Reducing Initial Loss to Follow-up Among People With Bacteriologically Confirmed Tuberculosis: LINKEDin, a Quasi-experimental Study in South Africa

Every person diagnosed with tuberculosis (TB) needs to initiate treatment. The World Health Organization estimated that 61% of people who developed TB in 2021 were included in a TB treatment registration system. Initial loss to follow-up (ILTFU) is the loss of persons to care between diagnosis and treatment initiation/registration. LINKEDin, a quasi-experimental study, evaluated the effect of 2 interventions (hospital recording and an alert-and-response patient management intervention) in 6 subdistricts across 3 high-TB burden provinces of South Africa. Using integrated electronic reports, we identified all persons diagnosed with TB (Xpert MTB/RIF positive) in the hospital and at primary health care facilities. We prospectively determined linkage to care at 30 days after TB diagnosis. We calculated the risk of ILTFU during the baseline and intervention periods and the relative risk reduction in ILTFU between these periods. We found a relative reduction in ILTFU of 42.4% (95% CI, 28.5%-53.7%) in KwaZulu Natal (KZN) and 22.3% (95% CI, 13.3%-30.4%) in the Western Cape (WC), with no significant change in Gauteng. In KZN and the WC, the relative reduction in ILTFU appeared greater in subdistricts where the alert-and-response patient management intervention was implemented (KZN: 49.3%; 95% CI, 32.4%-62%; vs 32.2%; 95% CI, 5.4%-51.4%; and WC: 34.2%; 95% CI, 20.9%-45.3%; vs 13.4%; 95% CI, 0.7%-24.4%). We reported a notable reduction in ILTFU in 2 provinces using existing routine health service data and applying a simple intervention to trace and recall those not linked to care. TB programs need to consider ILTFU a priority and develop interventions specific to their context to ensure improved linkage to care.

Closing the reporting gap for childhood tuberculosis in South Africa: improving hospital referrals and linkages

Setting

A referral hospital in Cape Town, Western Cape Province, Republic of South Africa.

Objective

To measure the impact of a hospital-based referral service (intervention) to reduce initial loss to follow-up among children with tuberculosis (TB) and ensure the completeness of routine TB surveillance data.

Design

A dedicated TB referral service was established in the paediatric wards at Tygerberg Hospital, Cape Town, in 2012. Allocated personnel provided TB education and counselling, TB referral support and weekly telephonic follow-up after hospital discharge. All children identified with TB were matched to electronic TB treatment registers (ETR.Net/EDRWeb). Multivariable logistic regression was used to compare reporting of culture-confirmed and drug-susceptible TB cases before (2007-2009) and during (2012) the intervention.

Results

Successful referral with linkage to care was confirmed in 267/272 (98%) and successful reporting in 227/272 (84%) children. Children with drug-susceptible, culture-confirmed TB were significantly more likely to be reported during the intervention period than in the pre-intervention period (OR 2.52, 95%CI 1.33-4.77). The intervention effect remained consistent in multivariable analysis (adjusted OR 2.62; 95%CI 1.31-5.25) after adjusting for age, sex, human immunodeficiency virus status and the presence of TB meningitis.

Conclusions

A simple hospital-based TB referral service can reduce initial loss to follow-up and improve recording and reporting of childhood TB in settings with decentralised TB services.

Delay and attrition before treatment initiation among MDR-TB patients in five districts of Gujarat, India

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.

The South African Tuberculosis Care Cascade: Estimated Losses and Methodological Challenges

Background

While tuberculosis incidence and mortality are declining in South Africa, meeting the goals of the End TB Strategy requires an invigorated programmatic response informed by accurate data. Enumerating the losses at each step in the care cascade enables appropriate targeting of interventions and resources.

Methods

We estimated the tuberculosis burden; the number and proportion of individuals with tuberculosis who accessed tests, had tuberculosis diagnosed, initiated treatment, and successfully completed treatment for all tuberculosis cases, for those with drug-susceptible tuberculosis (including human immunodeficiency virus (HIV)–coinfected cases) and rifampicin-resistant tuberculosis. Estimates were derived from national electronic tuberculosis register data, laboratory data, and published studies.

Results

The overall tuberculosis burden was estimated to be 532005 cases (range, 333760–764480 cases), with successful completion of treatment in 53% of cases. Losses occurred at multiple steps: 5% at test access, 13% at diagnosis, 12% at treatment initiation, and 17% at successful treatment completion. Overall losses were similar among all drug-susceptible cases and those with HIV coinfection (54% and 52%, respectively, successfully completed treatment). Losses were substantially higher among rifampicin- resistant cases, with only 22% successfully completing treatment.

Conclusion

Although the vast majority of individuals with tuberculosis engaged the public health system, just over half were successfully treated. Urgent efforts are required to improve implementation of existing policies and protocols to close gaps in tuberculosis diagnosis, treatment initiation, and successful treatment completion.

Comprehensiveness of primary services in the care of infectious tuberculosis patients in Rawalpindi, Pakistan

SETTING

All tuberculosis (TB) diagnostic centres of Rawalpindi District, Pakistan, including five tertiary care hospitals and 16 rural health centres.

OBJECTIVE

To identify among sputum smear-positive patients registered during 2009 in the laboratory register those who had not been recorded in a treatment register, defined in the study as 'initial loss to follow-up'.

DESIGN

A retrospective record review of routine TB data.

RESULTS

There were 16 145 suspects screened for TB and recorded in the laboratory registers. Of 1698 smear-positive patients identified in the laboratory registers, 101 (6%) could not be identified in the treatment registers. Eighty-six (10%) of 842 patients in tertiary care hospitals and 15/856 (2%) in rural health centres were not recorded (OR 6.4, 95%CI 3.6-11.6, P < 0.01).

CONCLUSION

The study shows a significant association between type of health facility and initial loss to follow-up. In rural health centres, the proportion lost to follow-up is low, reflecting more efficient care than in tertiary care hospitals. Strategies are urgently needed to improve the registration and follow-up of smear-positive cases in tertiary care institutions.