Stigma against tuberculosis may hinder non-household contact investigation: a qualitative study in Thailand

Setting

A northern province in Thailand.

Objectives

To explore experiences and perspectives on tuberculosis (TB) contact investigations in non-household contacts.

Design

Focus group discussions and in-depth interviews with eight groups: three groups of former TB patients (teachers, students and hospital staff) and five groups of representatives from congregate settings such as schools and workplaces. Data were analysed using the modified grounded theory.

Result

Annual health check-ups at the workplace contributed to the early detection of active TB in teachers. Former TB patients were highly exposed to non-household contacts, but contact investigations were limited to household contacts only. Barriers and facilitators for non-household contact investigations are associated with five factors, including information, awareness and knowledge about TB; stigma; empathy; health system response and informing non-household contacts about TB exposure. Stigma may be the main barrier to investigations among non-household contacts because TB patients tend to withhold information about their diagnosis from colleagues. Lack of knowledge and misperceptions regarding TB transmission contributed to stigma. Empathy with other people encouraged TB patients to inform non-household contacts.

Conclusion

Non-household contact investigations are not performed despite the risk of TB transmission. To promote contact investigations in congregate settings, interventions to overcome TB stigma and improve public knowledge about TB transmission are required.

Permanent employment or public assistance may increase tuberculosis survival among working-age patients in Japan

OBJECTIVES

To measure the effect of employment and health insurance status on the survival of working age tuberculosis (TB) patients in Japan.

METHODS

Retrospective cohort analysis of new smear-positive pulmonary TB patients aged 15-59 years registered in the Japanese national TB surveillance system between 2007 and 2010. We performed univariate and multivariate Cox proportional hazard model analysis. The survival curves for employment and health insurance status were calculated using Kaplan-Meier analysis.

RESULTS

Of 9097 patients studied, 267 (2.9%) died of TB within 12 months. After adjustment with a multivariate model, employment and health insurance status were independently associated with increased risk of TB death: unemployment (HR 2.80, 95%CI 2.11-3.72), absence of insurance (HR 1.48, 95%CI 1.02-2.15). The analysis of survival curves indicated that those with public assistance had almost the same survival rate as insured patients in the unemployed group. Permanent workers (employed >30 days) had the highest survival rates, followed by casual workers (employed <30 days) and the unemployed in the insured group.

CONCLUSION

Patients with permanent jobs had better survival rates than unemployed patients and casual workers. Despite being unemployed, receiving public assistance could improve survival. Health measures are required for the unemployed and casual workers.

High tuberculosis treatment success in Kabul, Afghanistan despite high patient transfers out

The National Tuberculosis (TB) Institute has the highest patient transfer-out rate in Afghanistan, but the result and treatment outcome of transferred patients were unknown in 2009. This operational research investigated the characteristics and treatment outcome of all transferred-out patients living in Kabul province. We analysed the 1-year TB register of the Institute (n = 1180 cases) and visited 24 health centres to review their TB registers. The results show the transfer-out rate was 52.6%. Of the transferred cases, 58.6% were women and 61.8% pulmonary TB cases (smear-positive 70.6%). The arrival rates of transfer-out patients at health centres in Kabul province were 87.6% for both men and women. Males aged 21-40 years were the most likely to be nonarrivals (OR = 8.91; 95% CI: 1.55-66.7). Treatment success rates in female and male patients were 84.4% and 77.5% respectively and default rates were 7.8% and 18.3%. Strategies to reduce the non-arrival to health centres and treatment interruption in male patients aged 20-40 years are warranted.

Informed patient consent for defaulter tracing: should we obtain it?

Active default tracing is an integral part of tuberculosis (TB) programmatic control. It can be differentiated into the tracing of defaulters (patients not seen at the clinic for > or =2 months) and 'late patients' (late for their scheduled appointments). Tracing is carried out to obtain reliable information about who has truly died, transferred out or stopped treatment, and, if possible, to persuade those who have stopped treatment to resume. This is important because, unlike routine care for non-communicable diseases, TB has the potential for transmission to other members of the community, and therefore presents the issue of the rights of the individual over the rights of the community. For this reason, default or 'late patient' tracing (defined together as default tracing in this article) has been incorporated into standard practice in most TB programmes and, in many industrialised countries, it is also a part of public health legislation. In resource-poor countries with limited access to phones or e-mails, default tracing involves active home visits. In this Unresolved Issues article, we discuss the need for patient consent within both the programmatic and the research context; we describe how this subject arose during operational research training at the Research Institute of Tuberculosis in Japan; we provide comments from individuals who are experienced and skilled at international and national TB control; and finally we offer some conclusions about the way forward. This is not an easy subject, and we welcome open debate on the issue.