Stool Testing for Tuberculosis Diagnosis in Pregnant Women and Under Five Children: A community based mixed method study from rural India

Introduction Sputum sample is the standard for diagnosing pulmonary tuberculosis (TB) but many people, including pregnant women (PW) struggle to produce adequate amounts of sputum. Mycobacterium tuberculosis (MTB) persists in gastric fluid, thereby organisms in swallowed sputum may be detectable in stool. Objectives This study evaluates the utility of stool testing to improve TB diagnostic yield among pregnant women and under five children and explores factors affecting the feasibility of its implementation in programmatic settings. Methods We conducted a community based sequential mixed methods study between October 2023 to December 2024 in two districts of Bihar, India. PW and U5C were screened for TB at HWC-PHC. Those individuals, who were unable to expectorate sputum, were offered stool testing using Xpert MTB/RIF Ultra. We estimated the additional yield of TB by stool testing and explored the feasibility of its implementation across beneficiaries and implementors. Results A total of 21 PwTB were detected overall (10.3% (4/39) in PW and 80.9% (17/21) in U5C), through stool testing. Factors like low awareness about stool testing, discomfort with handling stool samples, challenges in sample transport and stigma were major barriers in its implementation. Conclusion Stool testing may help detect missed cases of TB among PW and U5C. It may be feasible to implement it, under the current National TB Elimination Programme (NTEP) framework, if there is adequate awareness among community and health care providers, and basic resources for its operationalization are met.