Delays in the diagnosis of pulmonary tuberculosis in Coahuila, Mexico

Exploring the role of the private sector in tuberculosis detection and management in Lima, Peru: a mixed-methods patient pathway analysis

In Latin America, little is known about the involvement of private healthcare providers in TB detection and management. We sought to gain a better understanding of current and potential roles of the private sector in delivering TB services in Peru. We conducted a mixed-methods study in Lima, Peru. The quantitative component comprised a patient pathway analysis assessing the alignment of TB services with patient care-seeking behavior. The qualitative component comprised in-depth interviews with 18 private healthcare providers and 5 key informants. We estimated that 77% of patients initially sought care at a facility with TB diagnostic capacity and 59% at a facility with TB treatment capacity. The lack of TB services at initial care-seeking location was driven by the 41% of patients estimated to seek care first at a private facility. Among private facilities, 43% offered smear microscopy, 13% offered radiography, and none provided TB treatment. Among public sector facilities, 100% offered smear microscopy, 26% offered radiography, and 99% provided TB treatment. Interviews revealed that private providers believed that they offered shorter wait times and a quicker diagnosis, but they struggled with a lack of follow-up systems and communication barriers with the public sector. While expressing willingness to collaborate with public sector programs for diagnosis and referral, private providers had limited interest in treating TB. This study highlights the role of private providers in Peru as an entry point for TB care. Public-private collaboration is necessary to harness the potential of the private sector as an ally for early diagnosis.

Detection of risk clusters for deaths due to tuberculosis specifically in areas of southern Brazil where the disease was supposedly a non-problem

Background

Tuberculosis (TB) is the infectious disease that kills the most people worldwide. The use of geoepidemiological techniques to demonstrate the dynamics of the disease in vulnerable communities is essential for its control. Thus, this study aimed to identify risk clusters for TB deaths and their variation over time.

Methods

This ecological study considered cases of TB deaths in residents of Londrina, Brazil between 2008 and 2015. We used standard, isotonic scan statistics for the detection of spatial risk clusters. The Poisson discrete model was adopted with the high and low rates option used for 10, 30 and 50% of the population at risk, with circular format windows and 999 replications considered the maximum cluster size. Getis-Ord Gi* (Gi*) statistics were used to diagnose hotspot areas for TB mortality. Kernel density was used to identify whether the clusters changed over time.

Results

For the standard version, spatial risk clusters for 10, 30 and 50% of the exposed population were 4.9 (95% CI 2.6–9.4), 3.2 (95% CI: 2.1–5.7) and 3.2 (95% CI: 2.1–5.7), respectively. For the isotonic spatial statistics, the risk clusters for 10, 30 and 50% of the exposed population were 2.8 (95% CI: 1.5–5.1), 2.7 (95% CI: 1.6–4.4), 2.2 (95% CI: 1.4–3.9), respectively. All risk clusters were located in the eastern and northern regions of the municipality. Additionally, through Gi*, hotspot areas were identified in the eastern and western regions.

Conclusions

There were important risk areas for tuberculosis mortality in the eastern and northern regions of the municipality. Risk clusters for tuberculosis deaths were observed in areas where TB mortality was supposedly a non-problem. The isotonic and Gi* statistics were more sensitive for the detection of clusters in areas with a low number of cases; however, their applicability in public health is still restricted.

Comparing tuberculosis management under public and private healthcare providers: Victoria, Australia, 2002-2015

BACKGROUND

Private healthcare providers are important to tuberculosis (TB) management globally, although internationally there are reports of suboptimal management and disparities in treatment commencement in the private sector. We compared the management of TB patients receiving private versus public healthcare in Victoria, an industrialised setting with low tuberculosis (TB) incidence.

METHODS

Retrospective cohort study: 2002-2015. Private healthcare provision was included as an independent variable in several multivariate logistic and Cox proportional hazard regression models that assessed a range of outcome variables, encompassing treatment commencement delays, management and treatment outcomes.

RESULTS

Of 5106 patients, 275 (5.4%) exclusively saw private providers, and 4714 (92.32%) public. Private care was associated with a shorter delay to presentation (HR 1.36, p = 0.065, 95% CI 1.02-2.00). Private patients were less likely to have genotypic testing (OR 0.66, p = 0.009, 95% CI 0.48-0.90), those with pulmonary involvement were less likely to have a sputum smear (OR 0.52, p = 0.011, 95% CI 0.31-0.86) and provided samples were less likely to be positive (OR 0.54, p = 0.070, 95% CI 0.27-1.05). Private patients with extrapulmonary TB were less likely to have a smear sample (OR 0.7, 95% CI 0.48-0.90, p = 0.009) and radiological abnormalities (OR 0.71, p = 0.070, 95% CI 0.27-1.05). Treatment commencement delays from presentation were comparable for cases with pulmonary involvement and extrapulmonary TB, although public extrapulmonary TB patients received radiological examinations slightly earlier than private patients (HR 0.79, p = 0.043, 95% CI 0.63-0.99) and public patients with pulmonary involvement from high burden settings commenced treatment following an abnormal CXR more promptly than their private counterparts (HR 0.41, p = 0.011, 95% CI 0.21-0.81). Private patients were more likely to receive <4 first-line medications (OR 2.17, p = 0.001, 95% CI 1.36-3.46), but treatment outcomes were comparable between sectors.

CONCLUSIONS

The differences we identified are likely to reflect differing case-mix as well as clinician practice. Sputum smear status was an important covariable in our analysis; with its addition we found no significant disparity in the health-system delay to treatment commencement between sectors. Our study highlights the importance of TB programs engaging with private providers, enabling comprehensive data collection that is necessary for thorough and true comparison of TB management and optimisation of care.