Tuberculosis patients in an Indian mega-city: Where do they live and where are they diagnosed?

Improving measurement of tuberculosis care cascades to enhance people-centred care

Care cascades represent the proportion of people reaching milestones in care for a disease and are widely used to track progress towards global targets for HIV and other diseases. Despite recent progress in estimating care cascades for tuberculosis (TB) disease, they have not been routinely applied at national and subnational levels, representing a lost opportunity for public health impact. As researchers who have estimated TB care cascades in high-incidence countries (India, Madagascar, Nigeria, Peru, South Africa, and Zambia), we describe the utility of care cascades and identify measurement challenges, including the lack of population-based disease burden data and electronic data capture, the under-reporting of people with TB navigating fragmented and privatised health systems, the heterogeneity of TB tests, and the lack of post-treatment follow-up. We outline an agenda for rectifying these gaps and argue that improving care cascade measurement is crucial to enhancing people-centred care and achieving the End TB goals.

An explanation of the 15-year trend and investigation of the tuberculosis cascade in Kurdistan province

Objective

This study's objectives were to describe the 15-year trend from 2005 to 2019 and examine the tuberculosis cascade in the Kurdistan province from 21 march 2018–20 march 2019.

Methods

This retrospective study was in 2744 patients with tuberculosis from 2005 to 2019 who were registered in Kurdistan disease registration centers. For the initial evaluation of demographic data, we utilized SPSS software version 20 and excel. Additionally, to design a care cascade, we utilized draw.io software for registered patients between March 21, 2018, and March 20, 2019. As a result, 2489 new cases of tuberculosis remained in our study.

Results

The results showed that the mean of age of people with tuberculosis was 58 years and sex distribution were 1441 (57.9) female and 1048 (42.1) male. Additionally, a cascade model showed that in Kurdistan Province, an estimated 112 new cases of smear-positive pulmonary tuberculosis in 2018, of which 90% (101 people) were sent to medical facilities and underwent diagnostic testing, with 80% of these patients (81 people). Infection was identified in 81 individuals, all of whom had their diagnoses recorded in the medical database. 82% (67 patients) of the patients who were enrolled in the treatment system received access to treatment, and 65 patients, or 97 percent, experienced no recurrence for at least a year after treatment. Correct diagnosis and therapy represented the biggest gap.

Conclusion

Cascade can enhance surveillance program and focus activities to better cases, diagnose, connect to care, and help TB patients survive without recurrence.

Voices of Those Who Bear the Brunt - Experiences of Programme Personnel Concerning Private Sector Tuberculosis Notifications in Bengaluru City, India

This study aims to assess private and public sector contributions to Tuberculosis (TB) notification in Bengaluru city (2011 to 2016) and identify challenges of program personnel in their interaction with private practitioners and procedural barriers for TB notification from the private sector as perceived by them. A mixed methods study was carried out in Bengaluru city, India with TB notification data obtained from TB Units in addition to in-depth interviews with key program implementers. Results showed the contribution of private practitioners to TB notification to be about 20%. Barriers and challenges were: the private practitioners' hesitancy to refer the patients to public sector due to their fear of losing patients and dishonoring of diagnosis from private practitioners, lack of awareness about TB notification, lack of legal punitive measures and constant glitches on the notification website. These need to be resolved on priority to achieve the national target of TB elimination by 2025.

Understanding Nonadherence to Tuberculosis Medications in India Using Urine Drug Metabolite Testing: A Cohort Study

BACKGROUND

Poor adherence to tuberculosis (TB) treatment is associated with disease recurrence and death. Little research has been conducted in India to understand TB medication nonadherence.

METHODS

We enrolled adult drug-susceptible TB patients, approximately half of whom were people with human immunodeficiency virus (PWH), in Chennai, Vellore, and Mumbai. We conducted a single unannounced home visit to administer a survey assessing reasons for nonadherence and collect a urine sample that was tested for isoniazid content. We described patient-reported reasons for nonadherence and identified factors associated with nonadherence (ie, negative urine test) using multivariable logistic regression. We also assessed the association between nonadherence and treatment outcomes.

RESULTS

Of 650 participants in the cohort, 77 (11.8%) had a negative urine test. Nonadherence was independently associated with daily wage labor (adjusted odds ratio [aOR], 2.7; confidence interval [CI], 1.1-6.5; P = .03), the late continuation treatment phase (aOR, 2.0; CI, 1.1-3.9; P = .03), smear-positive pulmonary disease (aOR, 2.1; CI, 1.1-3.9; P = .03), alcohol use (aOR, 2.5; CI, 1.2-5.2; P = .01), and spending ≥30 minutes collecting medication refills (aOR, 6.6; CI, 1.5-29.5; P = .01). People with HIV reported greater barriers to collecting medications than non-PWH. Among 167 patients reporting missing doses, reported reasons included traveling from home, forgetting, feeling depressed, and running out of pills. The odds of unfavorable treatment outcomes were 4.0 (CI, 2.1-7.6) times higher among patients with nonadherence (P < .0001).

CONCLUSION

Addressing structural and psychosocial barriers will be critical to improve TB treatment adherence in India. Urine isoniazid testing may help identify nonadherent patients to facilitate early intervention during treatment.

TB notification rates across parliamentary constituencies in India: a step towards data-driven political engagement

OBJECTIVE

National averages obscure geographic variation in program performance. We determined Parliamentary Constituency (PC)-wise estimates of TB notification to guide political engagement.

METHODS

We extracted district-level TB notification data from the 2018 annual TB report. We derived PC-level estimates by building a 'cross-walk' between districts and PCs using boundary shapefiles. We described the spatial distribution of the PC-wise estimates of Total Notification Rate and percentage of Private Sector Notification.

RESULTS

The median PC-wise Total Notification Rate was 126.24/100 000 (IQR: 94.86/100 000, 162.22/100 000). The median PC-wise Percentage Private Sector Notification was 18.03% (IQR: 9.56%, 26.84%). Only 16 (2.94%) PCs met the target of 50% private sector notification. Most of high notification rates in PCs were driven by high notification in public sector. There was geographic - both interstate and within state inter-PC - variation in the estimates of these indicators. The study identified some geographic patterns of notification - high positive outlier PCs with adjoining PCs in lower deciles of notification rates, intra-state differences in PC performance, and similarities in notification rates of adjoining PCs in different states.

CONCLUSION

In addition to regional inequality, the study identified geospatial patterns that can aid in the formulation of suitable interventions. These include decongestion of overburdened facilities by strengthening poorly performing units. The PCs with a high percentage Private Sector Notification can act as role models for neighbouring PCs to improve private sector engagement. MPs can play a crucial role in mobilising additional resources, creating awareness, and establishing inter-PC and inter-state collaboration to improve TB program performance.

Understanding pretreatment loss to follow-up of tuberculosis patients: an explanatory qualitative study in Chennai, India

Introduction

Pretreatment loss to follow-up (PTLFU)-dropout of patients after diagnosis but before treatment registration-is a major gap in tuberculosis (TB) care in India and globally. Patient and healthcare worker (HCW) perspectives are critical for developing interventions to reduce PTLFU.

Methods

We tracked smear-positive TB patients diagnosed via sputum microscopy from 22 diagnostic centres in Chennai, one of India's largest cities. Patients who did not start therapy within 14 days, or who died or were lost to follow-up before official treatment registration, were classified as PTLFU cases. We conducted qualitative interviews with trackable patients, or family members of patients who had died. We conducted focus group discussions (FGDs) with HCWs involved in TB care. Interview and FGD transcripts were coded and analysed with Dedoose software to identify key themes. We created categories into which themes clustered and identified relationships among thematic categories to develop an explanatory model for PTLFU.

Results

We conducted six FGDs comprising 53 HCWs and 33 individual patient or family member interviews. Themes clustered into five categories. Examining relationships among categories revealed two pathways leading to PTLFU as part of an explanatory model. In the first pathway, administrative and organisational health system barriers-including the complexity of navigating the system, healthcare worker absenteeism and infrastructure failures-resulted in patients feeling frustration or resignation, leading to disengagement from care. In turn, HCWs faced work constraints that contributed to many of these health system barriers for patients. In the second pathway, negative HCW attitudes and behaviours contributed to patients distrusting the health system, resulting in refusal of care.

Conclusion

Health system barriers contribute to PTLFU directly and by amplifying patient-related challenges to engaging in care. Interventions should focus on removing administrative hurdles patients face in the health system, improving quality of the HCW-patient interaction and alleviating constraints preventing HCWs from providing patient-centred care.

TB diagnostic cascade among patients registered under the Revised National TB Control Programme in Chennai, South India

OBJECTIVE

To discern and quantify the TB diagnostic cascade among patients registered under the Revised National TB Control Programme, Chennai city, Tamil Nadu, South India.

METHODS

This cross-sectional study was conducted in metropolitan Chennai from February 2017 to March 2018. We interviewed TB patients retrospectively on their diagnostic attempt in different health facilities.

RESULTS

Of 455 TB patients, only 4.4% received their diagnosis at their first health facility. Of 1250 visits to health facilities, the vast majority (79.4 vs. 20.6%) was in the public rather than the private sector. 56% of patients went to a public facility as the first point of care, of whom 1.6% shifted to private facilities subsequently. The remaining 54.4% shifted between up to five government health facilities. Male patients and those with a higher family income were more likely to shift from private to public.

CONCLUSION

Most shifts between diagnostic facilities occurred in the public sector. This necessitates interventions at public health facilities for strengthening and extending services to TB patients at their first point of care.

User-experience and patient satisfaction with quality of tuberculosis care in India: A mixed-methods literature review

BACKGROUND

Tuberculosis affected 2.7 million people in India in 2017. The Revised National TB Control Programme has achieved milestones in coverage, however quality of TB care remains highly variable and often poor, with significant gaps in provider knowledge, practices, and patients consistently lost to follow-up. These quality gaps are largely informed by studies on provider practices or objective chart abstractions and case data. Per the knowledge of the author, no review has been conducted on first-hand patient perspectives on the quality of TB care they receive. This mixed-methods literature review aims to synthesize evidence on user-experience and patient satisfaction with TB care in India and inform areas for service quality improvement.

METHODS

Five medical databases, including PubMed, EMBASE, Global Health (Ovid), Web of Science, and CINAHL were searched for empirical studies on patient perspectives on TB health services published between January 1st, 2000 to December 31st, 2017. Studies in English with adult patients with any form of TB in the public or private health system were included. Studies prior to entering the health system, on distance to health facilities and cost were excluded. Seven Indian journals were hand searched and a grey literature search was conducted in GoogleScholar. Studies were assessed for methodological quality and thematic analysis was conducted by categorizing data using NVivo 12.

RESULTS

A total of 498 studies were screened, of which 23 met the inclusion criteria. 16 supplementary studies were identified from Indian journals and grey literature. Of the 39 total studies included most were quantitative (29; 74%), based in South India (17; 44%) and focused on drug-sensitive TB patients (19; 49%) within the public health system (25; 64%). Data collection methods were highly heterogenous which limited synthesis and comparisons across population demographics, health sectors, or regions. Overall quantitative patient satisfaction measured in seven studies was high. Two major themes identified were provider-related factors (n = 26 studies) and convenience (n = 25), and six minor themes were supplies and equipment availability (n = 12), confidence (n = 10), information and communication (n = 10), waiting time (n = 8), stigma (n = 4), and confidentiality (n = 4). Each reported positive and negative user-experiences. Most significantly, DOTS did not fit the daily needs and obligations of many patients, particularly due to conflicts with employment and frequency of visits; while positive provider support, information, and flexibility helped patients adhere to treatment.

CONCLUSION

Although quantitative patient satisfaction was found to be high, data were not collected using robust, validated tools. Qualitative and quantitative user-experiences in each theme were variable, making them both barriers and facilitators of good quality TB care. Poor user-experiences were often responsible for patients interrupting treatment or dropping out of TB care. Patient-centeredness, or user-friendliness of TB care can be improved by introducing individualized or flexible DOTS that is responsive to user circumstances and needs. User-experience data should be systematically collected using a standardized, national tool for identification of specific bottlenecks and successes in quality of TB care from the patients' perspective.

Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care

The cascade of care is a model for evaluating patient retention across sequential stages of care required to achieve a successful treatment outcome. This approach was first used to evaluate HIV care and has since been applied to other diseases. The tuberculosis (TB) community has only recently started using care cascade analyses to quantify gaps in quality of care. In this article, we describe methods for estimating gaps (patient losses) and steps (patients retained) in the care cascade for active TB disease. We highlight approaches for overcoming challenges in constructing the TB care cascade, which include difficulties in estimating the population-level burden of disease and the diagnostic gap due to the limited sensitivity of TB diagnostic tests. We also describe potential uses of this model for evaluating the impact of interventions to improve case finding, diagnosis, linkage to care, retention in care, and post-treatment monitoring of TB patients.

Pretreatment loss to follow-up of tuberculosis patients in Chennai, India: a cohort study with implications for health systems strengthening

Background

Pretreatment loss to follow-up (PTLFU) is a barrier to tuberculosis (TB) control in India’s Revised National TB Control Programme (RNTCP). PTLFU studies have not been conducted in India’s mega-cities, where patient mobility may complicate linkage to care.

Methods

We collected data from patient registries for May 2015 from 22 RNTCP designated microscopy centers (DMCs) in Chennai and audited addresses and phone numbers for patients evaluated for suspected TB to understand how missing contact information may contribute to PTLFU. From November 2015 to June 2016, we audited one month of records from each of these 22 DMCs and tracked newly diagnosed smear-positive patients using RNTCP records, phone calls, and home visits. We defined PTLFU cases as including: (1) patients who did not start TB therapy within 14 days and (2) patients who started TB therapy but were lost to follow-up or died before official RNTCP registration. We used multivariate logistic regression to identify factors associated with PTLFU.

Results

In the audit of May 2015 DMC registries, out of 3696 patients evaluated for TB, 1273 (34.4%) had addresses and phone numbers that were illegible or missing. Out of 344 smear-positive patients tracked from November 2015 to June 2016, 40 (11.6%) did not start TB therapy within 14 days and 36 (10.5%) started therapy but were lost to follow-up or died before official RNTCP registration, for an overall PTLFU rate of 22.1% (95%CI: 17.8%—26.4%). Of all PTLFU patients, 55 (72.4%) were lost to follow-up and 21 (27.6%) died before starting treatment or before RNTCP registration. In the regression analysis, age > 50 years (OR 2.9, 95%CI 1.4—6.5), history of prior TB (OR 3.9, 95%CI 2.2—7.1), evaluation at a high patient volume DMC (OR 3.2, 95% CI 1.7—6.3), and absence of legible patient contact information (OR 4.5, 95%CI 1.3—15.1) were significantly associated with PTLFU.

Conclusions

In an Indian mega-city, we found a high PTLFU rate, especially in patients with a prior TB history, who are at greater risk for having drug-resistance. Enhancing quality of care and health system transparency is critical for improving linkage of newly diagnosed patients to TB care in urban India.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3039-3) contains supplementary material, which is available to authorized users.