feasible in hospitals.

Discussion

This study is the first of its kind in Nepal to explore the current context of FAST implementation in Nepal. Our study explored the view of frontline health care providers and managers on the current implementation status, barriers and enablers in the FAST approach to early diagnosis of TB and infection prevention. As a feasibility study, our study analyzed the different aspects of organizational, technical, operational and financial aspects of FAST [12]. Our study revealed that hospital ownership and administrative support are fundamental factors in the implementation FAST approach effectively. The structural arrangement is a key factor to prevent infection transmission in a hospital setting, so to make FAST as a sustainable approach for infection prevention, infrastructure, and patient queue management is required [13]. Our research reveals that a separate well-ventilated room should be managed to prevent the infection transmission to other patients from suspected patients, this result is similar with the study conducted in Nigeria and recommended by the WHO policy on TB infection control [14, 15]. This study highlighted that policy formulation is necessary for the FAST strategy functioning, so the hospitals will be obliged to implement the process in healthcare facilities [15]. Effective coordination between health care providers, administrative staff, other hospital staff, and interdepartmental coordination is necessary to optimize the benefits of the program. Concurring with the findings of our study, findings from Bangladesh show that dedicated implementation team efforts are needed for better performance at the hospital level [8]. Our study explored that the screening approach increases the workload at laboratory to test all the samples which were also similar to the study conducted in Tanzania [16]. The use of the GeneXpert machine for sputum examination will reduce the turn-around time, for this, a continuous uninterrupted supply of cartridge is required, and the capacity of the laboratory should be increased. Our study identified that the GeneXpert module failure and delay in maintenance, which is also shown in Bangladesh [8]. The result is similar to the study conducted in Bangladesh which identified that the laboratory capacity is important for the sustainability and scalability of the program [8]. We also identified few issues in information and health education materials as a gap in hospital settings such as display of flex board, information booklet, wall chart, pamphlets and poster inside the hospital to convey adequate information to patients will increase the understanding of FAST approach and utilization of services among patients. This clearly calls program managers and hospital administrators to design information education and communication (IEC) materials and advertisement of FAST process and TB screening.

This study reveals that FAST is a non-costed intervention as there is no additional financial burden for hospitals. So, this study found out that FAST can be implemented from the available resources and routine supplies from National Tuberculosis Control Centre. As similar to the finding of our result this is particularly relevant in Nigeria where research identified that FAST can be easily implemented with minimal resources [9]. This study identifies that the proper space or separate room for segregate the suspected patients inside the hospital is a major barrier to the proper implementation, this is consistent with findings in Nigeria [9]. Research paper described that patient flow, separation, airborne isolation rooms, air disinfection, and respiratory protection always plays a vital role in TB patient management [8]. As found in this study, limited capacity of GeneXpert machine, irregular supply of cartridge for GeneXpert, and timely maintenance of the machine were considered as barriers for uninterrupted delivery of laboratory services, a similar finding was reported from the study conducted in Nepal [17]. The results of this study indicate that the FAST approach supports to evaluate presumptive TB patients actively, separated and enrolled in the DOTS center when required [18]. As same as the result of this study, a large number of undiagnosed cases of TB can be identified by systematic screening of the OPD patients in Pakistan [19]. The major benefit of the FAST strategy is early diagnosis and prevent transmission at the hospital which is reported by a similar study in Russia that FAST plays an important role to limit the possible consequences of MDR tuberculosis [20].

We could not access all the hospitals and all healthcare providers, managers and focal persons because of limited time period of study however the information and result obtained from this result may be useful for planners and stakeholders to further improvement in similar context and settings. Few patients who performed the sputum examination in the hospital were not returned to receive laboratory results, so it was challenging to take a client exit interview in government hospital however interview was taken with other patients who perform sputum examination after the FAST approach.

Our study showed that consolidated framework for implementation research (CFIR) is very useful for collecting qualitative data in low resource because it helps to cover the various aspects of program implementation. We were able to capture comprehensive and organized information by using CFIR. As CFIR provided different constructs of questionnaires, the complete information during FGD and KII was collected easily. Sometimes, few constructs such as the inner setting and client’s perspective were scattered, and it makes it difficult to analyze the constructs separately. However, our study and experience suggest that using CFIR improves our research quality, especially on tools designing and capturing complete information including barriers and enablers of the program implementation.

Conclusions

This study provides valuable information for implementation and feasibility of FAST strategy in Nepal. The findings of this research conclude that the implementation set-up and service delivery mechanism at hospitals is not yet well practiced as a routine process for the FAST approach however it can be managed if hospital administration takes responsibility to institutionalization this approach. Various factors were identified such as hospital ownership, separate room, interdepartmental coordination, the establishment of FAST desk, sputum collection booth is identified as an essential factor for the proper implementation. Similarly, the Availability of GeneXpert services, regular supply of cartridge, maintenance of GeneXpert machine and availability of DOTS treatment center in the same hospital are identified technical factors. From the results obtained, it is suggestive that FAST strategy is feasible to implement for early diagnosis of TB and infection prevention in healthcare settings however the identified factors should be managed to ensure effective program implementation.

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3 Dec 2020

PONE-D-20-20684

Feasibility of Finding Actively Separating and Treatment (FAST) Strategy for Early Diagnosis of TB in Nepal: An Implementation Research

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Feasibility of Finding Actively Separating and Treatment (FAST) Strategy for Early Diagnosis of TB in Nepal: An Implementation Research

PONE-D-20-20684 Reviewer comments

Overall critique

FAST (Find cases Actively, Separate safely and Treat effectively) is a refocused TB infection control strategy, originally designed to reduce TB transmission in inpatient healthcare facilities (where TB treatment could be initiated based on rapid molecular diagnostic testing). Results from a large implementation trial of FAST in Peru are pending but FAST is being scaled up in various settings. This article presents an analysis of FAST implementation in different healthcare contexts in Nepal using qualitative research methods. While data analyzing implementation of an administrative TB transmission prevention strategy such as FAST hold great value, in its current form the manuscript does not adequately discuss the critical component of early initiation of effective treatment (central to FAST), lacks adequate detail regarding the qualitative methodology used (for example, CFIR is mentioned in the discussion as a framework used to guide data collection but not mentioned earlier) and does not present a sufficiently nuanced discussion of the themes identified (nor does it even specify whether these themes arose from inductive vs deductive analysis). Although one of the major strengths of the study is the wide range of stakeholders that were interviewed, the analysis does not convey this as it is often unclear which stakeholders and settings each descriptive theme or sub-theme refer to or discuss differences between these contexts and perspectives which is a missed opportunity. Finally the conclusions drawn do not represent assertions that can be made based on these data and should be revised.

Specific comments by section

Title – this needs revision as it does not encompass the full definition of FAST (see above first line of comments) as FAST is not merely about early diagnosis but early diagnosis coupled with effective treatment

Abstract

Needs full definition of FAST as above

Sentence beginning line 23 needs to incorporate importance of effective treatment and would not focus on OPD here as FAST was initially designed for inpatient settings

Introduction last three sentences read in a disjointed fashion – suggest revising

Methods (would remove materials as not relevant to this study type) – state prospective vs retrospective study

Focus rather than focused group discussion

Methods section is too brief – suggest shortening introduction to enable addition of text re: healthcare setting/country context and analytic methodology

Results are not well organized and primarily consist of lists, suggest revising

Conclusion – sentence about hospital ownership is important but requires a bit more explanation e.g. hospital ownership (as opposed to?)

Introduction

Update data in first sentences based on WHO 2020 report

Line 56- unclear relevance of latent TB for this study- suggest removing

Line 57 – 44% of cases – I think this refers to active rather than latent TB? Would move or remove since you later discuss Nepal specific data.

Line 65 – would rephrase incidences as people who become sick with TB

Lines 66-68 – unclear why you are discussing the 2013-2015 data since this study was done subsequently

Line 68-69 – this statistic repeats the earlier statistic re: 12-13 000 cases missed/year

Lines 70-71 – suggest rephrasing

Line 72 – as mentioned above please define FAST as per Barrera, Nardell IJTLD reference and cite this

Line 74 – early diagnosis to enable prompt initiation of effective treatment

Line 75-76 - would replace chest symptomatic with potentially infectious patient

Line 77-79 – would remove as FAST has not been proven to be the best strategy as stated

Line 79-81 - would state that FAST was initially designed for implementation in inpatient settings because of the central importance of early effective treatment playing a major role in decreasing transmission

Line 84-85 – would remove by healthcare workers and cough officers as optimal approach for implementing FAST has not yet been established

Lines 92-94 – this describes the study results and so should not be in the introduction

Methods

Line 98 – revise sentence re: study design

Line 99 – focus rather than focused group

Lines 100-101 – please briefly describe purposive sampling method/describe how participants were recruited

Lines 106-107 – difference between 1) and 2) is not entirely clear- please clarify.

Lines 108-110 – this answers some of the prior question re: purposive sampling, would move

Line 114 - you say similarly but test appears to be more in keeping with ‘In contrast..’ and you mention this is a community rather than referral hospital so unclear what is similar?

Line 119-120 – describe how these stakeholders were selected/sampled and from which healthcare contexts?

Line 124 – what qualitative research instruments? Explain this? Also you have not defined KII earlier.

Line 125 – KII not defined before

Line 128 – clear that patient interviews were exit interviews- how and when were interviews with health workers performed?

Line 129 – how were these instruments developed?

Lines 133- 137 – requires more detail e.g. inductive versus deductive analysis and reference for thematic analysis e.g. Braun and Clarke

Context of how FAST implementation occurred in the country and at your sites should be described in the methods, including how was responsible for implementing FAST

Also need description of what FAST implementation means e.g. screening all patients with cough vs other respiratory symptoms? Did all get Xpert? Did some get chest x-ray?

Results

Characteristics – should report numbers for all types of data including focus groups. For KIIs, would not list districts but FAST implementing sites as you do for the patients

I recommend a paragraph describing how and which themes were derived before describing findings, currently unclear if these subheadings are the themes based on inductive versus deductive analysis

Line 164 – what does good result re: case notification mean?

Line 165 – what does implemented as a non-costed intervention mean?

Lines 168-179 – see above comment re: context of how FAST implementation occurred in the country and at your sites should be described in the methods

Line 180 – when you say respondent, should specify from which participant group

Line 186 – crowded not crowed

Line 197-199 – clarify you mean this could be changed with administrative buy-in/support

Lines 217-218 – please clarify what this means: case identification was not as expected and low number of patients were screened for TB

Line 223 – remove stigmatizing term suspected, also in line 272, 284

Line 232 – what about initiation of treatment?

Line 249 – which hospital does this quote refer to?

Lines 289-300 – is this all hospitals/some hospitals? Which respondents?

Line 299 – who were these patient navigators?

Line 385 – again explain non-costed intervention? Integrated into routine care?

Line 400 – what are IEC materials?

Discussion

Line 437-439 – unclear relevance of this citation?

Line 461-463 – similar to earlier, unclear relevance of this citation?

Line 471-473 – this contradicts what you say re: need for space and dedicated staff?

Line 485 – repetition with earlier section at line 455 re: Xpert

Lines 489-490 – this citation does not refer to FAST so clarification needs to be made

Line 493 – rephrase, I think you mean prevent transmission?

Lines 506-517 – this is the first mention of CFIR (should cite Damschroeder 2009) and this discussion is inadequate. If CFIR was used to guide data collection this should be in the methods and the themes described should discuss CFIR domains e.g. inner/outer setting more clearly

Conclusion

Lines 522-523 - need to rephrase

Lines 533-534 – you do not provide information that FAST reduces transmission or even provide data about number of cases diagnosed so cannot conclude this

Supplemental data link does not work

Reviewer #2: Introduction

Line no 25: Please remove visiting

Line no 25: It should be Tb infections..

Line no 28: “This study also explored barriers and enablers that

influence the proper implementation of the FAST strategy in Nepal”.. it sounds much better if we rephrase it as “In addition, this study also…”

line no 36: change was to were.. change to as per the requirement

line 44: please rephrase the sentences “freely available of services”

line no 55: does “ill” mean people were sick from TB or were they just infected with TB bacilli? Not all TB infected people become sick from TB.

line no 56: “In 2017, 1.6 million people were died” should be rewritten was 1.6 million people died from TB.

line no 58-60: please rephrase the sentences.

Line no 64-65: “As per the estimation made by WHO, Nepal is still missing around 12,000 to 13,000 incidences”—is this the detection gap? Incidences or cases?

Line 66-69: please rephrase the sentences as its confusing.

Line no 71: spread in health facility or community?

Line no 106: change to different settings

Line no 130-131: PI collected data using FGD guideline and KII tool.

Line no 139: delete be.

Line no 151: A total of fourteen health care providers,: was it 14 health care providers or total participants were 14?.. rephrase as there were total 14 participants, which included..

Line 163: “high OPD patient flow hospitals.” Please rephrase this sentences

Result section

The result section needs to be rewritten. Its quite difficult to comprehend some sentences.

General comments

Proof reading has to be done to check for grammar and sentencing.

**********

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: review plos one.docx

Click here for additional data file.

9 Feb 2021

Respected Sir,

Thank you for the opportunity to revise our manuscript entitled “Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) strategy for Early Diagnosis of TB in Nepal: An Implementation Research” PONE-D-20-20684. We are thankful to both reviewer 1 and reviewer 2 for the constructive comments and feedback on our manuscript.

We feel that the suggestions received from reviewers are insightful and helped us in improving the manuscript. We have made attempt to fully address these comments and incorporate the feedback in the revised manuscript and believe our revised manuscript represents a significant improvement over our initial submission. Please find attached a response to reviewers for your kind consideration. We hope that you find our responses satisfactory.

In addition, I would like to kindly inform you that the available data sets for this manuscript are also attached in supporting files.

Many thanks again.

Sincerely,

Sagun Paudel, MPH

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

18 Jun 2021

PONE-D-20-20684R1

Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) strategy for early diagnosis of TB in Nepal: An implementation research

PLOS ONE

Dear Dr. Paudel,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The reviewers felt that although the previous points were largely addressed, some concerns remained. They felt that the methodology and study design should be better justified, and some of the variable better defined. They also felt that some of the conclusions were not directly supported by the results of the study and should be revised. Their comments can be viewed in full, below.

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Associate Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Partly

Reviewer #4: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: I Don't Know

Reviewer #4: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: No

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Overall, it is an important and needed topic for the health system especially on the 'How'

I have minimal competency in qualitative design to do justice to the paper-especially on the methodology and analysis

There is a need for better justification, gap analysis in existing knowledge and practice and alignment with a clear study objectives.

It will be helpful to describe better the variables considered under organizational, technical & financial factors in the data collection and analysis section-line 123

Line 151-157 should all be part of the methodology

The conclusion: line 529-532 especially linking the conclusion with early diagnosis is not supported by the study.

There is a need for better use of scholarly tone and editing

Reviewer #4: Comments to the author:

The authors address an important subject in TB transmission prevention and control, such as implementing FAST strategy. As long as the process is complex and requires input of different governmental and non-governmental associations in addition to healthcare facility members, the study covers most of the aspects that might be associated with difficulties of proper functioning of the strategy. Even though the sample size is small it seems to be enough to notch up gaps which should be considered and covered by National TB control program. It would also be interesting to follow-up the process over the time.

Please find the recommended changes in the manuscript below.

Abstract

Point 1: line 24 OPD – change to full wording

Point 2: line 35 – rephrase “study identified that the current setting of implementation…”

Point 3: line 37-38 – rephrase – “…showed that hospital ownership is crucial/is important for mobilizing staff (not staffs)….”

Point 4: line 38 – remove “that”

Point 5: line 40 - cartridge not cartilage

Point 6: line 40 – manpower (not fair with women) = human resources

Point 7: line 44 – rephrase “… effective function of the strategy”

Introduction

Point 8: line 50 – rephrase, it is not top ten it is among top ten, caused by single infectious agent, update WHO report date – 2017 to the newer version.

Point 9: line 52 - remove “which is steady in 2018”

Point 10: line 57 – add “… among the leading causes of death in the country”

Point 11: line 64 - rephrase – “Early case detection is important to interrupt infection transmission chain within healthcare facilities and community, in addition to reduce time of patients` suffering.”

Point 12: line 63 – NTC needs full wording

Point 13: line 65 – change activity to process.

Point 14: line 68-70 - remove sentence starting with “Fast was initially…”

Point 15: line 71 – figure 1 – figure misses “No” in the upper right option of current cough and the options of two conditions such as: 1. Signs and symptoms – yes / chest xray –normal; 2. Signs and symptoms –no / chest xray abnormal; - what happens in such situations?

Point 16: line 73 – define DR- TB

Point 17: line 77 – change early diagnosis to early detection

Point 18: line 82-88– rephrase to – “In order to suggest National Tuberculosis control program the areas which are crucial to be improved to strengthen the health facility based diagnosis and prompt treatment of TB, we aimed to explore organizational, technical and financial factors needed to implement FAST activities in four hospitals.”

Materials and methods

Point 19: line 97 – define criteria for “purposively selected patients” – meaning they were selected based on…?

Point 20: line 92 – include FGD abbreviation with focus group discussion

Point 21: Study setting – start paragraph with line 110 – “The FAST is a global fund-supported activity, where various non-governmental organizations are providing technical support to the …..” continue with line 106, “The FAST strategy was prepared by ….”

Point 22: line 115 change “The FAST approach” to “As FAST approach”

Point 23: line 117 change “separated presumptive TB cases to collect sputum for GeneXpert and diagnosed patients were enrolled for the treatment”

Point 24: line 120 – difference or different?

Point 25: line 125 – remove part of the sentence starting from “because these hospitals…”

Results

Point 26: line 188 remove “purposively”

Point 27: line 190 – define groups clearly, eg. i) implementation context, ii) identified factors for feasibility iii) barriers and enablers iv) way forward for the program implementation

Point 28: Table 1 – Patient who is 40 years old, is over 40 or below 40? Define age categories like ≥40 and <40 at least. Or 18-39 / 40 and up… Same goes to work experience length.

Point 29: line 197 – respondent or respondents?

Point 30: line 199-200 rephrase

Point 31: line 219 – change “So, it is difficult” to “Therefore it is difficult to pick the patient, compared to the Teaching hospital and Achham hospital.”

Point 32: line 222-225 rephrase whole paragraph “…and physical space can be managed inside the hospitals.”

Point 33: line 228 –include “[sic]” at the end of every quote, indicating there might be grammatical problems and you are not interfering with corrections.

Point 34: line 231 – change “… increased in implementing” to “… increased in the selected hospitals.”

Point 35: line 232 remove chest and change “… are prioritized to be examined faster.”

Point 36: line 242 – “as per the expectation at the initial stage…”

Point 37: line 243 – “…results show that the TB…”

Point 38: line 246 – rephrase – “…at the hospitals was performed per protocol, however…”

Point 39: paragraph lines 250-259 – shorten too many repetitions. Needs just a few sentences.

Point 40: lines 272- 275 – unclear, please rephrase, avoid repetition of the specific words.

Point 41: line 282 – change stressed to defined

Point 42: line 286 – rephrase “… limited space overcrowded with patients…”

Point 43: line 311 – Respondent or respondents?

Point 44: line 324 – explain the meaning of “birami sahayogi”.

Point 45: line 327 – rephrase “… support staffs mobilized..” to “… support personnel mobilized…”

Point 46: line 348 – remove “... so it was not necessary for FAST”, but would be better to rephrase the whole sentence.

Point 47: line 361- result waiting time is turn-around time or reporting time. Change “unitl the next day.”

Point 48: lines 362-363 – rephrase to “… the patients within a day, however…”

Point 49: line 375 – add “the” – “… to the other institutions...”

Point 50: line 386 – rephrase – “The results showed absence of uniformity on counseling….”

Point 51: line 408 – rephrase voiced to pointed out. Remove “is required” at the end of the sentence.

Point 52: line 425 – manpower = human resources / work force

Point 53: line 428 – full wording for IEC.

Point 54: line 438 - “… DOTS service …. was also noticed as the enabling factor”

Point 55: line 441 - change stressed to highlighted

Point 56: line 453 – maybe easy adoptable instead of “doable and possible”

Discussion – Overall, this section is too big. There are many unnecessary parts, please shorten considerably. Do not repeat results as they already are in the section above.

Point 57: line 464 “… support are fundamental factors…”

Point 58: line 466 – “… prevent infection transmission in a hospital setting…”

Point 59: line 472 – “… is necessary for the FAST strategy functioning, so the hospitals will be obliged to implement the process in healthcare facilities.”

Point 60: line 485 – “… delay in the maintenance..,”

Point 61: line 502 – “…barrier to the proper…”

Point 62: line 507 – “… and timely maintenance…”

Point 63: line 508 – “… were considered as barriers for…”

Point 63: lines 517-520 – remove and start “We could not access…”

Point 64: lines 529 -533 – remove and start “Our study showed that CFIR….”

Conclusion

Point 65: line 542 – rephrase “This study provides valuable information for implementation and feasibility of FAST strategy in Nepal”.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Gidado Mustapha

Reviewer #4: Yes: Nino Maghradze

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

26 Jun 2021

To,

Associate Editor

PLOS ONE

Subject: Re-submission of the revision of manuscript PONE-D-20-20684R1

Respected Sir,

Thank you for your consideration of our manuscript entitled “Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) Strategy for Early Diagnosis of TB in Nepal: An Implementation Research” PONE-D-20-20684R1. We have reviewed the comments of the reviewers and have thoroughly revised our manuscript We are thankful to both reviewer 3 and reviewer 4 for the constructive comments and feedback on our manuscript.

We found the comments, correction and suggestions received from reviewers are insightful and helped us in improving the manuscript. We have made attempt to fully address these comments and incorporate the feedback in the revised manuscript and believe our revised manuscript represents a significantly improved. Please find attached a point-by-point response to reviewers for your kind consideration. We hope that you find our responses satisfactory, and that the manuscript will be accepted for publication.

Many thanks again.

Sincerely,

Sagun Paudel, MPH

Response to Reviewers

Reviewer #4

Abstract

Point 1: line 24 OPD – change to full wording

Response: This has been updated with ‘Out-patient department’

Point 2: line 35 – rephrase “study identified that the current setting of implementation…”

Response: Updated as per suggestion.

Point 3: line 37-38 – rephrase – “…showed that hospital ownership is crucial/is important for mobilizing staff (not staffs)….”

Response: Rephrased as per suggestion.

Point 4: line 38 – remove “that”

Response: Removed.

Point 5: line 40 - cartridge not cartilage

Response: Corrected.

Point 6: line 40 – manpower (not fair with women) = human resources

Response: Added as per suggestion.

Point 7: line 44 – rephrase “… effective function of the strategy”

Response: Rephrased as per suggestion.

Introduction

Point 8: line 50 – rephrase, it is not top ten it is among top ten, caused by single infectious agent, update WHO report date – 2017 to the newer version.

Response: Updated as per latest report.

Point 9: line 52 - remove “which is steady in 2018”

Response: Removed.

Point 10: line 57 – add “… among the leading causes of death in the country”

Response: Added as per suggestion.

Point 11: line 64 - rephrase – “Early case detection is important to interrupt infection transmission chain within healthcare facilities and community, in addition to reduce time of patients` suffering.”

Response: Rephrased as per suggestion.

Point 12: line 63 – NTC needs full wording

Response: Updated National Tuberculosis Control Center

Point 13: line 65 – change activity to process.

Response: Changed as per suggestion.

Point 14: line 68-70 - remove sentence starting with “Fast was initially…”

Response: Removed as per recommendation

Point 15: line 71 – figure 1 – figure misses “No” in the upper right option of current cough and the options of two conditions such as: 1. Signs and symptoms – yes / chest x-ray –normal; 2. Signs and symptoms –no / chest x-ray abnormal; - what happens in such situations?

Response: Figure 1 has been updates and modified to make it simple.

Point 16: line 73 – define DR- TB

Response: Added as Drug-resistant tuberculosis (DR-TB)

Point 17: line 77 – change early diagnosis to early detection

Response: Updated as per suggestion.

Point 18: line 82-88– rephrase to – “In order to suggest National Tuberculosis control program the areas which are crucial to be improved to strengthen the health facility-based diagnosis and prompt treatment of TB, we aimed to explore organizational, technical and financial factors needed to implement FAST activities in four hospitals.”

Response: Updated as per recommendation.

Materials and methods

Point 19: line 97 – define criteria for “purposively selected patients” – meaning they were selected based on…?

Response: Those patients, who attended the out-patient department with chest symptomatic features and screened for TB were selected for the interview purpose.

Point 20: line 92 – include FGD abbreviation with focus group discussion

Response: Updated as focus group discussion.

Point 21: Study setting – start paragraph with line 110 – “The FAST is a global fund-supported activity, where various non-governmental organizations are providing technical support to the …..” continue with line 106, “The FAST strategy was prepared by ….”

Response: Changed as per the suggestion.

Point 22: line 115 change “The FAST approach” to “As FAST approach”

Response: Added as per suggestion.

Point 23: line 117 change “separated presumptive TB cases to collect sputum for GeneXpert and diagnosed patients were enrolled for the treatment”

Response: Corrected.

Point 24: line 120 – difference or different?

Response: It is different, Corrected.

Point 25: line 125 – remove part of the sentence starting from “because these hospitals…”

Response: Removed as per suggestion.

Results

Point 26: line 188 remove “purposively”

Response: Removed.

Point 27: line 190 – define groups clearly, eg. i) implementation context, ii) identified factors for feasibility iii) barriers and enablers iv) way forward for the program implementation

Response: Result groups are defined as per suggestion.

Point 28: Table 1 – Patient who is 40 years old, is over 40 or below 40? Define age categories like ≥40 and <40 at least. Or 18-39 / 40 and up… Same goes to work experience length.

Response: Corrected as ≥ 40 and ≥ 17 in age and work experiences respectively.

Point 29: line 197 – respondent or respondents?

Response: It was respondents, corrected.

Point 30: line 199-200 rephrase

Response: Rephrased as ‘‘National stakeholders described that FAST is implemented as a non-costed intervention as there is no financial implication for program implementation, where TB screening and treatment services are offered at different hospitals.’’

Point 31: line 219 – change “So, it is difficult” to “Therefore it is difficult to pick the patient, compared to the Teaching hospital and Achham hospital.”

Response: Revised as per suggestion.

Point 32: line 222-225 rephrase whole paragraph “…and physical space can be managed inside the hospitals.”

Response: Rephrased as ‘‘Participants explained that the implementation setting was not readily structured as per the requirements however they strongly argued that the hospital setting, and service operation process can be easily modified as per FAST guideline to implement the FAST approach and physical space can manage inside hospitals.’’

Point 33: line 228 –include “[sic]” at the end of every quote, indicating there might be grammatical problems and you are not interfering with corrections.

Response: Corrected.

Point 34: line 231 – change “… increased in implementing” to “… increased in the selected hospitals.”

Response: Revised as per suggestion.

Point 35: line 232 remove chest and change “… are prioritized to be examined faster.”

Response: Changed accordingly.

Point 36: line 242 – “as per the expectation at the initial stage…”

Response: Corrected.

Point 37: line 243 – “…results show that the TB…”

Response: Corrected per suggestion.

Point 38: line 246 – rephrase – “…at the hospitals was performed per protocol, however…”

Response: Updated as per suggestion.

Point 39: paragraph lines 250-259 – shorten too many repetitions. Needs just a few sentences.

Response: Rephrased as ‘‘As the FAST approach consists of series of activities in the hospital setting, our study identified that the actively screening, counseling, and sputum examination was conducted as per the framework of FAST strategy however separation of the patient from the queue and place them in the isolated or well-ventilated room was not followed as per the requirement of the program. It was found that the diagnosed cases were properly enrolled for DOTS. As per the FAST framework, the main problem was identified on the separation of patients. This study identified that the treatment of diagnosed TB cases was initiated timely and the patients were enrolled at DOTS therapy within hospitals.’’

Point 40: lines 272- 275 – unclear, please rephrase, avoid repetition of the specific words.

Response: Rephrased as ‘‘Participants repeatedly stressed that strong hospital ownership is a fundamental factor for staff mobilization, arrangement of the client flow system, registration desk, and waiting room. Similarly, hospital ownership is required for overall program implementation, monitoring, recording, reporting, and evaluation of the program. We identified that the hospital ownership was established in a community hospital and NGO-operated hospital to mobilize local resources for FAST whereas the government hospital didn’t realize it.’’

Point 41: line 282 – change stressed to defined

Response: Corrected.

Point 42: line 286 – rephrase “… limited space overcrowded with patients…”

Response: Corrected as per suggestion.

Point 43: line 311 – Respondent or respondents?

Response: Corrected as respondents.

Point 44: line 324 – explain the meaning of “birami sahayogi”.

Response: Birami sahayogi is the administrative staff mobilized to support patients for searching service rooms inside hospitals.

Point 45: line 327 – rephrase “… support staffs mobilized..” to “… support personnel mobilized…”

Response: Corrected as per suggestion.

Point 46: line 348 – remove “... so it was not necessary for FAST”, but would be better to rephrase the whole sentence.

Response: Removed as per suggestion and rephrased.

Point 47: line 361- result waiting time is turn-around time or reporting time. Change “until the next day.”

Response: Changed.

Point 48: lines 362-363 – rephrase to “… the patients within a day, however…”

Response: Corrected.

Point 49: line 375 – add “the” – “… to the other institutions...”

Response: Corrected.

Point 50: line 386 – rephrase – “The results showed absence of uniformity on counseling….”

Response: Corrected.

Point 51: line 408 – rephrase voiced to pointed out. Remove “is required” at the end of the sentence.

Response: Corrected.

Point 52: line 425 – manpower = human resources / work force

Response: Corrected.

Point 53: line 428 – full wording for IEC.

Response: Added. Information, education, and communication (IEC)

Point 54: line 438 - “… DOTS service …. was also noticed as the enabling factor”

Response: Corrected. DOTS service in the same hospital were also noticed as an enabling factor.

Point 55: line 441 - change stressed to highlighted

Response: Corrected.

Point 56: line 453 – maybe easy adoptable instead of “doable and possible”

Response:

Discussion – Overall, this section is too big. There are many unnecessary parts, please shorten considerably. Do not repeat results as they already are in the section above.

Response: Attempted to reduce the duplicate content from results.

Point 57: line 464 “… support are fundamental factors…”

Response: Corrected.

Point 58: line 466 – “… prevent infection transmission in a hospital setting…”

Response: Corrected as per suggestion.

Point 59: line 472 – “… is necessary for the FAST strategy functioning, so the hospitals will be obliged to implement the process in healthcare facilities.”

Response: This has been revised.

Point 60: line 485 – “… delay in the maintenance..,”

Response: Corrected.

Point 61: line 502 – “…barrier to the proper…”

Response: Corrected.

Point 62: line 507 – “… and timely maintenance…”

Response: Revised.

Point 63: line 508 – “… were considered as barriers for…”

Response: Revised.

Point 63: lines 517-520 – remove and start “We could not access…”

Response: Removed and corrected.

Point 64: lines 529 -533 – remove and start “Our study showed that CFIR….”

Response: Removed as per suggestion.

Conclusion

Point 65: line 542 – rephrase “This study provides valuable information for implementation and feasibility of FAST strategy in Nepal”.

Response: Added as per suggestion.

Reviewer #3:

Point 1: It will be helpful to describe better the variables considered under organizational, technical & financial factors in the data collection and analysis section-line 123

Response: Variables considered for this study has been updated. Please refer 180 to 185.

Point 2: Line 151-157 should all be part of the methodology

Response: It was updated as per the suggestion of previous reviewer.

Point 3: The conclusion: line 529-532 especially linking the conclusion with early diagnosis is not supported by the study.

Response: Revised.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

21 Jul 2021

PONE-D-20-20684R2

Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) strategy for early diagnosis of TB in Nepal: An implementation research

PLOS ONE

Dear Dr. Paudel,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Kind regards,

Frederick Quinn

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: N/A

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: No

Reviewer #4: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: As I early indicated, I have minimal competency to give a fair judgement on qualitative method. However, I studied both my feedback and that of other revivers and realized that the author have addressed all concerns.

However, this manuscript will need significant editing and use of scholarly tone, and in-text citation.

Reviewer #4: Comments to the author:

Thank you for addressing all the comments. I fully understand that the review process is long and labor consuming, however there are still minor corrections needed.

Please pay attention to the grammar and academic writing.

Line 25 – remove “settings” - change to “… TB transmission in hospitals”

Line 36 – “…current settings…”

Line 60-61 – re-phrase: “Tuberculosis is a major public health problem in Nepal, as it is ranked as the sixth among the leading causes of death in the country.”

Line 67 – add to deletion - “—tome of patient” (there is a repetition)

Line 93 – insert full stop after “...improve.”

Line 126- delete “…to the...” (There is a repetition)

Line 150 – correct – “Another study area/site…”

Line 243 – Remove – “So it is difficult” and start with “Therefore it is difficult”

Line 248 – Add comma after “requirements” change full stop to comma after “setting”

Line 253 – Correct “…physical space can be managed inside the hospitals”

Line 261- re-correct – “…as well as symptomatic patients are prioritized to examine faster.” Remove repetition.

Line 282 – Divide the sentence, use full stop after “strategy.” And start following sentence with “However separation…”

Line 409 – change waiting time to reporting time

Line 536 – change waiting time to reporting or turn-around time

Line 562 – remove “a” “were considered as barriers”

Lines 228, 237, 246, 256, 265, 268, 323, 339, 347, 380, 440, 453, 500 – at the end of each quote include [sic], e.g. “‘‘It is a very basic matter,…. Space management, a supportive laboratory staff, GeneXpert and one dedicated staff is enough to implement FAST. [sic] ’’ (Hospital focal person, community hospital, KII)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: Gidado Mustapha

Reviewer #4: Yes: Nino Maghradze

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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16 Sep 2021

Subject: Re-submission of the revision of manuscript PONE-D-20-20684R2

Respected Sir/Madam,

Thank you very much for this opportunity to submit a revised draft of manuscript entitled “Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) Strategy for Early Diagnosis of TB in Nepal: An Implementation Research” PONE-D-20-20684R2. We really appreciate the time and effort provided by Editors and reviewers and providing insightful feedback to improve our paper. We have reviewed the corrections and feedback received and and have thoroughly revised our manuscript.

We found the comments, correction and suggestions received from reviewers are insightful and helped us in improving the manuscript. Please find attached a point-by-point response to reviewers for your kind consideration. We hope that you find our responses satisfactory, and that the manuscript will be accepted for publication.

Many thanks again.

Sincerely,

Sagun Paudel, MPH

Response to Reviewers

Reviewer #4:

Line 25 – remove “settings” - change to “… TB transmission in hospitals”

Response: This has been updated.

Line 36 – “…current settings…”

Response: Changed.

Line 60-61 – re-phrase: “Tuberculosis is a major public health problem in Nepal, as it is ranked as the sixth among the leading causes of death in the country.”

Response: Rephrased as per suggestion

Line 67 – add to deletion - “—tome of patient” (there is a repetition)

Response: Deleted the repeated words ‘time of patient’

Line 93 – insert full stop after “...improve.”

Response: Added.

Line 126- delete “…to the...” (There is a repetition)

Response: Removed

Line 150 – correct – “Another study area/site…”

Response: Corrected.

Line 243 – Remove – “So it is difficult” and start with “Therefore it is difficult”

Response: Removed.

Line 248 – Add comma after “requirements” change full stop to comma after “setting”

Response: Changed.

Line 253 – Correct “…physical space can be managed inside the hospitals”

Response: Corrected.

Line 261- re-correct – “…as well as symptomatic patients are prioritized to examine faster.” Remove repetition.

Response: Removed.

Line 282 – Divide the sentence, use full stop after “strategy.” And start following sentence with “However separation…”

Response: Corrected

Line 409 – change waiting time to reporting time

Response: Changed.

Line 536 – change waiting time to reporting or turn-around time

Response: Changed to turn-around time.

Line 562 – remove “a” “were considered as barriers”

Response: Removed

Lines 228, 237, 246, 256, 265, 268, 323, 339, 347, 380, 440, 453, 500 – at the end of each quote include [sic], e.g. “‘‘It is a very basic matter,…. Space management, a supportive laboratory staff, GeneXpert and one dedicated staff is enough to implement FAST. [sic] ’’ (Hospital focal person, community hospital, KII)

Response: Added

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

8 Oct 2021

Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) strategy for early diagnosis of TB in Nepal: An implementation research

PONE-D-20-20684R3

Dear Dr. Paudel,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Frederick Quinn

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #4: Yes: Nino Maghradze

13 Oct 2021

PONE-D-20-20684R3

Feasibility of Find cases Actively, Separate safely and Treat effectively (FAST) strategy for early diagnosis of TB in Nepal: An implementation research

Dear Dr. Paudel:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Frederick Quinn

Academic Editor

PLOS ONE