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Das S, Kumar R, Krishnan A, Kant S, Mohan A. Patient costs for drug-resistant TB diagnosis and pre-treatment evaluation in North India. Public Health Action 2024; 14:129-134. [PMID: 39239156 PMCID: PMC11373743 DOI: 10.5588/pha.24.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 06/05/2024] [Indexed: 09/07/2024] Open
Abstract
INTRODUCTION India's National TB Elimination Programme (NTEP) aims to eliminate TB-related catastrophic expenditure by offering free diagnosis and treatment. However, 3.9% of TB patients have drug-resistant TB (DR-TB) and are facing higher costs. OBJECTIVE To assess DR-TB patients' diagnosis and pre-treatment evaluation costs, catastrophic cost incidence, and its relation to patient characteristics. METHODS The study included DR-TB patients from three District Drug-Resistant TB Centres in Delhi and Faridabad (October 2021-June 2022). Socio-economic and clinical characteristics and direct medical and non-medical costs from drug susceptibility testing eligibility to the start of DR-TB treatment were collected using patient interviews and records. Indirect costs were calculated via the human capital approach, defining catastrophic costs as expenses over 20% of household annual income. Multivariable regression was used to estimate the effects of patient characteristics on catastrophic costs. RESULTS Of 158 patients, 37.3% were aged 19-30 years, and 55.7% were women. Median total cost was USD326.6 (IQR 132.7-666.7), with 48.2% for diagnosis and 66.0% indirect. 32% faced catastrophic costs, with manual labourers at higher risk (adjusted OR 4.4). CONCLUSION Despite free diagnosis and treatment, a significant portion of DR-TB households in India incur catastrophic costs, mainly from indirect expenses, indicating a need for targeted policy and programme interventions.
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Affiliation(s)
- S Das
- Centre for Community Medicine, and
| | - R Kumar
- Centre for Community Medicine, and
| | | | - S Kant
- Centre for Community Medicine, and
| | - A Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi
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Akalu TY, Clements ACA, Gebreyohannes EA, Xu Z, Bai L, Alene KA. Risk factors for diagnosis and treatment delay among patients with multidrug-resistant tuberculosis in Hunan Province, China. BMC Infect Dis 2024; 24:159. [PMID: 38308252 PMCID: PMC10835895 DOI: 10.1186/s12879-024-09036-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/19/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Multidrug-resistant tuberculosis (MDR-TB) is a global health threat associated with high morbidity and mortality rates. Diagnosis and treatment delays are associated with poor treatment outcomes in patients with MDR-TB. However, the risk factors associated with these delays are not robustly investigated, particularly in high TB burden countries such as China. Therefore, this study aimed to measure the length of diagnosis and treatment delays and identify their risk factors among patients with MDR-TB in Hunan province. METHODS A retrospective cohort study was conducted using MDR-TB data from Hunan province between 2013 and 2018. The main outcomes of the study were diagnosis and treatment delay, defined as more than 14 days from the date of symptom to diagnosis confirmation (i.e., diagnosis delay) and from diagnosis to treatment commencement (i.e., treatment delay). A multivariable logistic regression model was fitted, and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to identify factors associated with diagnosis and treatment delay. RESULTS In total, 1,248 MDR-TB patients were included in this study. The median length of diagnosis delays was 27 days, and treatment delays were one day. The proportion of MDR-TB patients who experienced diagnosis and treatment delay was 62.82% (95% CI: 60.09-65.46) and 30.77% (95% CI: 28.27-33.39), respectively. The odds of experiencing MDR-TB diagnosis delay among patients coming through referral and tracing was reduced by 41% (AOR = 0.59, 95% CI: 0.45-0.76) relative to patients identified through consultations due to symptoms. The odds of experiencing diagnosis delay among ≥ 65 years were 65% (AOR = 0.35, 0.14-0.91) lower than under-15 children. The odds of developing treatment delay among foreign nationalities and people from other provinces were double (AOR = 2.00, 95% CI: 1.31-3.06) compared to the local populations. Similarly, the odds of experiencing treatment delay among severely ill patients were nearly 2.5 times higher (AOR = 2.49, 95% CI: 1.41-4.42) compared to patients who were not severely ill. On the other hand, previously treated TB cases had nearly 40% (AOR = 0.59, 95% CI: 0.42-0.85) lower odds of developing treatment delay compared with new MDR-TB cases. Similarly, other ethnic minority groups had nearly 40% (AOR = 0.57, 95% CI: 0.34-0.96) lower odds of experiencing treatment delay than the Han majority. CONCLUSIONS Many MDR-TB patients experience long diagnosis and treatment delays in Hunan province. Strengthening active case detection can significantly reduce diagnosis delays among MDR-TB patients. Moreover, giving attention to patients who are new to MDR-TB treatment, are severely ill, or are from areas outside Hunan province will potentially reduce the burden of treatment delay among MDR-TB patients.
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Affiliation(s)
- Temesgen Yihunie Akalu
- School of Population Health, Faculty of Health Sciences, Curtin University, Perth, WA, 6102, Australia.
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia.
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Archie C A Clements
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Eyob Alemayehu Gebreyohannes
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia
- School of Allied Health, University of Western Australia, Perth, WA, Australia
| | - Zuhui Xu
- Xiangya School of Public Health, Central South University, Changsha, China
| | - Liqiong Bai
- TB Control Institute of Hunan Province, Changsha, China
| | - Kefyalew Addis Alene
- School of Population Health, Faculty of Health Sciences, Curtin University, Perth, WA, 6102, Australia
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Noman MZI, Islam S, Aktar S, Parray AA, Amando DG, Karki J, Atsna Z, Mitra DK, Hossain SAS. Healthcare seeking behavior and delays in case of Drug-Resistant Tuberculosis patients in Bangladesh: Findings from a cross-sectional survey. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0001903. [PMID: 38266032 PMCID: PMC10807832 DOI: 10.1371/journal.pgph.0001903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/02/2023] [Indexed: 01/26/2024]
Abstract
The emergence of Drug-Resistant Tuberculosis (DR-TB) has become a major threat globally and Bangladesh is no exception. Delays in healthcare seeking, proper diagnosis and initiation of treatment cause continuous transmission of the resistant tubercule bacilli through the communities. This study aimed to assess the different health care-seeking behaviors and delays among DR-TB patients in Bangladesh. A prospective cross-sectional study was conducted from November to December 2018, among 92 culture positive and registered DR-TB patients in four selected hospitals in Bangladesh. Data were collected through face-to-face interviews with survey questionnaire as well as record reviews. Among the 92 study participants, the median patient delay was 7 (IQR 3, 15) days, the median diagnostic delay was 88 (IQR 36.5, 210), the median treatment delay was 7 (IQR 4,12) days, and the median total delay among DR-TB patients was 108.5 (IQR 57.5, 238) days. 81.32% sought initial care from informal healthcare providers. The majority (68.48%) of the informal healthcare providers were drug sellers while 60.87% of patients sought care from more than four healthcare points before being diagnosed with DR-TB. The initial care seeking from multiple providers was associated with diagnostic and total delays. In Bangladesh, DR-TB cases usually seek care from multiple providers, particularly from informal providers, and among them, alarmingly higher healthcare-seeking related delays were noted. Immediate measures should be taken both at the health system levels and, in the community, to curb transmission and reduce the burden of the disease.
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Affiliation(s)
- Md. Zulqarnine Ibne Noman
- BRAC James P. Grant School of Public Health (JPGSPH), BRAC University, Dhaka, Bangladesh
- EcoHealth Alliance Bangladesh Programs, Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh
| | - Shariful Islam
- EcoHealth Alliance Bangladesh Programs, Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh
| | - Shaki Aktar
- BRAC James P. Grant School of Public Health (JPGSPH), BRAC University, Dhaka, Bangladesh
- International Centre for Diarrhoeal Disease Research (icddr,b), Bangladesh, Dhaka, Bangladesh
| | - Ateeb Ahmad Parray
- BRAC James P. Grant School of Public Health (JPGSPH), BRAC University, Dhaka, Bangladesh
- Department of International Health, Health Systems Program, The Johns Hopkins University, Baltimore, MD, United States of America
| | - Dennis G. Amando
- BRAC James P. Grant School of Public Health (JPGSPH), BRAC University, Dhaka, Bangladesh
| | - Jyoti Karki
- BRAC James P. Grant School of Public Health (JPGSPH), BRAC University, Dhaka, Bangladesh
| | - Zafria Atsna
- BRAC James P. Grant School of Public Health (JPGSPH), BRAC University, Dhaka, Bangladesh
| | - Dipak Kumar Mitra
- Department of Public Health, North South University, Dhaka, Bangladesh
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Silitonga P, Jiang W, Wyatt S, Burhan E, Kes EFM, Long Q, Long Q. Factors affecting time to treatment initiation after diagnosis for multidrug-resistant/rifampicin-resistant tuberculosis patients: A mixed-methods study in Jakarta, Indonesia. Trop Med Int Health 2023; 28:43-52. [PMID: 36477995 DOI: 10.1111/tmi.13838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the time to treatment initiation (TTI) for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) patients after diagnosis in Indonesia and biological, psychological and social factors associated with the time interval. METHODS This study was conducted in Persahabatan Hospital, Jakarta using a mixed-methods approach. Registry data and medical records of MDR/RR-TB patients were collected and matched (hospital dataset), and linked with psychosocial assessment results (linked dataset). Descriptive analysis was conducted to understand patient characteristics and the distribution of TTI after RR-TB diagnosis by GeneXpert. Generalised linear regression was used to analyse factors associated with delay duration, and logistic regression to explore factors associated with the delay longer than the median duration for both datasets (basic vs. extended model). In-depth interviews were conducted with patients and healthcare workers to understand the procedure of treatment initiation and how different factors led to delay. RESULTS The hospital dataset included 275 patient-matched cases, and 188 were further linked with psychosocial assessment results. The median time interval was 24 days [interquartile range (IQR) 23.5] and 26 days (IQR 21.25), respectively. Regression analysis showed that in the extended model, comorbidities (exp [coefficient]= 1.93), unemployment (exp [coefficient] = 1.80) and poor knowledge of MDR/RR-TB (exp (coefficient) = 1.67) seemed to have the strongest effects on prolonging the time interval (p < 0.05). Unsuccessful TB treatment history was the only factor that significantly increased the risk of delay longer than the median duration (p < 0.05) in the basic model, while none of the factors were significant in the extended model. The qualitative study identified provider-side factors (centralised service provision and insufficient human resources) and patient-side factors (physical weakness, psychological stress and financial concern) associated with treatment delay. CONCLUSION MDR/RR-TB patients in Persahabatan Hospital, Jakarta, Indonesia waited around 25 days for treatment initiation after RR-TB diagnosis. Health system solutions are needed to address challenges facing both MDR/RR-TB patients and healthcare providers to reduce delay in treatment initiation.
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Affiliation(s)
- Permata Silitonga
- Global Health Research Center, Duke Kunshan University, Kunshan, China
| | - Weixi Jiang
- School of Public Health, Fudan University, Shanghai, China
| | - Sage Wyatt
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Erlina Burhan
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Indonesia-Persahabatan Hospital, Jakarta, Indonesia
| | | | - Qian Long
- Global Health Research Center, Duke Kunshan University, Kunshan, China
| | - Qian Long
- Global Health Research Center Duke Kunshan University Kunshan Jiangsu China
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Coit J, Wong M, Galea JT, Mendoza M, Marin H, Tovar M, Chiang SS, Lecca L, Franke MF. Uncovering reasons for treatment initiation delays among children with TB in Lima, Peru. Int J Tuberc Lung Dis 2021; 24:1254-1260. [PMID: 33317668 DOI: 10.5588/ijtld.20.0079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND: Timely diagnosis and treatment of pediatric tuberculosis (TB) is critical to reducing mortality but remains challenging in the absence of adequate diagnostic tools. Even once a TB diagnosis is made, delays in treatment initiation are common, but for reasons that are not well understood.METHODS: To examine reasons for delay post-diagnosis, we conducted semi-structured interviews with Ministry of Health (MoH) physicians and field workers affiliated with a pediatric TB diagnostic study, and caregivers of children aged 0-14 years who were diagnosed with pulmonary TB in Lima, Peru. Interviews were analyzed using systematic comparative and descriptive content analysis.RESULTS: We interviewed five physicians, five field workers and 26 caregivers with children who initiated TB treatment < 7 days after diagnosis (n = 15) or who experienced a delay of ≥7 days (n = 11). Median time in delay from diagnosis to treatment initiation was 26 days (range 7-117). Reasons for delay included: health systems challenges (administrative hurdles, medication stock, clinic hours), burden of care on families and caregiver perceptions of disease severity.CONCLUSION: Reasons for delay in treatment initiation are complex. Interventions to streamline administrative processes and tools to identify and support families at risk for delays in treatment initiation are urgently needed.
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Affiliation(s)
- J Coit
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - M Wong
- Socios En Salud Sucursal, Lima, Peru
| | - J T Galea
- School of Social Work, University of South Florida, Tampa, FL, College of Public Health, University of South Florida, Tampa, FL
| | - M Mendoza
- Socios En Salud Sucursal, Lima, Peru
| | - H Marin
- Socios En Salud Sucursal, Lima, Peru
| | - M Tovar
- Socios En Salud Sucursal, Lima, Peru
| | - S S Chiang
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, Center for International Health Research, Rhode Island Hospital, Providence, RI, USA
| | - L Lecca
- Socios En Salud Sucursal, Lima, Peru
| | - M F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Mpagama SG, Ezekiel MJ, Mbelele PM, Chongolo AM, Kibiki GS, de Guex KP, Heysell SK. Gridlock from diagnosis to treatment of multidrug resistant tuberculosis (MDR-TB) in Tanzania: patients' perspectives from a focus group discussion. BMC Public Health 2020; 20:1667. [PMID: 33160327 PMCID: PMC7648291 DOI: 10.1186/s12889-020-09774-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Molecular diagnostics have revolutionized the diagnosis of multidrug resistant tuberculosis (MDR-TB). Yet in Tanzania we found delay in diagnosis with more than 70% of MDR-TB patients having a history of several previous treatment courses for TB signaling prior opportunities for diagnosis. We aimed to explore patients' viewpoints and experiences with personal and socio-behavioral obstacles from MDR-TB diagnosis to treatment in an attempt to understand these prior findings. METHODS The study was conducted in December 2016 with MDR-TB patients admitted at Kibong'oto Infectious Diseases Hospital. A qualitative approach deploying focus group discussions (FGDs) was used to gather information. Groups were sex aggregated to allow free interaction and to gauge gender specific issues in the social and behavioral contexts. The FGDs explored pathways and factors in the service delivery that may have contributed in the delay in accessing MDR-TB diagnostics and/or treatment. Collected data were coded, categorized and thematically interpreted. RESULTS Forty MDR-TB patients participated in six FGDs. Challenges and barriers contributing to the delay in accessing MDR-TB diagnosis to treatment were as follows: 1) Participants had a different understanding of MDR-TB that led to seeking services outside the conventional health system; 2) Socio-economic adversity made health-seeking behavior difficult and often unproductive; 3) In the health system, challenges included inadequacy of MDR-TB diagnostic centers, lack of knowledge on behalf of health care providers to consider MDR-TB and order appropriate diagnostics; 4) The specimen referral system for early diagnosis of MDR-TB was inefficient. Non-adherence of TB patients to first-line anti-TB drugs prior to MDR-TB diagnosis, given the multitude of barriers discussed, was coupled with both intentional and unintentional non-adherence of health care providers to international standards of TB care. CONCLUSION Patient-centered strategies bridging communities and the health system are urgently required for optimum MDR-TB control in Tanzania.
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Affiliation(s)
- Stellah G. Mpagama
- Kibong’oto Infectious Diseases Hospital –Sanya Juu Siha/Kilimanjaro Clinical Research Institute Kilimanjaro Tanzania, Mae Street, Lomakaa road, Siha Kilimanjaro, Tanzania
| | - Mangi J. Ezekiel
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Peter M. Mbelele
- Kibong’oto Infectious Diseases Hospital –Sanya Juu Siha/Kilimanjaro Clinical Research Institute Kilimanjaro Tanzania, Mae Street, Lomakaa road, Siha Kilimanjaro, Tanzania
| | - Anna M. Chongolo
- Kibong’oto Infectious Diseases Hospital –Sanya Juu Siha/Kilimanjaro Clinical Research Institute Kilimanjaro Tanzania, Mae Street, Lomakaa road, Siha Kilimanjaro, Tanzania
| | | | - Kristen Petros de Guex
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA USA
| | - Scott K. Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA USA
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Gong HZ, Han C, Yang FL, Wang CF, Wang JL, Wang MS. Treatment delay in childhood pleural tuberculosis and associated factors. BMC Infect Dis 2020; 20:793. [PMID: 33109109 PMCID: PMC7590447 DOI: 10.1186/s12879-020-05496-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 10/08/2020] [Indexed: 11/30/2022] Open
Abstract
Background Delay in diagnosis and treatment worsens the disease and clinical outcomes, which further enhances the transmission of tuberculosis (TB) in the community. Therefore, this study aims to assess treatment delay and its associated factors among childhood pleural TB patients in China. Methods Between January 2006 and December 2019, consecutive patients aged ≤15 years with definite or possible pleural TB were included for analysis. Treatment delay duration was defined as the time interval from the onset of symptoms to treatment initiation and was stratified into two categories: < 30 days, ≥30 days (median delay day is 30 days). The electronic medical records of children were reviewed to obtain demographic characteristics, clinical characteristics, laboratory examinations, and radiographic findings. Univariate and multivariate logistic regressions were used to explore the factors associated with treatment delay in patients. Results A total of 154 children with pleural TB were included, with a mean age of 12.4 ± 3.3 years. The median treatment delay was 30 days (interquartile range, 10–60 days) and 51.3% (n = 79) of patients underwent a treatment delay. Multivariate analysis revealed that heart rate (≤92 beats/min, age-adjusted OR = 2.503, 95% CI: 1.215, 5.155) and coefficient of variation of red cell distribution width (RDW-CV, ≥12.9%, age-adjusted OR = 4.705, 95% CI: 2.048, 10.811) were significant risk factors for treatment delays in childhood pleural TB. Conclusion Our findings suggested that a significant treatment delay occurs among children with pleural TB in China. Patients with a low heart rate or a high RDW-CV experienced delays in the initiation of anti-TB therapy. Therefore, well awareness of the associations between clinical characteristics and treatment delay may improve the management of children with pleural TB and enable us to develop preventive strategies to reduce the treatment delay. Supplementary information Supplementary information accompanies this paper at 10.1186/s12879-020-05496-4.
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Affiliation(s)
- Huai-Zheng Gong
- Department of Lab Medicine, Shandong Provincial Chest Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chao Han
- Department of Geriatrics, Shandong Mental Health Center, Jinan, China
| | - Feng-Lian Yang
- School of Pharmacy, Youjiang Medical University for Nationalities, Baise, China
| | - Chun-Fang Wang
- Department of Lab Medicine, The Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
| | - Jun-Li Wang
- Department of Lab Medicine, The Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China.
| | - Mao-Shui Wang
- Department of Lab Medicine, Shandong Provincial Chest Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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Hapolo E, Ilai J, Francis T, du Cros P, Taune M, Chan G. TB treatment delay associated with drug resistance and admission at Daru General Hospital in Papua New Guinea. Public Health Action 2019; 9:S50-S56. [PMID: 31579650 DOI: 10.5588/pha.18.0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/11/2018] [Indexed: 11/10/2022] Open
Abstract
SETTING Daru General Hospital, Daru Island, Papua New Guinea, where high rates of tuberculosis (TB) have been reported. Prompt diagnosis and effective treatment are needed for improving TB outcomes and to prevent nosocomial transmission. OBJECTIVE To assess the time to treatment initiation and the risk factors associated with delayed treatment for patients started on TB treatment at Daru General Hospital from January to September 2017. DESIGN This was a retrospective cohort study that entailed reviewing the records from treatment, admission, discharge and presumptive TB registers. RESULTS The study included 360 patients on TB treatment. The median time from presentation to treatment initiation was 7 days [IQR 3-11]. Treatment was started <7 days for 215 patients (60%); however, only 16.2% commenced treatment <2 days. Risk factors for delayed treatment were diagnosis of TB as an inpatient (OR 2.67, 95% CI 1.35-5.28, P = 0.005) and having drug-resistant TB (OR 2.65, 95% CI 1.5-4.68. P = 0.001). CONCLUSION A high proportion of TB patients commenced treatment <7 days. Inpatient status, DR-TB and lack of microbiological confirmation were associated with delays in treatment initiation. We recommend that programmes monitor the time from presentation to treatment initiation, and propose that a period of >3 days from presentation to treatment initiation be considered as delayed treatment initiation.
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Affiliation(s)
- E Hapolo
- Daru General Hospital, Daru, Western Province, Papua New Guinea
| | - J Ilai
- Daru General Hospital, Daru, Western Province, Papua New Guinea
| | - T Francis
- Daru General Hospital, Daru, Western Province, Papua New Guinea
| | - P du Cros
- Burnet Institute, Melbourne, Victoria, Australia
| | - M Taune
- Daru General Hospital, Daru, Western Province, Papua New Guinea
| | - G Chan
- Burnet Institute, Melbourne, Victoria, Australia
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Sharma AK, Gupta N, Verma S, Chandran A, Dixit R. A study on procedural delay in diagnosis and start of treatment in drug resistant tuberculosis under RNTCP. Indian J Tuberc 2019; 66:394-401. [PMID: 31439186 DOI: 10.1016/j.ijtb.2018.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 02/19/2018] [Accepted: 04/09/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Multi-drug-resistant TB (MDR-TB) has become a significant public health problem and an obstacle to effective TB control. Rapid diagnostic tests for anti tubercular drugs sensitivity have significantly reduced total time in initiation of treatment. Still there is a significant gap between MDR diagnosis and start of category IV treatment. Delay in establishing the diagnosis may cause disease progression, transmission, lost to follow up and death. This study was planned to assess the actual delay from day one of sputum examination to the day of initiation of category IV in operational settings. METHODOLOGY MDR-TB suspected patients attending the Respiratory medicine department, JLNMC, Ajmer from June-15 to July-16 were followed from sputum examination to sample deposition for drug sensitivity testing (LPA/CBNAAT) to MDR detection to category IV initiation, for assessment of procedural delay at various steps. RESULTS LPA group (371 patients): Sputum smear to LPA deposition mean duration was 8.02 days, LPA deposition to LPA result upload mean duration was 3.78 days, LPA deposition to patients received LPA reports mean duration was 21.73 days and reports received to PMDT site admission (if drug resistant) mean duration was 3.61 days. Total time duration in category IV initiation was 32.63 days. CBNAAT group (50 patients): Sputum smear to CBNAAT deposition mean duration was 6.70 days, CBNAAT deposition to CBNAAT result upload mean duration was 1.13 days, CBNAAT deposition to patients received CBNAAT reports mean duration was 6.53 days and reports received to PMDT site admission (if R-resistant) mean duration was 3.8 days. Total time duration in category IV initiation was 12.4 days. CONCLUSION Major delay seen on part of receiving sensitivity reports indicates the need to stress upon field staff motivation, appropriate training, sensitisation and expert counselling.
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Affiliation(s)
- Amit Kumar Sharma
- Resident, Department of Respiratory Medicine, J.L.N. Medical College, Ajmer, India.
| | - Neeraj Gupta
- Professor and Head, Department of Respiratory Medicine, J.L.N. Medical College, Ajmer, India
| | - Satyadeep Verma
- Resident, Department of Respiratory Medicine, J.L.N. Medical College, Ajmer, India
| | - Arjun Chandran
- Resident, Department of Respiratory Medicine, J.L.N. Medical College, Ajmer, India
| | - Ramakant Dixit
- Professor, Department of Respiratory Medicine, J.L.N. Medical College, Ajmer, India
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Tefera KT, Mesfin N, Reta MM, Sisay MM, Tamirat KS, Akalu TY. Treatment delay and associated factors among adults with drug resistant tuberculosis at treatment initiating centers in the Amhara regional state, Ethiopia. BMC Infect Dis 2019; 19:489. [PMID: 31151423 PMCID: PMC6544973 DOI: 10.1186/s12879-019-4112-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/20/2019] [Indexed: 11/10/2022] Open
Abstract
Background A delayed initiation of tuberculosis treatment results in high morbidity, mortality, and increased person-to-person transmissions. The aim of this study was to assess treatment delay and its associated factors among adult drug resistant tuberculosis patients in the Amhara Regional State, Ethiopia. Methods An institution based cross-sectional study was conducted on all adult drug resistant tuberculosis patients who initiated treatment from September 2010 to December 2017. Data were collected from patient charts, registration books, and computer databases using abstraction sheets. The data were entered using Epi-info version 7 and exported to SPSS version 20 for analysis. Summary statistics, like means, medians, and proportions were used to present it. Binary logistic regression was fitted; Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) was also computed. Variables with p-value < 0.05 in the multi-variable logistic regression model was declared as significantly associated with treatment delay. Results The median time to commence treatment after drug resistant tuberculosis diagnosis was 8 (IQR: 3–37) days. Being diagnosed by Line probe assay [AOR = 5.59; 95% CI: 3.48–8.98], Culture [AOR = 5.15; 95% CI: 2.53–10.47], and history of injectable anti-TB drugs [AOR = 2.12; 95% CI: 1.41–3.19] were associated with treatment delays. Conclusion Treatment delay was long, especially among patients diagnosed by Culture or LPA and those who had a prior history of injectable anti-TB drugs. That suggested that the need for universal accesses to rapid molecular diagnostic tests, such as Gene Xpert and the PMDT team were needed to promptly decide to minimize unnecessary delays.
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Affiliation(s)
| | - Nebiyu Mesfin
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mebratu Mitiku Reta
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Malede Mequanent Sisay
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Koku Sisay Tamirat
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Temesgen Yihunie Akalu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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11
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Htun YM, Khaing TMM, Aung NM, Yin Y, Myint Z, Aung ST, Soonthornworasiri N, Silachamroon U, Kasetjaroen Y, Kaewkungwal J. Delay in treatment initiation and treatment outcomes among adult patients with multidrug-resistant tuberculosis at Yangon Regional Tuberculosis Centre, Myanmar: A retrospective study. PLoS One 2018; 13:e0209932. [PMID: 30596734 PMCID: PMC6312206 DOI: 10.1371/journal.pone.0209932] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/13/2018] [Indexed: 11/19/2022] Open
Abstract
Background Myanmar faces a health security threat, with an increasing number of multidrug-resistant tuberculosis (MDR-TB) cases. Long delays in the initiation of treatment are a barrier to MDR-TB control. Objectives The main objectives of this study were (1) to identify the determinants of delay in treatment initiation after MDR-TB diagnosis, and (2) to explore the effects of treatment delay on disease infectivity, severity, treatment adherence, and treatment outcomes. Methods This retrospective study reviewed 330 MDR-TB treatment cards for patients enrolled for treatment at Yangon Regional Tuberculosis Centre, in 2014. Results Median treatment delay was 105 days, interquartile range (IQR) 106 (61–167) days; (51.5%) of patients experienced a long treatment delay (≥ 105 days). Regarding the determinants of treatment delay, this study identified important patient-healthcare system interaction factors. Significant risk factors of long treatment delay included female sex, age > 30 years, and prior contact with patients with MDR-TB. Patients with long treatment delays were significantly different from those with short delays, in terms of having high sputum smear grade, resistance to more than two main drugs (isoniazid and rifampicin), and long culture conversion time. In this study, delay in the initiation of treatment was associated with poor treatment outcome, but this was not statistically significant after adjusting for other risk factors. Median treatment-delay times were longer among patients with poor outcomes (144 days) than those with successful outcomes (102 days). Conclusions Post-diagnosis delays in the initiation of treatment among MDR-TB patients were significantly long. The study results showed that inadequate MDR-TB treatment initiation center, centralization of treatment initiation, limitation of human resources, were health-system factors delaying timely treatment initiation and implementation of an effective TB-control program. Our findings highlight the need for immediate interventions to reduce treatment delay and improve treatment outcomes, including scaling up diagnostic capacity with Xpert MTB/RIF at township level, expansion of decentralized MDR-TB treatment initiation centers, ensuring a productive health workforce comprising trained health personnel, and providing health education and treatment-adherence counseling to patients and family members.
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Affiliation(s)
- Ye Minn Htun
- Defence Services Medical School, Hmawbi, Yangon, Myanmar
| | | | - Nay Myo Aung
- Department of Chest Medicine, Defence Services Medical Academy, Yangon, Myanmar
| | - Yin Yin
- Regional Tuberculosis Center, Yangon, Myanmar
| | - Zaw Myint
- Regional Tuberculosis Center, Yangon, Myanmar
| | - Si Thu Aung
- National Tuberculosis Programme, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | | | - Udomsak Silachamroon
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Jaranit Kaewkungwal
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- * E-mail: ,
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12
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Htun YM, Khaing TMM, Yin Y, Myint Z, Aung ST, Hlaing TM, Soonthornworasiri N, Silachamroon U, Kasetjaroen Y, Kaewkungwal J. Delay in diagnosis and treatment among adult multidrug resistant tuberculosis patients in Yangon Regional Tuberculosis Center, Myanmar: a cross-sectional study. BMC Health Serv Res 2018; 18:878. [PMID: 30458776 PMCID: PMC6247709 DOI: 10.1186/s12913-018-3715-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/14/2018] [Indexed: 12/05/2022] Open
Abstract
Background Delays in diagnosis and treatment initiation may allow the emergence of new cases by transmission to the community, and is one of the challenges facing programme management of drug resistance in Myanmar. This study aimed to explore delays in diagnosis and treatment initiation, and associated factors among patients with multidrug-resistant tuberculosis. Methods A cross-sectional study was conducted at Yangon Regional Tuberculosis Centre, Myanmar. Data were collected by face-to-face interviews and treatment-card reviews of all adult patients who had registered and started treatment with the standard regimen from May to November, 2017. Delay time was categorized by using median cut-off and analyzed using SPSS version 23.0. Logistic regression analysis was performed to assess the relative impact of predictor variables on diagnosis and treatment delays. Results A total of 210 patients participated in this study. The median diagnosis delay was 9 days, IQR 3 (8–11) and 58.6% of the patients experienced a long diagnosis delay. Below middle school education (adjusted odds ratio [AOR] = 2.75, 95% CI = 1.22–6.21), non-permanent salaried employment (AOR = 3.03, 95% CI = 1.32–6.95), co-existing diabetes mellitus (AOR = 5.06, 95% CI = 1.97–13.01) and poor awareness (AOR = 2.99, 95% CI = 1.29–6.92) were independent predictors of long diagnosis delay. The median treatment delay was 13 days, IQR 9 (8–17) and 51% of the patients experienced long treatment delay. Age 31–50 years (AOR = 4.50, 95% CI = 1.47–13.97) and age > 50 years (AOR = 9.40, 95% CI = 2.55–34.83), history with MDR-TB patient (AOR = 3.16, 95% CI = 1.29–7.69), > 20 km away from a Regional TB Centre (AOR = 14.33, 95% CI = 1.91–107.64) and poor awareness (AOR = 4.62, 95% CI = 1.56–13.67) were independent predictors of long treatment delay. Conclusions Strengthening comprehensive health education, enhancing treatment adherence counseling, providing more Xpert MTB/RIF machines, expanding decentralized MDR-TB treatment centers, ensuring timely sputum transportation, provision of a patient support package immediately after confirmation, and strengthening contact-tracing for all household contacts with MDR-TB patients and active tuberculosis screening were the most effective ways to shorten delays in MDR-TB diagnosis and treatment initiation.
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Affiliation(s)
- Ye Minn Htun
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Yin Yin
- Regional Tuberculosis Center, Yangon, Myanmar
| | - Zaw Myint
- Regional Tuberculosis Center, Yangon, Myanmar
| | - Si Thu Aung
- National Tuberculosis Programme, Department of Public Health, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | | | | | - Udomsak Silachamroon
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Jaranit Kaewkungwal
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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13
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Ehsanul Huq KATM, Moriyama M, Zaman K, Chisti MJ, Long J, Islam A, Hossain S, Shirin H, Raihan MJ, Chowdhury S, Rahman MM. Health seeking behaviour and delayed management of tuberculosis patients in rural Bangladesh. BMC Infect Dis 2018; 18:515. [PMID: 30314453 PMCID: PMC6186095 DOI: 10.1186/s12879-018-3430-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 10/02/2018] [Indexed: 12/12/2022] Open
Abstract
Background Early diagnosis of tuberculosis (TB) and involvement of the public-private partnership are critical to eradicate TB. Patients need to receive proper treatment through the National Tuberculosis Control Programme (NTP). This study describes various predictors for health seeking behaviour of TB patients and health system delay made by the different health care providers. Methods A cross-sectional study was conducted in a public health facility of a rural area in Bangladesh. Newly diagnosed smear positive pulmonary TB (PTB) patients who were ≥ 15 years of age were sequentially enrolled in this study. The socio-demographic characteristics and proportion of health care utilization by the patients, and health system delay made by the health care providers were calculated. Multivariate analysis was conducted to determine the independent association of the risk factors with the time to seek medical care. Results Two hundred and eighty patients were enrolled in this study. Among them, 73.6% were male and 26.4% were female. A hundred percent of patients primarily sought treatment for their cough, 170 (60.7%) first consulted a non-qualified practitioner while 110 patients (39.3%) first consulted with qualified practitioners about their symptoms. Pharmacy contact was the highest (27.9%) among the non-qualified practitioners, and 58.9% non-qualified practitioners prescribed treatment without any laboratory investigation. The average health system delay was 68.5 days. Multiple logistic regressions revealed a significant difference between uneducated and educated patients (OR 2.33; CI 1.39–3.92), and qualified and non-qualified practitioners (OR 2.34; CI 1.38–3.96) to be independent predictors of health system delay. Conclusions Compared to men, fewer women sought TB treatment. Uneducated patients and questionably qualified practitioners made for a longer delay in detecting TB. Increasing public health awareness and improving health seeking behavior of females and uneducated patients, and greater participation of the qualified practitioners in the NTP are highly recommended. Electronic supplementary material The online version of this article (10.1186/s12879-018-3430-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- K A T M Ehsanul Huq
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Kasumi 1-2-3 Minami-ku, Hiroshima, 734-8553, Japan.
| | - Michiko Moriyama
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Kasumi 1-2-3 Minami-ku, Hiroshima, 734-8553, Japan
| | - Khalequ Zaman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | | | | | - Shahed Hossain
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Habiba Shirin
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Sajeda Chowdhury
- Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Md Moshiur Rahman
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Kasumi 1-2-3 Minami-ku, Hiroshima, 734-8553, Japan
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14
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Shewade HD, Shringarpure KS, Parmar M, Patel N, Kuriya S, Shihora S, Ninama N, Gosai N, Khokhariya R, Popat C, Thanki H, Modi B, Dave P, Baxi RK, Kumar AMV. Delay and attrition before treatment initiation among MDR-TB patients in five districts of Gujarat, India. Public Health Action 2018; 8:59-65. [PMID: 29946521 DOI: 10.5588/pha.18.0003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/24/2018] [Indexed: 12/26/2022] Open
Abstract
Setting: Gujarat, a state in west India. Background: Although treatment initiation has been improving among patients diagnosed with multidrug-resistant tuberculosis (MDR-TB) in programme settings, it has still not reached 100%. Objectives: To determine pre-treatment attrition (not initiated on treatment within 6 months of diagnosis), delay in treatment initiation (>7 days from diagnosis) and associated factors among MDR-TB patients diagnosed in 2014 in five selected districts served by two genotypic drug susceptibility testing (DST) facilities and a drug-resistant TB centre in Gujarat. Design: This was a retrospective cohort study involving record review. Results: Among 257 MDR-TB patients, pre-treatment attrition was seen in 20 (8%, 95%CI 5-12). Patients with 'follow-up sputum-positive' as their DST criterion and sputum smear microscopy status 'unknown' at the time of referral for DST were less likely to be initiated on treatment. The median delay to treatment initiation was 8 days (interquartile range 6-13). Patients referred for DST from medical colleges were more likely to face delays in treatment initiation. Conclusion: The Gujarat TB programme is performing well in initiating laboratory-confirmed MDR-TB patients on treatment. However, there is further scope for reducing delay.
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Affiliation(s)
- H D Shewade
- International Union Against Tuberculosis and Lung Disease, South-East Asia Office, New Delhi, India.,The Union, Paris, France
| | - K S Shringarpure
- Department of Preventive and Social Medicine, Medical College, Vadodara, India
| | - M Parmar
- World Health Organization Country Office for India, New Delhi, India
| | - N Patel
- Department of Preventive and Social Medicine, Medical College, Vadodara, India
| | - S Kuriya
- Department of Preventive and Social Medicine, Medical College, Vadodara, India
| | - S Shihora
- Department of Preventive and Social Medicine, Medical College, Vadodara, India
| | - N Ninama
- Department of Preventive and Social Medicine, Medical College, Vadodara, India
| | - N Gosai
- Department of Preventive and Social Medicine, Medical College, Vadodara, India
| | - R Khokhariya
- Department of Preventive and Social Medicine, Medical College, Vadodara, India
| | - C Popat
- Department of Preventive and Social Medicine, Medical College, Vadodara, India
| | - H Thanki
- World Health Organization Country Office for India, New Delhi, India
| | - B Modi
- Department of Community Medicine, Gujarat Medical Education & Research Society Medical College and Hospital, Gandhinagar, India
| | - P Dave
- Department of Health and Family Welfare, Government of Gujarat, Gandhinagar, India
| | - R K Baxi
- Department of Preventive and Social Medicine, Medical College, Vadodara, India
| | - A M V Kumar
- International Union Against Tuberculosis and Lung Disease, South-East Asia Office, New Delhi, India.,The Union, Paris, France
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15
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Nathavitharana RR, Daru P, Barrera AE, Mostofa Kamal SM, Islam S, Ul-Alam M, Sultana R, Rahman M, Hossain MS, Lederer P, Hurwitz S, Chakraborty K, Kak N, Tierney DB, Nardell E. FAST implementation in Bangladesh: high frequency of unsuspected tuberculosis justifies challenges of scale-up. Int J Tuberc Lung Dis 2018; 21:1020-1025. [PMID: 28826452 DOI: 10.5588/ijtld.16.0794] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
SETTING National Institute of Diseases of the Chest and Hospital, Dhaka; Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka; and Chittagong Chest Disease Hospital, Chittagong, Bangladesh. OBJECTIVE To present operational data and discuss the challenges of implementing FAST (Find cases Actively, Separate safely and Treat effectively) as a tuberculosis (TB) transmission control strategy. DESIGN FAST was implemented sequentially at three hospitals. RESULTS Using Xpert® MTB/RIF, 733/6028 (12.2%, 95%CI 11.4-13.0) patients were diagnosed with unsuspected TB. Patients with a history of TB who were admitted with other lung diseases had more than twice the odds of being diagnosed with unsuspected TB as those with no history of TB (OR 2.6, 95%CI 2.2-3.0, P < 0.001). Unsuspected multidrug-resistant TB (MDR-TB) was diagnosed in 89/1415 patients (6.3%, 95%CI 5.1-7.7). Patients with unsuspected TB had nearly five times the odds of being diagnosed with MDR-TB than those admitted with a known TB diagnosis (OR 4.9, 95%CI 3.1-7.6, P < 0.001). Implementation challenges include staff shortages, diagnostic failure, supply-chain issues and reliance on external funding. CONCLUSION FAST implementation revealed a high frequency of unsuspected TB in hospitalized patients in Bangladesh. Patients with a previous history of TB have an increased risk of being diagnosed with unsuspected TB. Ensuring financial resources, stakeholder engagement and laboratory capacity are important for sustainability and scalability.
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Affiliation(s)
- R R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - P Daru
- University Research Co., Washington DC
| | - A E Barrera
- Faculty of Nursing Science, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S M Mostofa Kamal
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - S Islam
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - M Ul-Alam
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - R Sultana
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - M Rahman
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - Md S Hossain
- National Institute of Diseases of the Chest Hospital, Dhaka, Bangladesh
| | - P Lederer
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | - S Hurwitz
- Division of Biostatistics, Brigham and Women's Hospital Center for Clinical Investigation, Boston, Massachusetts
| | | | - N Kak
- University Research Co., Washington DC
| | - D B Tierney
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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16
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Dale KD, Tay EL, Trauer JM, Trevan PG, Denholm JT. Comparing tuberculosis management under public and private healthcare providers: Victoria, Australia, 2002-2015. BMC Infect Dis 2017; 17:324. [PMID: 28468641 PMCID: PMC5415803 DOI: 10.1186/s12879-017-2421-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/26/2017] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Private healthcare providers are important to tuberculosis (TB) management globally, although internationally there are reports of suboptimal management and disparities in treatment commencement in the private sector. We compared the management of TB patients receiving private versus public healthcare in Victoria, an industrialised setting with low tuberculosis (TB) incidence. METHODS Retrospective cohort study: 2002-2015. Private healthcare provision was included as an independent variable in several multivariate logistic and Cox proportional hazard regression models that assessed a range of outcome variables, encompassing treatment commencement delays, management and treatment outcomes. RESULTS Of 5106 patients, 275 (5.4%) exclusively saw private providers, and 4714 (92.32%) public. Private care was associated with a shorter delay to presentation (HR 1.36, p = 0.065, 95% CI 1.02-2.00). Private patients were less likely to have genotypic testing (OR 0.66, p = 0.009, 95% CI 0.48-0.90), those with pulmonary involvement were less likely to have a sputum smear (OR 0.52, p = 0.011, 95% CI 0.31-0.86) and provided samples were less likely to be positive (OR 0.54, p = 0.070, 95% CI 0.27-1.05). Private patients with extrapulmonary TB were less likely to have a smear sample (OR 0.7, 95% CI 0.48-0.90, p = 0.009) and radiological abnormalities (OR 0.71, p = 0.070, 95% CI 0.27-1.05). Treatment commencement delays from presentation were comparable for cases with pulmonary involvement and extrapulmonary TB, although public extrapulmonary TB patients received radiological examinations slightly earlier than private patients (HR 0.79, p = 0.043, 95% CI 0.63-0.99) and public patients with pulmonary involvement from high burden settings commenced treatment following an abnormal CXR more promptly than their private counterparts (HR 0.41, p = 0.011, 95% CI 0.21-0.81). Private patients were more likely to receive <4 first-line medications (OR 2.17, p = 0.001, 95% CI 1.36-3.46), but treatment outcomes were comparable between sectors. CONCLUSIONS The differences we identified are likely to reflect differing case-mix as well as clinician practice. Sputum smear status was an important covariable in our analysis; with its addition we found no significant disparity in the health-system delay to treatment commencement between sectors. Our study highlights the importance of TB programs engaging with private providers, enabling comprehensive data collection that is necessary for thorough and true comparison of TB management and optimisation of care.
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Affiliation(s)
- Katie D Dale
- Victorian Tuberculosis Program, The Peter Doherty Institute for Infection and Immunity, Victoria, Australia.
| | - Ee Laine Tay
- Department of Health and Human Services, Victoria, Australia
| | - James M Trauer
- Victorian Tuberculosis Program, The Peter Doherty Institute for Infection and Immunity, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Peter G Trevan
- Victorian Tuberculosis Program, The Peter Doherty Institute for Infection and Immunity, Victoria, Australia
| | - Justin T Denholm
- Victorian Tuberculosis Program, The Peter Doherty Institute for Infection and Immunity, Victoria, Australia
- Department of Microbiology and Immunology, The University of Melbourne, Victoria, Australia
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17
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Xu Z, Xiao T, Li Y, Yang K, Tang Y, Bai L. Reasons for Non-Enrollment in Treatment among Multi-Drug Resistant Tuberculosis Patients in Hunan Province, China. PLoS One 2017; 12:e0170718. [PMID: 28114320 PMCID: PMC5257000 DOI: 10.1371/journal.pone.0170718] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/09/2017] [Indexed: 11/19/2022] Open
Abstract
In 2015, only 49% of notified multi-drug resistant tuberculosis (MDR-TB) patients in China were estimated to have initiated treatment, compared with 90% of those worldwide. A case-control study was conducted to identify the reasons for non-enrollment in treatment among MDR-TB patients in Hunan province, China. All detected MDR-TB patients registered in designated MDR-TB hospitals in Hunan province from 2011 to 2014 were included and followed until June 2015 to determine their treatment status. Approximately 33.8% (482/1425) of patients were not enrolled in standardized treatment. Factors associated with lower enrollment rate were: age greater than 60 years, living in rural area, unemployed or occupation unreported. Of those who were not enrolled in MDR-TB treatment, the primary reasons for non-enrollment included economic hardship (23.0%), out-migration for work (18.0%), concerns about work and studies (13.7%), and the belief that they were cured after undergoing drug-sensitive TB treatment (12.4%). Therefore, comprehensive strategies targeting priority populations, especially those enhancing treatment affordability and availability, need to be implemented to improve MDR-TB control.
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Affiliation(s)
- Zuhui Xu
- Department of tuberculosis control, Tuberculosis Control Institute of Hunan Province, Changsha city, Hunan province, China
| | - Tao Xiao
- Department of tuberculosis control, Tuberculosis Control Institute of Hunan Province, Changsha city, Hunan province, China
| | - Yanhong Li
- Department of tuberculosis control, Tuberculosis Control Institute of Hunan Province, Changsha city, Hunan province, China
| | - Kunyun Yang
- Department of MDR-TB internal medicine, Hunan Chest hospital, Changsha city, Hunan province, China
| | - Yi Tang
- Department of tuberculosis control, Tuberculosis Control Institute of Hunan Province, Changsha city, Hunan province, China
| | - Liqiong Bai
- Department of director’s office, Tuberculosis Control Institute of Hunan Province, Changsha city, Hunan province, China
- * E-mail:
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18
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Mohanan M, Goldhaber-Fiebert JD, Giardili S, Vera-Hernández M. Providers' knowledge of diagnosis and treatment of tuberculosis using vignettes: evidence from rural Bihar, India. BMJ Glob Health 2016; 1:e000155. [PMID: 28588984 PMCID: PMC5321391 DOI: 10.1136/bmjgh-2016-000155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/03/2016] [Accepted: 11/13/2016] [Indexed: 12/04/2022] Open
Abstract
Background Almost 25% of all new cases of tuberculosis (TB) worldwide are in India, where drug resistance and low quality of care remain key challenges. Methods We conducted an observational, cross-sectional study of healthcare providers' knowledge of diagnosis and treatment of TB in rural Bihar, India, from June to September 2012. Using data from vignette-based interviews with 395 most commonly visited healthcare providers in study areas, we scored providers' knowledge and used multivariable regression models to examine their relationship to providers' characteristics. Findings 80% of 395 providers had no formal medical qualifications. Overall, providers demonstrated low levels of knowledge: 64.9% (95% CI 59.8% to 69.8%) diagnosed correctly, and 21.7% (CI 16.8% to 27.1%) recommended correct treatment. Providers seldom asked diagnostic questions such as fever (31.4%, CI 26.8% to 36.2%) and bloody sputum (11.1%, CI 8.2% to 14.7%), or results from sputum microscopy (20.0%, CI: 16.2% to 24.3%). After controlling for whether providers treat TB, MBBS providers were not significantly different, from unqualified providers or those with alternative medical qualifications, on knowledge score or offering correct treatment. MBBS providers were, however, more likely to recommend referrals relative to complementary medicine and unqualified providers (23.2 and 37.7 percentage points, respectively). Interpretation Healthcare providers in rural areas in Bihar, India, have low levels of knowledge regarding TB diagnosis and treatment. Our findings highlight the need for policies to improve training, incentives, task shifting and regulation to improve knowledge and performance of existing providers. Further, more research is needed on the incentives providers face and the role of information on quality to help patients select providers who offer higher quality care.
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Affiliation(s)
- Manoj Mohanan
- Sanford School of Public Policy, Duke Global Health Institute, and Department of Economics, Duke University, Durham, North Carolina, USA
| | - Jeremy D Goldhaber-Fiebert
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, USA
| | - Soledad Giardili
- School of Economics and Finance, Queen Mary University of London, London, UK
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Nair D, Navneethapandian PD, Tripathy JP, Harries AD, Klinton JS, Watson B, Sivaramakrishnan GN, Reddy DS, Murali L, Natrajan M, Swaminathan S. Impact of rapid molecular diagnostic tests on time to treatment initiation and outcomes in patients with multidrug-resistant tuberculosis, Tamil Nadu, India. Trans R Soc Trop Med Hyg 2016; 110:534-541. [DOI: 10.1093/trstmh/trw060] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 09/09/2016] [Indexed: 11/13/2022] Open
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20
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Yanogo PK, Schmit JL, Fresse AS, Andrejak C, Castelain S, Adjodah C, Ganry O. Factors associated with delayed screening of contacts of tuberculosis cases in the Somme, France. Rev Epidemiol Sante Publique 2016; 64:247-53. [PMID: 27594695 DOI: 10.1016/j.respe.2016.03.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 02/05/2016] [Accepted: 03/11/2016] [Indexed: 11/16/2022] Open
Abstract
AIM To analyze the factors associated with the time to initiating tuberculosis contact investigations in the Somme department, France. METHODS All reported tuberculosis cases and all their contacts screened between 2007 and 2011 were retrospectively included. Univariate and multivariate analyses were conducted to determine the factors associated with a "system delay"≤1 month and a "contact delay"≤0 days. RESULTS The mean time between the mandatory notification of a case of tuberculosis and the date set for the contact's screening (system delay) was 35.3 days and the average time between that date and when the contact was actually screened (contact delay) was 12.5 days. In multivariate analysis, a smear-positive sputum sample (OR: 3.68; 95% CI: 1.63-8.30) and a diagnosis at the university hospital (OR: 2.61; 95% CI: 1.14-5.96) were significantly associated with a system delay≤1 month. A smear-positive sputum sample (OR: 1.35; 95% CI: 1.08-1.69), male gender (OR: 1.21; 95% CI: 1.01-1.49), being born in a foreign country (OR: 1.31; 95% CI: 1.02-1.69), being a family member (OR: 1.37; 95% CI: 1.05-1.77), or being another type of close contact of the case (OR: 2.47; 95% CI: 1.81-3.36) were significantly associated with a contact delay≤0 days. CONCLUSION System and contact delays were longer than recommended, and the factors associated with the lengthening of these delays need to be taken into account.
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Affiliation(s)
- P K Yanogo
- Amiens University Hospital, Center for Prevention of Communicable Diseases, hôpital Sud, avenue Réné-Laennec, 80480 Amiens, France.
| | - J L Schmit
- Amiens University Hospital, Department of Infectious Diseases, hôpital Sud, avenue Réné-Laennec, 80480 Amiens, France
| | - A S Fresse
- Amiens University Hospital, Center for Prevention of Communicable Diseases, hôpital Sud, avenue Réné-Laennec, 80480 Amiens, France
| | - C Andrejak
- Amiens University Hospital, Respiratory Intensive Care Unit, hôpital Sud, avenue Réné-Laennec, 80480 Amiens, France
| | - S Castelain
- Amiens University Hospital, Department of Virology, hôpital Sud, avenue Réné-Laennec, 80480 Amiens, France
| | - C Adjodah
- Amiens University Hospital, Department of Infectious Diseases, hôpital Sud, avenue Réné-Laennec, 80480 Amiens, France
| | - O Ganry
- Amiens University hospital, Cancer Registry of the Somme-Inserm EA-DGS EA 4666 Epidemiology and Public Health Service, hôpital Sud, avenue Réné-Laennec, 80480 Amiens, France
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Charambira K, Ade S, Harries AD, Ncube RT, Zishiri C, Sandy C, Mutunzi H, Takarinda K, Owiti P, Mafaune P, Chonzi P. Diagnosis and treatment of TB patients with rifampicin resistance detected using Xpert(®) MTB/RIF in Zimbabwe. Public Health Action 2016; 6:122-8. [PMID: 27358806 DOI: 10.5588/pha.16.0005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 02/18/2016] [Indexed: 11/10/2022] Open
Abstract
SETTING In Zimbabwe, there are concerns about the management of tuberculosis (TB) patients with rifampicin (RMP) resistance diagnosed using Xpert(®) MTB/RIF. OBJECTIVE To assess linkages between diagnosis and treatment for these patients in Harare and Manicaland provinces in 2014. DESIGN A retrospective cohort study. RESULTS Of 20 329 Xpert assays conducted, 90% were successful, 11% detected Mycobacterium tuberculosis and 4.5% showed RMP resistance. Of 77 patients with RMP-resistant TB diagnosed by Xpert, 70% had samples sent to the reference laboratory for culture and drug susceptibility testing (CDST); 53% of the samples arrived. In 21% the samples showed M. tuberculosis growth, and in 17% the DST results were recorded, all of which confirmed RMP resistance. Of the 77 patients, 34 (44%) never started treatment for multidrug-resistant (MDR) TB, with documented reasons being death, loss to follow-up and incorrect treatment. Of the 43 patients who started MDR-TB treatment, 12 (71%) in Harare and 17 (65%) in Manicaland started within 2 weeks of diagnosis. CONCLUSION Xpert has been rolled out successfully in two Zimbabwe provinces. However, the process of confirming CDST for Xpert-diagnosed RMP-resistant TB works poorly, and many patients are either delayed or never initiate MDR-TB treatment. These shortfalls must be addressed at the programmatic level.
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Affiliation(s)
- K Charambira
- International Union Against Tuberculosis and Lung Disease (The Union), Harare, Zimbabwe
| | - S Ade
- The Union, Paris, France ; National Tuberculosis Programme, Cotonou, Benin
| | - A D Harries
- The Union, Paris, France ; London School of Hygiene & Tropical Medicine, London, UK
| | - R T Ncube
- International Union Against Tuberculosis and Lung Disease (The Union), Harare, Zimbabwe
| | - C Zishiri
- International Union Against Tuberculosis and Lung Disease (The Union), Harare, Zimbabwe
| | - C Sandy
- Ministry of Health and Child Care, Harare, Zimbabwe
| | - H Mutunzi
- Ministry of Health and Child Care, Harare, Zimbabwe
| | - K Takarinda
- The Union, Paris, France ; Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - P Mafaune
- Ministry of Health and Child Care, Harare, Zimbabwe
| | - P Chonzi
- Harare City Health Department, Harare, Zimbabwe
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