Ways and Means to Utilize Private Practitioners for Tuberculosis Care in India

What ails tuberculosis notification from the private sector in urban India: a qualitative study among stakeholders in Bengaluru City, southern India

Background

Tuberculosis (TB) case reporting is vital for national and subnational surveillance and is mandated in India since 2012. All health providers, public and private, must report through the web-based system, "Nikshay." The prevalence: notification ratio from 2019 to 2021 was 2.84 (prevalence was almost 3 times the notification), suggesting under-notification. This study explores the experiences, identifies barriers and facilitators, and examines perceptions regarding mandatory notification and incentives among private providers (PPs) in diverse contexts in Bengaluru city.

Methods

Focused group discussions were held with specialist faculty of Pediatrics, Internal Medicine, and Pulmonology across three medical colleges and in-depth interviews included freelancing specialists and general practitioners. Data was collected in Bengaluru from January 2018 to July 2019, analyzed using a framework approach, referencing social learning theory, precede/proceed model, and theory of learned behavior. Thematic content analysis linked emerging themes to codes.

Results

There was unmet expectation regarding lack of feedback from the NTEP regarding the patients notified. Emphasis on bacteriological diagnosis for every patient by NTEP deterred notification. Incentives were felt either to be insufficient for doctors or the PPs felt they were obliged to the national programme to notify. Barriers included obligation to maintain confidentiality, stigma, lack of knowledge of how to notify and facilitators included being recognized for their efforts and implementation of compulsory notification in letter and spirit.

Conclusion

Strategies to minimize stigma through education of patients at diagnosis and regular communication with private providers about the notification process, guidelines, and policy improvements can decrease resistance to notification. Recognizing best practices and rewarding on professional platforms could motivate private providers, alongside continued monetary incentives. Finally, demonstrating effective implementation of mandatory notification provision may boost private providers' morale.

First contact investigations and compliance to treatment in patients with uveitis

AIM

To ascertain the pattern of investigations at first contact in uveitic patients and evaluate compliance to treatment.

METHODS

An observational study comprised of 201 uveitic patients presenting for the first time to our centre from January 2019 to June 2020. Detailed information regarding systemic investigations undertaken by specialists at the time of first contact and the cost of these investigations were reviewed on the first visit to our centre. Compliance with the treatment was determined and reasons behind non-compliance were evaluated on the first follow-up in patients who had no improvement in clinical signs and symptoms.

RESULTS

The mean age of the study group was 35.35±14.1y and gender composition was 59.7% males and 40.3% females. Anterior uveitis was observed in 45.3% of patients, intermediate uveitis in 31.8% of patients, posterior uveitis in 14.9% of patients and panuveitis in 8.0% of patients. Association with a systemic disease was evident in 17.9% of patients. When compared with standard guidelines and uveitis patterns, systemic investigations were identified to be relevant only in 38.3% of patients. Non-compliance to treatment was documented in 22.4% of patients. Common reasons for non-compliance were inadequate counselling by the treating physician about treatment in 26.7% of patients and a busy schedule at work/school in 22.2% of patients.

CONCLUSION

Significant number of investigations performed at first contact is found to be contrary to standard guidelines and are not contributory to the care. About a quarter of patients in this study are found to be non-compliant with the treatment. Compliance is more challenging to achieve in school-going children and working adults. The availability of comprehensive, periodically updated, evidence-based guidelines on the role of investigations and the use of trained counsellors may help to channelize proper evaluation and improve compliance to treatment, respectively, in patients with uveitis.

Oral anti-tuberculosis drugs: An urgent medication reconciliation at hospitals in Indonesia

Background: Four oral anti-tuberculosis drugs are conceived to be the most effective ones to eradicate Mycobacterium tuberculosis bacteria and to obviate the resistant organisms. However, the patients’ adherence and medication discrepancies are obstacles to achieving the goal. This study aimed to define the anti-tuberculosis drugs used in the hospitals and to detect the discrepancies in the continuity of the tuberculosis treatment.

Design and Methods: This retrospective cross-sectional study was based on medical records of adult patients, and was conducted in two district tertiary care hospitals. Only 35 out of 136 patient records from Hospital A and 33 out of 85 records from Hospital B met the inclusion criteria.

Results: The most common systemic anti-infective drugs in the study were ceftriaxone (51.80 DDD/100 patient-days) used in Hospital A and isoniazid (59.53 DDD/100 patient-days) used in Hospital B. The number of rifampicin prescriptions was less than that of isoniazid. Each patient received an average of two DDD/100 patient-days, which is an under dosage for an effective treatment.

Conclusion: This study showed a medication discrepancy of tuberculosis therapy. Tuberculosis patients’ medical histories are not under the full attention of treating physicians wherever they are admitted. Thus, medication reconciliation is needed to accomplish the goal of a Tuberculosis-free world in 2050.

Estimation of the burden of bacteriologically positive Tuberculosis among Adults in Kashmir: A baseline for future surveys in the Valley

Background:

India has the highest burden of both Tuberculosis and MDR-Tuberculosis based on estimates reported in the Global Tuberculosis Report 2016. The estimates have been revised upwards based on the newer evidence, and the current study was done to estimate the prevalence of bacteriologically positive pulmonary Tuberculosis among the adult population and to provide baseline information for future measurements of Tuberculosis burden and trends.

Methods:

A cluster-based sampling design was adopted in 10 districts of Kashmir valley in India. Assuming a prevalence of 217 per lakh population, a design effect of 2.5, a relative precision of 0.25% and the expected participation rate of 80%, a sample size of 49,716 was achieved. A total of 67 clusters were identified where each cluster had 750 subjects aged ≥15 years, and eligible individuals were questioned for pulmonary symptoms suggestive of Tuberculosis.

Results:

Of the total 42,805 that were interviewed, 3.85% had pulmonary Tuberculosis symptoms. A total of 1539 sputum samples were collected from symptomatic and 1351 chest X- rays were done. Cartridge based nucleic acid amplification test (CBNAAT) tests were done on individuals with suspicious X-ray findings. The prevalence of bacteriologically positive pulmonary Tuberculosis was found to be 147 per 100,000 population. Females are affected more than males, and the age of female Tuberculosis patients is less than that of males.

Conclusion:

The study is the first survey of its kind providing a baseline for further research in the state. CBNAAT is going to be game-changer which surmounts the drawbacks of sputum smear microscopy.