1
|
Shah HD, Chaudhary S, Desai B, Patel J, Yasobant S, Bhavsar P, Saha S, Sinha AK, Saxena D, Patel Y, Modi B. Exploring private sector perspectives on barriers and facilitators in availing tuberculosis care cascade services: a qualitative study from the Indian state. BMC PRIMARY CARE 2024; 25:5. [PMID: 38166734 PMCID: PMC10759326 DOI: 10.1186/s12875-023-02244-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION The private sector plays an important role in tuberculosis (TB) elimination by providing access to quality TB care services like diagnosis and treatment, advocacy for preventive measures, innovation to address challenges in TB elimination, vaccines etc. The study aims to understand the perspectives of private practitioners on patients' TB care cascade to reinforce existing interventions by assuring the quality of care to TB patients. METHODS The study utilized a qualitative design through in-depth interviews of private practitioners and was conducted in Ranchi and Purbi Singhbhum District of Jharkhand State from March-August 2021. The pilot-tested, semi-structured, open-ended interview guide questionnaire collected information from private practitioners on various aspects of the TB care cascade. The data from the provider interviews were transcribed into multiple codes and themes on the TB program. An inductive analysis was carried out with a focus on content credibility to eliminate bias. Ethical approval was received from the Institutional Ethics Committee of the Indian Institute of Public Health Gandhinagar (IIPHG), India. Written consent was taken from the private practitioners involved in the study. RESULT In-depth interviews of 17 private practitioners reveal various factors contributing to delays in TB care cascades, especially delay in access to TB diagnosis and TB Care, delay in providing treatment once after diagnosis and poor adherence to the TB treatment. According to the perception of private practitioners, there was an array of client, provider and system side factors affecting the TB care cascade gaps positively and negatively. Positive aspects mainly emerged from interviews: strong governance, consistent supply chain management, innovative PPP models and financial schemes reducing out-of-pocket expenditure (OOPE). Various factors affecting the TB care cascade negatively include awareness among the patient, socio-economic status, approach and decision-making power of providers, adverse effects of drugs, staff capacity building, etc. CONCLUSIONS: Engaging private practitioner in TB elimination efforts is critical to achieving global targets and reducing the burden of TB. The study helps to determine geography-specific barriers and facilitators of the TB care cascade to achieve the aim of providing universal access to TB healthcare with the inclusion of private practitioners.
Collapse
Affiliation(s)
- Harsh D Shah
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Opp. Air Force Head Quarters, Nr. Lekawada, Gandhinagar, Gujarat, 382042, India.
| | - Shalu Chaudhary
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Opp. Air Force Head Quarters, Nr. Lekawada, Gandhinagar, Gujarat, 382042, India
| | - Bharat Desai
- State Health System Resource Center, Government of Gujarat, Gujarat, India
| | - Jay Patel
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Opp. Air Force Head Quarters, Nr. Lekawada, Gandhinagar, Gujarat, 382042, India
| | - Sandul Yasobant
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Opp. Air Force Head Quarters, Nr. Lekawada, Gandhinagar, Gujarat, 382042, India
- School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, India
| | - Priya Bhavsar
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Opp. Air Force Head Quarters, Nr. Lekawada, Gandhinagar, Gujarat, 382042, India
| | - Somen Saha
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Opp. Air Force Head Quarters, Nr. Lekawada, Gandhinagar, Gujarat, 382042, India
- State Health System Resource Center, Government of Gujarat, Gujarat, India
| | - Anish K Sinha
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Opp. Air Force Head Quarters, Nr. Lekawada, Gandhinagar, Gujarat, 382042, India
| | - Deepak Saxena
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Opp. Air Force Head Quarters, Nr. Lekawada, Gandhinagar, Gujarat, 382042, India
- State Health System Resource Center, Government of Gujarat, Gujarat, India
| | - Yogesh Patel
- John Snow India Pvt. Ltd. (JSIPL), New Delhi, India
| | - Bhavesh Modi
- Department of Community & Family Medicine, All India Institute of Medical Sciences, Rajkot, Gujarat, India
| |
Collapse
|
2
|
Yasobant S, Shah H, Bhavsar P, Patel J, Saha S, Sinha A, Puwar T, Patel Y, Saxena D. Why and where?-Delay in Tuberculosis care cascade: A cross-sectional assessment in two Indian states, Jharkhand, Gujarat. Front Public Health 2023; 11:1015024. [PMID: 36778538 PMCID: PMC9911525 DOI: 10.3389/fpubh.2023.1015024] [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: 08/09/2022] [Accepted: 01/02/2023] [Indexed: 01/28/2023] Open
Abstract
Tuberculosis (TB) is the second leading cause of death due to infectious diseases globally, and delay in the TB care cascade is reported as one of the major challenges in achieving the goals of the TB control programs. The main aim of this study was to investigate the delay and responsible factors for the delay in the various phases of care cascade among TB patients in two Indian states, Jharkhand and Gujarat. This cross-sectional study was conducted among 990 TB patients from the selected tuberculosis units (TUs) of two states. This study adopted a mixed-method approach for the data collection. The study targeted a diverse profile of TB patients, such as drug-sensitive TB (DSTB), drug resistance TB (DRTB), pediatric TB, and extra-pulmonary TB. It included both public and private sector patients. The study findings suggested that about 41% of pulmonary and 51% of extra-pulmonary patients reported total delay. Delay in initial formal consultation is most common, followed by a delay in diagnosis and treatment initiation in pulmonary patients. While in extra-pulmonary patients, delay in treatment initiation is most common, followed by the diagnosis and first formal consultation. DR-TB patients are more prone to total delay and delay in the treatment initiation among pulmonary patients. Addiction, co-morbidity and awareness regarding monetary benefits available for TB patients contribute significantly to the total delay among pulmonary TB patients. There were system-side factors like inadequacy in active case findings, poor infrastructure, improper adverse drug reaction management and follow-up, resulting in delays in the TB care cascade in different phases. Thus, the multi-disciplinary strategies covering the gambit of both system and demand side attributes are recommended to minimize the delays in the TB care cascade.
Collapse
Affiliation(s)
- Sandul Yasobant
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India,School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, India
| | - Harsh Shah
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India
| | - Priya Bhavsar
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India
| | - Jay Patel
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India
| | - Somen Saha
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India
| | - Anish Sinha
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India
| | - Tapasvi Puwar
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India
| | | | - Deepak Saxena
- Department of Public Health Science, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, India,School of Epidemiology and Public Health, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, India,*Correspondence: Deepak Saxena ✉
| |
Collapse
|
3
|
Engel N, Ochodo EA, Karanja PW, Schmidt BM, Janssen R, Steingart KR, Oliver S. Rapid molecular tests for tuberculosis and tuberculosis drug resistance: a qualitative evidence synthesis of recipient and provider views. Cochrane Database Syst Rev 2022; 4:CD014877. [PMID: 35470432 PMCID: PMC9038447 DOI: 10.1002/14651858.cd014877.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Programmes that introduce rapid molecular tests for tuberculosis and tuberculosis drug resistance aim to bring tests closer to the community, and thereby cut delay in diagnosis, ensure early treatment, and improve health outcomes, as well as overcome problems with poor laboratory infrastructure and inadequately trained personnel. Yet, diagnostic technologies only have an impact if they are put to use in a correct and timely manner. Views of the intended beneficiaries are important in uptake of diagnostics, and their effective use also depends on those implementing testing programmes, including providers, laboratory professionals, and staff in health ministries. Otherwise, there is a risk these technologies will not fit their intended use and setting, cannot be made to work and scale up, and are not used by, or not accessible to, those in need. OBJECTIVES To synthesize end-user and professional user perspectives and experiences with low-complexity nucleic acid amplification tests (NAATs) for detection of tuberculosis and tuberculosis drug resistance; and to identify implications for effective implementation and health equity. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, PsycInfo and Science Citation Index Expanded databases for eligible studies from 1 January 2007 up to 20 October 2021. We limited all searches to 2007 onward because the development of Xpert MTB/RIF, the first rapid molecular test in this review, was completed in 2009. SELECTION CRITERIA We included studies that used qualitative methods for data collection and analysis, and were focused on perspectives and experiences of users and potential users of low-complexity NAATs to diagnose tuberculosis and drug-resistant tuberculosis. NAATs included Xpert MTB/RIF, Xpert MTB/RIF Ultra, Xpert MTB/XDR, and the Truenat assays. Users were people with presumptive or confirmed tuberculosis and drug-resistant tuberculosis (including multidrug-resistant (MDR-TB)) and their caregivers, healthcare providers, laboratory technicians and managers, and programme officers and staff; and were from any type of health facility and setting globally. MDR-TB is tuberculosis caused by resistance to at least rifampicin and isoniazid, the two most effective first-line drugs used to treat tuberculosis. DATA COLLECTION AND ANALYSIS We used a thematic analysis approach for data extraction and synthesis, and assessed confidence in the findings using GRADE CERQual approach. We developed a conceptual framework to illustrate how the findings relate. MAIN RESULTS We found 32 studies. All studies were conducted in low- and middle-income countries. Twenty-seven studies were conducted in high-tuberculosis burden countries and 21 studies in high-MDR-TB burden countries. Only one study was from an Eastern European country. While the studies covered a diverse use of low-complexity NAATs, in only a minority of studies was it used as the initial diagnostic test for all people with presumptive tuberculosis. We identified 18 review findings and grouped them into three overarching categories. Critical aspects users value People with tuberculosis valued reaching diagnostic closure with an accurate diagnosis, avoiding diagnostic delays, and keeping diagnostic-associated cost low. Similarly, healthcare providers valued aspects of accuracy and the resulting confidence in low-complexity NAAT results, rapid turnaround times, and keeping cost to people seeking a diagnosis low. In addition, providers valued diversity of sample types (for example, gastric aspirate specimens and stool in children) and drug resistance information. Laboratory professionals appreciated the improved ease of use, ergonomics, and biosafety of low-complexity NAATs compared to sputum microscopy, and increased staff satisfaction. Challenges reported to realizing those values People with tuberculosis and healthcare workers were reluctant to test for tuberculosis (including MDR-TB) due to fears, stigma, or cost concerns. Thus, low-complexity NAAT testing is not implemented with sufficient support or discretion to overcome barriers that are common to other approaches to testing for tuberculosis. Delays were reported at many steps of the diagnostic pathway owing to poor sample quality; difficulties with transporting specimens; lack of sufficient resources; maintenance of low-complexity NAATs; increased workload; inefficient work and patient flows; over-reliance on low-complexity NAAT results in lieu of clinical judgement; and lack of data-driven and inclusive implementation processes. These challenges were reported to lead to underutilization. Concerns for access and equity The reported concerns included sustainable funding and maintenance and equitable use of resources to access low-complexity NAATs, as well as conflicts of interest between donors and people implementing the tests. Also, lengthy diagnostic delays, underutilization of low-complexity NAATs, lack of tuberculosis diagnostic facilities in the community, and too many eligibility restrictions hampered access to prompt and accurate testing and treatment. This was particularly the case for vulnerable groups, such as children, people with MDR-TB, or people with limited ability to pay. We had high confidence in most of our findings. AUTHORS' CONCLUSIONS Low-complexity diagnostics have been presented as a solution to overcome deficiencies in laboratory infrastructure and lack of skilled professionals. This review indicates this is misleading. The lack of infrastructure and human resources undermine the added value new diagnostics of low complexity have for recipients and providers. We had high confidence in the evidence contributing to these review findings. Implementation of new diagnostic technologies, like those considered in this review, will need to tackle the challenges identified in this review including weak infrastructure and systems, and insufficient data on ground level realities prior and during implementation, as well as problems of conflicts of interest in order to ensure equitable use of resources.
Collapse
Affiliation(s)
- Nora Engel
- Department of Health, Ethics & Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Eleanor A Ochodo
- Centre for Evidence-based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Bey-Marrié Schmidt
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Ricky Janssen
- Department of Health, Ethics & Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sandy Oliver
- EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London, London, UK
- Africa Centre for Evidence, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
| |
Collapse
|
4
|
Yasobant S, Bhavsar P, Kalpana P, Memon F, Trivedi P, Saxena D. Contributing Factors in the Tuberculosis Care Cascade in India: A Systematic Literature Review. Risk Manag Healthc Policy 2021; 14:3275-3286. [PMID: 34408513 PMCID: PMC8364383 DOI: 10.2147/rmhp.s322143] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/22/2021] [Indexed: 12/27/2022] Open
Abstract
Tuberculosis (TB) care cascade is a recently evolved care model for patient retention across the sequential stages of care for a successful treatment outcome. The care cascade is multi-folded and complex in setting where the health system is reforming for its resilience. India, one of the countries with the highest burden of tuberculosis mortality and morbidity, is not an exception to this complexity. With the diverse challenges in the Indian health system and societal diversity, it is essential to understand the factors contributing to this TB care cascade. Thus, this study aims to map all the contributing factors to the TB care cascade in India. Further, it also captures the different patterns of factors explored so far in different countries’ regions. This systematic literature review was conducted between October 2020 and February 2021 in India using PubMed databases, Web of Science, and Google Scholar. Two reviewers extracted the data from eligible studies to summarize and tabulate important findings. Data were extracted and tabulated for study design, location of the study, type of TB patients, methodological approach, system side challenges, and demand-side challenges in the study’s findings. Out of 692 initial hits from the literature search, 28 studies were finally included to synthesize evidence in this review as per the inclusion and exclusion criteria. This review provides an insight into different factors such as the system-side (health workforce, institutional) and the demand-side (individual, societal) contributing towards the care cascade. The prime factors reflected in most of the studies were socio-economic condition, disease awareness, myths/beliefs, addictions among the demand-side factors and accessibility, the attitude of the healthcare staff, delay in referral for diagnosis among the system-side factors. The accountability for addressing these diverse factors is recommended to close the gaps in the TB care cascade.
Collapse
Affiliation(s)
- Sandul Yasobant
- Department of Epidemiology, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, 382042, India.,Center for One Health Education, Research, and Development (COHERD), Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, 382042, India
| | - Priya Bhavsar
- Department of Epidemiology, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, 382042, India
| | - Pachillu Kalpana
- Department of Epidemiology, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, 382042, India
| | - Farjana Memon
- Department of Epidemiology, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, 382042, India
| | - Poonam Trivedi
- Department of Epidemiology, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, 382042, India
| | - Deepak Saxena
- Department of Epidemiology, Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, 382042, India.,Center for One Health Education, Research, and Development (COHERD), Indian Institute of Public Health Gandhinagar (IIPHG), Gandhinagar, 382042, India.,Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (DMIMS), Wardha, 442004, India
| |
Collapse
|
5
|
Ranganath R, Shewade HD, Bahadur AK, Naik V, Nagaraja SB, Kumar AMV, Peerapur BV, Babu S, Somshekhar N, Singarajipur A. Uptake of universal drug susceptibility testing among people with TB in a south Indian district: How are we faring? Trans R Soc Trop Med Hyg 2021; 116:43-49. [PMID: 33823556 DOI: 10.1093/trstmh/trab051] [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: 11/05/2020] [Revised: 02/09/2021] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND India implements universal drug susceptibility testing (UDST) using rapid genotypic tests (cartridge-based nucleic acid amplification test CBNAAT - and line probe assay - LPA). to bridge the gap of diagnosis of multidrug/rifampicin-resistant TB. There is limited evidence assessing the implementation of UDST in India. We assessed the implementation among people with pulmonary TB notified from public facilities in October 2019 from Raichur (Karnataka), India. METHODS A cohort study involving secondary data in routine programme settings was conducted. All people with TB underwent a rapid genotypic DST for rifampicin resistance followed by first line-LPA (FL-LPA) if sensitive and second line-LPA (SL-LPA) if resistant. RESULTS Of 217 people, 15.7% (n=34) did not undergo rapid genotypic DST. Of 135 who were rifampicin-sensitive detected on CBNAAT, 68.1% (n=92) underwent FL-LPA, and out of the six rifampicin-resistant cases, 66.7% (n=4) underwent SL-LPA. Overall, 65.4% (142/217) completed the UDST algorithm. Children (aged <15 y) and people with bacteriological non-confirmation on microscopy were less likely to undergo rapid genotypic DST. Of 183 patients who underwent both rapid genotypic DST and sputum smear microscopy, 150 were bacteriologically confirmed and, of them, 9 (6%) were 'rapid DST-negative'. CONCLUSION We found gaps at various steps. There were a significant number of 'rapid DST-negative, smear-positive' patients.
Collapse
Affiliation(s)
- Rajani Ranganath
- Department of Microbiology , Raichur Institute of Medical Sciences (RIMS), Raichur 584102, India
| | - Hemant Deepak Shewade
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,Operational Research Unit, The Union South-East Asia Office, New Delhi, India
| | - Abdul K Bahadur
- Department of Microbiology , Raichur Institute of Medical Sciences (RIMS), Raichur 584102, India
| | - Venkatesh Naik
- Department of Microbiology , Raichur Institute of Medical Sciences (RIMS), Raichur 584102, India
| | | | - Ajay M V Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,Operational Research Unit, The Union South-East Asia Office, New Delhi, India.,Department of Community Medicine, Yenepoya Medical College, Yenapoya (Deemed to be Universty) Mangaluru, India
| | - Basavaraj V Peerapur
- Department of Microbiology , Raichur Institute of Medical Sciences (RIMS), Raichur 584102, India
| | | | | | | |
Collapse
|
6
|
Ismail IM, Kibballi Madhukeshwar A, Naik PR, Nayarmoole BM, Satyanarayana S. Magnitude and Reasons for Gaps in Tuberculosis Diagnostic Testing and Treatment Initiation: An Operational Research Study from Dakshina Kannada, South India. J Epidemiol Glob Health 2020; 10:326-336. [PMID: 32959619 PMCID: PMC7758854 DOI: 10.2991/jegh.k.200516.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 03/30/2020] [Indexed: 11/30/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Imaad Mohammed Ismail
- Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed to be University), Mangalore, India
| | | | - Poonam Ramesh Naik
- Department of Community Medicine, Yenepoya Medical College, Yenepoya (Deemed to be University), Mangalore, India
| | | | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| |
Collapse
|
7
|
Krishnamurthy SKG, Nagaraja SB, Anand T, Sagili KD, Gowda C, S, Poojar B, Satyanarayana S. Threefold Increase in the Number of Drug Resistant TB Cases after Introduction of Universal Drug Susceptibility Testing: Experiences from Two South India Districts. ACTA ACUST UNITED AC 2020. [DOI: 10.4236/jtr.2020.82005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
8
|
Xu C, Li R, Shewade HD, Jeyashree K, Ruan Y, Zhang C, Wang L, Zhang H. Attrition and delays before treatment initiation among patients with MDR-TB in China (2006-13): Magnitude and risk factors. PLoS One 2019; 14:e0214943. [PMID: 30958841 PMCID: PMC6453446 DOI: 10.1371/journal.pone.0214943] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/22/2019] [Indexed: 11/30/2022] Open
Abstract
Background China’s national tuberculosis programme does not have cohort wise information regarding attrition and delays in the multidrug resistant tuberculosis (MDR-TB) diagnosis and treatment pathway. Objective Under the Global Fund programmatic management of drug-resistant TB (2006–13), we assessed the attrition and delay in the pathway and the factors associated. Methods Cohort study involving secondary programme data. All patients identified as presumptive MDR-TB (defined as i) previously treated TB patients which included recurrent TB, return after loss to follow up, treatment after failure and ii) new TB patients that were non-converters at three months of treatment or in close contact with a known MDR-TB patient) during October 2006 to June 2013 were eligible for phenotypic drug susceptibility testing (DST). Pre-diagnosis attrition (presumptive MDR-TB not undergoing culture and DST) and pre-treatment attrition (confirmed MDR-TB patients not initiated on treatment) was calculated. Diagnosis delay was the time interval from DST eligibility to DST result, treatment initiation delay was fom DST result to treatment initiation and total delay was from DST eligbility to treatment initiation. Factors associated with attrition and delay were identified using log binomial regression and linear regression, respectively. Results Of 78 564 presumptive MDR-TB patients, 2 470 (3.1%) underwent pre-diagnosis attrition. Of 9 283 MDR-TB patients, 3 361 (36.2%) underwent pre-treatment attrition. Median(IQR) diagnosis delay was 84 (64, 114) days; treatment initation delay was 23(6,68) days and total delay was 117(77,187) days. Long diagnosis delay was an independent predictor of pre-treatment attrition in a dose response relationship. While pre-treatment attrition was less likely among presumptive criterion ‘previously treated’ and with increasing time period, it was more likey among elderly and in east and west region. While the diagnosis delay increased with time period, treatment initiation delay and total delay reduced with time period. Short diagnosis delay was associated with west region, smear negative patients and presumptive criterion ‘treatment after lost to follow up’. Short treatment initiation delay was associatied with east and west regions while long treatment initiation delay was associated with elderly and presumptive criterion ‘recurrent TB’. Total delay predictors were similar to treatment initiation delay. In addition, short total delay was associated with presumptive criterion ‘treatment after failure’. Conclusion The diagnosis and treatment delay were long and the pre-treatment attrition was considerable high. Long diagnosis delay is likely to predict pre-treatment attrition.
Collapse
Affiliation(s)
- Caihong Xu
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control (CDC), Beijing, China
| | - Renzhong Li
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control (CDC), Beijing, China
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
- Karuna Trust, Bengaluru, India
| | | | - Yunzhou Ruan
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control (CDC), Beijing, China
| | - Canyou Zhang
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control (CDC), Beijing, China
| | - Lixia Wang
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control (CDC), Beijing, China
| | - Hui Zhang
- National Center for Tuberculosis Control and Prevention, China Center for Disease Control (CDC), Beijing, China
- * E-mail: ,
| |
Collapse
|
9
|
Newtonraj A, Venables E, Selvaraj K, Kundu D, Purty AJ, Manikandan M, Shewade HD. Xpert negative means no TB: A mixed-methods study into early implementation of Xpert in Puducherry, India. J Family Med Prim Care 2019; 8:1379-1385. [PMID: 31143725 PMCID: PMC6510069 DOI: 10.4103/jfmpc.jfmpc_421_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Xpert MTB/RIF was implemented in 2016 as the initial diagnostic test for extrapulmonary, pediatric, and human immunodeficiency virus-associated tuberculosis (TB) and as an add-on test for sputum microscopy-negative patients under Revised National TB Control Programme, Puducherry, India. We intended to study the change in TB case notification rates (CNRs) after 2015 and explore the enablers and barriers for implementation of Xpert. MATERIALS AND METHODS Sequential mixed-methods study, quantitative phase followed by a descriptive qualitative phase (key informant interviews with healthcare providers in the program). RESULTS The TB (all forms) CNR increased in 2016 followed by a drop to 2015 levels in 2017. There was a reduction in patients notified as sputum-negative pulmonary TB and pediatric TB during 2016-2017. Healthcare providers used a negative Xpert result in ruling out TB among patients who would previously get diagnosed clinically. Perceived benefits of Xpert were efficiency, rapid results, and detecting resistance. Barriers included poor awareness among medical colleges and the private sector, difficulty in motivating sputum microscopy-negative patients for Xpert, and incompletely filled referral forms. CONCLUSION Xpert-negative results should be interpreted cautiously after clinical assessment. Identified barriers should be addressed to ensure that all eligible undergo testing.
Collapse
Affiliation(s)
- Ariarathinam Newtonraj
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Emilie Venables
- Luxembourg Operational Research Unit, Médecins Sans Frontières, Luxembourg City, Luxembourg
| | | | - Debashish Kundu
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Anil Jacob Purty
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Mani Manikandan
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| |
Collapse
|