Does pre-diagnostic loss to follow-up among presumptive TB patients differ by type of health facility? An operational research from Hwange, Zimbabwe in 2017

Pre-diagnosis and pre-treatment loss to follow-up and associated factors among patients with presumed tuberculosis and those diagnosed in Uganda

BACKGROUND

Loss to follow-up (LTFU) of patients with presumed tuberculosis (TB) before completing the diagnostic process (pre-diagnosis LTFU) and before initiating treatment for those diagnosed (pre-treatment LTFU) is a challenge in the realization of the End TB Strategy. We assessed the proportion of pre-diagnosis and pre-treatment LTFU and associated factors among patients with presumed TB and those diagnosed in the selected health facilities.

METHODS

This was a retrospective cohort study involving a review of routinely collected data from presumptive, laboratory and TB treatment registers from January 2019 to December 2022. The study was conducted in three general hospitals and one lower-level health center IV in Central Uganda. We defined pre-diagnosis LTFU as failure to test for TB and obtain results within 30 days from the date of being presumed and pre-treatment LTFU as failure to initiate TB treatment within 14 days from the date of diagnosis. Modified Poisson regression was used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) of factors associated with pre-diagnosis and pre-treatment LTFU.

RESULTS

Of the 13,064 patients with presumed TB, 39.9% were aged 25 to 44 years, and 57.1% were females. Almost a third, 28.3% (3,699/13.064) experienced pre-diagnosis LTFU and 13.7% (163/1187) did not initiate treatment within 14 days from being diagnosed. Pre-diagnosis LTFU was more likely to occur among patients aged 0-14 years (adj PR 1.1, 95% CI: 1.06,1.24), females (adj.PR=1.06, 95% CI: 1.01, 1.12) and those with no record of place of residence (adj. PR=2.7, 95% CI: 2.54, 2.93). In addition, patients with no record of phone contact were more likely to be LTFU, (adj. PR=1.1, 95% CI: 1.05, 1.17). Pre-treatment LTFU was also more likely among patients with no record of place of residence (adj PR 7.1, 95% CI: 5.13,9.85) and those with no record of phone contact (adj PR 2.2, 95% CI: 1.63,2.86). Patients presumed from the HIV clinics were 40% less likely to experience pre-treatment LTFU compared to those in the outpatient departments (adj PR 0.6, 95% CI: 0.41,0.88).

CONCLUSION

High proportions of pre-diagnosis and pre-treatment LTFU were observed in this study. This calls for urgent interventions at these time points in the TB care cascade to be able to realise the End TB Strategy.

"Together against Tuberculosis": Cascade of Care of Patients Referred by the Private Health Care Providers in the Kyrgyz Republic

Until 2021, in the Kyrgyz Republic, tuberculosis (TB) was diagnosed and treated only in the public sector. With funding support of the STOP-TB partnership, the private providers in four regions of the country and Bishkek city were mapped, trained and incentivized to screen for and identify presumptive TB patients and refer them to the public facilities for diagnosis and treatment. In this study, we describe the cascade of care of such patients. This was a cohort study involving secondary analysis of routine data. Of 79,352 patients screened during February 2021-March 2022, 2511 (3%) had presumptive TB, of whom 903 (36%) were not tested for TB [pre-diagnostic loss to follow-up]. A total of 323 (13%) patients were diagnosed with TB, of whom, 42 (13%) were not started on treatment [pre-treatment loss to follow-up]. Among 257 patients eligible for outcome assessment, 197 (77%) had treatment success, 29 (11%) were lost-to-follow-up, 13 (5%) died, 4 (2%) had treatment failure and 14 (5%) were not evaluated. While this donor-funded, pioneering initiative was successful in engaging the private sector, we recommend that the national TB programme scales up the initiative nationally with dedicated budgets, activities and plans to monitor progress. Qualitative research is urgently needed to understand the reasons for the gaps in the care cascade.

Increasing TB/HIV Case Notification through an Active Case-Finding Approach among Rural and Mining Communities in Northwest Tanzania

While Tanzania is among the high TB burden countries to reach the WHO's End TB 2030 milestones, 41% of the people estimated to have had TB in 2020 were not diagnosed and notified. As part of the response to close the TB treatment coverage gap, SHDEPHA+ Kahama conducted a TB REACH active case-finding (ACF) intervention among rural and mining communities in Northwest Tanzania to increase TB/HIV case notification from July 2017 to June 2020. The intervention successfully linked marginalized mining communities with integrated TB/HIV screening, diagnostic, and referral services, screening 144,707 people for TB of whom 24,200 were tested for TB and 4,478 were tested for HIV, diagnosing 1,499 people with TB and 1,273 people with HIV (including at least 154 people with TB/HIV coinfection). The intervention revealed that community-based ACF can ensure high rates of linkage to care among hard-to-reach populations for TB. Providing integrated TB and HIV screening and diagnostic services during evening hours (Moonlight Events) in and around mining settlements can yield a large number of people with undiagnosed TB and HIV. For TB, this is true not only amongst miners but also FSW living in the same communities, who appear to be at similar or equally high risk of infection. Local NGOs can help to bridge the TB treatment coverage gap and to improve TB and HIV health outcomes by linking these marginalized groups with public sector services. Capturing the number of referrals arriving at CTCs is an important next step to identify how well the integrated TB/HIV outreach services operate and how they can be strengthened.

Mobile digital x-ray and portable cartridge based nucleic acid amplification test machines for point-of-care diagnosis of TB in rural India

BACKGROUND

There is no experience of point-of-care (POC) microbiological confirmation for TB in India in field settings.

METHODS

Under the TB-Free Haryana project, a mobile van-mounted digital x-ray and portable GeneXpert system screened all presumptive TB patients with strong clinic-radiological suspicion for TB.

RESULTS

Of 1673 x-rays, 215 (13%) had findings suggestive of TB, 109 had strong clinical suspicion and were eligible for POC GeneXpert, in whom a test was performed in 82 (75%) cases; 59 (72%) tested positive and were initiated on treatment within 24 h.

CONCLUSIONS

A mobile van equipped with digital x-ray and POC GeneXpert is feasible and has a good success rate with potential for replication.

Magnitude and Reasons for Gaps in Tuberculosis Diagnostic Testing and Treatment Initiation: An Operational Research Study from Dakshina Kannada, South India

Background: In India, ensuring all Persons with Presumptive TB (PPTB) undergo TB diagnostic tests and initiating all diagnosed TB patients on treatment are two major implementation challenges.

Objectives: In a coastal district of Karnataka state, South India, to (1) determine the number and proportion of PPTB who did not undergo any TB diagnostic test, and the number and proportion of TB patients who were not initiated on treatment (2) explore the facilitators and barriers in TB diagnostic testing and treatment initiation from health care providers’ perspective.

Methods: For objective-1, we used a cross-sectional design involving review of data of PPTB enrolled for care during January–March 2019 and for objective-2, we used a qualitative design involving key informant interviews of health care providers.

Results: Of 8822 PPTB patients enrolled for evaluation of TB, 767 (9%) had not undergone any TB diagnostic test. In those who had undergone any TB diagnostic test, a total of 822 were diagnosed with TB and of them, 26 (3%) were not initiated on treatment. Cartridge-based nucleic acid amplification tests was used as a diagnostic test only among 1188 (13.5%) PPTB patients. The gaps in diagnostic testing were due to: non-availability of doctors/lab-technicians, inadequate knowledge about TB diagnostic tests among health care providers, reluctance of patients to undergo the TB diagnostic tests due to stigma/confidentiality issues and sub-optimal engagement of private health facilities for TB control.

Conclusion: About 9% of PPTB not undergoing any test for TB and 3% of the TB patients not initiated on treatment are of major concern. Revised National TB Control Programme needs to address the identified barriers to improve the process of TB diagnosis and treatment initiation.

Pre-diagnostic drop out of presumptive TB patients and its associated factors at Bugembe Health Centre IV in Jinja, Uganda

BACKGROUND

Drop out of presumptive TB individuals before making a final diagnosis poses a danger to the individual and their community. We aimed to determine the proportion of these presumptive TB drop outs and their associated factors in Bugembe Health Centre, Jinja, Uganda.

METHODS

We used data from the DHIS2, presumptive and laboratory registers of Bugembe Health Centre IV for 2017. Descriptive statistics were used to summarize the population characteristics. A modified Poisson regression model via the generalized linear model (GLM) with log link and robust standard errors was used for bivariate and multivariate analysis.We used data from the DHIS2, presumptive and laboratory registers of Bugembe Health Centre IV for 2017. Descriptive statistics were used to summarize the population characteristics. A modified Poisson regression model via the generalized linear model (GLM) with log link and robust standard errors was used for bivariate and multivariate analysis.

RESULT

Among the 216 registered presumptive TB patients who were less than 1% of patients visiting the outpatients' department, 40.7% dropped out before final diagnosis was made. Age and HIV status were significantly associated with pre-diagnostic drop out while gender and distance from the health center were not.

CONCLUSION

A high risk to individuals and the community is posed by the significant proportion of presumptive TB patients dropping out before final diagnosis. Health systems managers need to consider interventions targeting young persons, male patients, HIV positive persons.

Prediagnostic loss to follow-up in an active case finding tuberculosis programme: a mixed-methods study from rural Bihar, India

OBJECTIVE

To quantify the prediagnostic loss to follow-up (PDLFU) in an active case finding tuberculosis (TB) programme and identify the barriers and enablers in undergoing diagnostic evaluation.

DESIGN

Explanatory mixed-methods design.

SETTING

A rural population of 1.02 million in the Samastipur district of Bihar, India.

PARTICIPANTS

Based on their knowledge of health status of families, community health workers or CHWs (called accredited social health activist or locally) and informal providers referred people to the programme. The field coordinators (FCs) in the programme screened the referrals for TB symptoms to identify presumptive TB cases. CHWs accompanied the presumptive TB patients to free diagnostic evaluation, and a transport allowance was given to the patients. Thereafter, CHWs initiated and supported the treatment of confirmed cases. We included 13 395 community referrals received between January and December 2018. To understand the reasons of the PDLFU, we conducted in-depth interviews with patients who were evaluated (n=3), patients who were not evaluated (n=4) and focus group discussions with the CHWs (n=2) and FCs (n=1).

OUTCOME MEASURES

Proportion and characteristics of PDLFU and association of demographic and symptom characteristics with diagnostic evaluation.

RESULTS

A total of 11 146 presumptive TB cases were identified between January and December 2018, out of which 4912 (44.1%) underwent diagnostic evaluation. In addition to the free TB services in the public sector, the key enablers were CHW accompaniment and support. The major barriers identified were misinformation and stigma, deficient family and health provider support, transport challenges and poor services in the public health system.

CONCLUSION

Finding the missing cases will require patient-centric diagnostic services and urgent reform in the health system. A community-oriented intervention focusing on stigma, misinformation and patient support will be critical to its success.

Where are patients missed in the tuberculosis diagnostic cascade? A prospective cohort study in Ghana

Background

Ghana’s national prevalence survey showed higher than expected tuberculosis (TB) prevalence, indicating that many people with TB are not identified and treated. This study aimed to identify gaps in the TB diagnostic cascade prior to starting treatment.

Methods

A prospective cohort study was conducted in urban and rural health facilities in south-east Ghana. Consecutive patients routinely identified as needing a TB test were followed up for two months to find out if sputum was submitted and/or treatment started. The causal effect of health facility location on submitting sputum was assessed before risk factors were investigated using logistic regression.

Results

A total of 428 persons (mean age 48 years, 67.3% female) were recruited, 285 (66.6%) from urban and 143 (33.4%) from rural facilities. Of 410 (96%) individuals followed up, 290 (70.7%) submitted sputum, among which 27 (14.1%) had a positive result and started treatment. Among those who visited an urban facility, 245/267(91.8%) submitted sputum, compared to 45/143 (31.5%) who visited a rural facility. Participants recruited at the urban facility were far more likely to submit a sputum sample (odds ratio (OR) 24.24, 95%CI 13.84–42.51). After adjustment for confounding, there was still a strong association between attending the urban facility and submitting sputum (adjusted OR (aOR) 9.52, 95%CI 3.87–23.40). Travel distance of >10 km to the laboratory was the strongest predictor of not submitting sputum (aOR 0.12, 95%CI 0.05–0.33).

Conclusion

The majority of presumptive TB patients attending a rural health facility did not submit sputum for testing, mainly due to the long travel distance to the laboratory. Bridging this gap in the diagnostic cascade may improve case detection.