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Thomas BE, Subbaraman R, Sellappan S, Suresh C, Lavanya J, Lincy S, Raja AL, Javeed B, Kokila S, Arumugam S, Swaminathan S, Mayer KH. Pretreatment loss to follow-up of tuberculosis patients in Chennai, India: a cohort study with implications for health systems strengthening. BMC Infect Dis 2018; 18:142. [PMID: 29587651 PMCID: PMC5872574 DOI: 10.1186/s12879-018-3039-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 03/04/2018] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Beena E Thomas
- Department of Social and Behavioral Research, National Institute for Research in Tuberculosis, No. 1, Mayor Sathiyamoorthy Road, Chetpet, Chennai, 600031, India.
| | - Ramnath Subbaraman
- Nutrition Infection Unit, Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave., Boston, 02111, USA.,Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, 260 Tremont St., Boston, 02111, USA
| | - Senthil Sellappan
- Department of Social and Behavioral Research, National Institute for Research in Tuberculosis, No. 1, Mayor Sathiyamoorthy Road, Chetpet, Chennai, 600031, India
| | - Chandra Suresh
- Department of Social and Behavioral Research, National Institute for Research in Tuberculosis, No. 1, Mayor Sathiyamoorthy Road, Chetpet, Chennai, 600031, India
| | - J Lavanya
- District Tuberculosis Office, No. 26 Pulianthope High Road, Pulianthope, Chennai, 600012, India
| | - Savari Lincy
- Department of Social and Behavioral Research, National Institute for Research in Tuberculosis, No. 1, Mayor Sathiyamoorthy Road, Chetpet, Chennai, 600031, India
| | - Agnes Lawrence Raja
- Department of Social and Behavioral Research, National Institute for Research in Tuberculosis, No. 1, Mayor Sathiyamoorthy Road, Chetpet, Chennai, 600031, India
| | - B Javeed
- Department of Social and Behavioral Research, National Institute for Research in Tuberculosis, No. 1, Mayor Sathiyamoorthy Road, Chetpet, Chennai, 600031, India
| | - S Kokila
- Department of Social and Behavioral Research, National Institute for Research in Tuberculosis, No. 1, Mayor Sathiyamoorthy Road, Chetpet, Chennai, 600031, India
| | - S Arumugam
- Department of Social and Behavioral Research, National Institute for Research in Tuberculosis, No. 1, Mayor Sathiyamoorthy Road, Chetpet, Chennai, 600031, India
| | - Soumya Swaminathan
- World Health Organization Headquarters, Avenue Appia 20, 1202, Geneva, Switzerland
| | - Kenneth H Mayer
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis St., Boston, 02215, USA.,The Fenway Institute, 1340 Boylston St, 8th floor, Boston, MA, 02215, USA
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Phalkey RK, Butsch C, Belesova K, Kroll M, Kraas F. From habits of attrition to modes of inclusion: enhancing the role of private practitioners in routine disease surveillance. BMC Health Serv Res 2017; 17:599. [PMID: 28841872 PMCID: PMC5574140 DOI: 10.1186/s12913-017-2476-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 07/27/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Private practitioners are the preferred first point of care in a majority of low and middle-income countries and in this position, best placed for the surveillance of diseases. However their contribution to routine surveillance data is marginal. This systematic review aims to explore evidence with regards to the role, contribution, and involvement of private practitioners in routine disease data notification. We examined the factors that determine the inclusion of, and the participation thereof of private practitioners in disease surveillance activities. METHODS Literature search was conducted using the PubMed, Web of Knowledge, WHOLIS, and WHO-IRIS databases to identify peer-reviewed and gray full-text documents in English with no limits for year of publication or study design. Forty manuscripts were reviewed. RESULTS The current participation of private practitioners in disease surveillance efforts is appalling. The main barriers to their participation are inadequate knowledge leading to unsatisfactory attitudes and misperceptions that influence their practices. Complicated reporting mechanisms with unclear guidelines, along with unsatisfactory attitudes on behalf of the government and surveillance program managers also contribute to the underreporting of cases. Infrastructural barriers especially the availability of computers and skilled human resources are critical to improving private sector participation in routine disease surveillance. CONCLUSION The issues identified are similar to those for underreporting within the Integrated infectious Disease Surveillance and Response systems (IDSR) which collects data mainly from public healthcare facilities. We recommend that surveillance program officers should provide periodic training, supportive supervision and offer regular feedback to the practitioners from both public as well as private sectors in order to improve case notification. Governments need to take leadership and foster collaborative partnerships between the public and private sectors and most importantly exercise regulatory authority where needed.
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Affiliation(s)
- Revati K. Phalkey
- Division of Epidemiology & Public Health, University of Nottingham, C111, Clinical Sciences Building 2, City Hospital, Hucknall Road, NG5 1PB Nottingham, Nottingham, UK
- Institute of Public Health, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
- Institute of Geography, University of Cologne, Albertus-Magnus-Platz, D-50923 Cologne, Germany
| | - Carsten Butsch
- Institute of Geography, University of Cologne, Albertus-Magnus-Platz, D-50923 Cologne, Germany
| | - Kristine Belesova
- London School of Hygiene and Tropical Medicine (LSHTM), 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - Marieke Kroll
- Institute of Geography, University of Cologne, Albertus-Magnus-Platz, D-50923 Cologne, Germany
| | - Frauke Kraas
- Institute of Geography, University of Cologne, Albertus-Magnus-Platz, D-50923 Cologne, Germany
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The Tuberculosis Cascade of Care in India's Public Sector: A Systematic Review and Meta-analysis. PLoS Med 2016; 13:e1002149. [PMID: 27780217 PMCID: PMC5079571 DOI: 10.1371/journal.pmed.1002149] [Citation(s) in RCA: 166] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 09/09/2016] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND India has 23% of the global burden of active tuberculosis (TB) patients and 27% of the world's "missing" patients, which includes those who may not have received effective TB care and could potentially spread TB to others. The "cascade of care" is a useful model for visualizing deficiencies in case detection and retention in care, in order to prioritize interventions. METHODS AND FINDINGS The care cascade constructed in this paper focuses on the Revised National TB Control Programme (RNTCP), which treats about half of India's TB patients. We define the TB cascade as including the following patient populations: total prevalent active TB patients in India, TB patients who reach and undergo evaluation at RNTCP diagnostic facilities, patients successfully diagnosed with TB, patients who start treatment, patients retained to treatment completion, and patients who achieve 1-y recurrence-free survival. We estimate each step of the cascade for 2013 using data from two World Health Organization (WHO) reports (2014-2015), one WHO dataset (2015), and three RNTCP reports (2014-2016). In addition, we conduct three targeted systematic reviews of the scientific literature to identify 39 unique articles published from 2000-2015 that provide additional data on five indicators that help estimate different steps of the TB cascade. We construct separate care cascades for the overall population of patients with active TB and for patients with specific forms of TB-including new smear-positive, new smear-negative, retreatment smear-positive, and multidrug-resistant (MDR) TB. The WHO estimated that there were 2,700,000 (95%CI: 1,800,000-3,800,000) prevalent TB patients in India in 2013. Of these patients, we estimate that 1,938,027 (72%) TB patients were evaluated at RNTCP facilities; 1,629,906 (60%) were successfully diagnosed; 1,417,838 (53%) got registered for treatment; 1,221,764 (45%) completed treatment; and 1,049,237 (95%CI: 1,008,775-1,083,243), or 39%, of 2,700,000 TB patients achieved the optimal outcome of 1-y recurrence-free survival. The separate cascades for different forms of TB highlight different patterns of patient attrition. Pretreatment loss to follow-up of diagnosed patients and post-treatment TB recurrence were major points of attrition in the new smear-positive TB cascade. In the new smear-negative and MDR TB cascades, a substantial proportion of patients who were evaluated at RNTCP diagnostic facilities were not successfully diagnosed. Retreatment smear-positive and MDR TB patients had poorer treatment outcomes than the general TB population. Limitations of our analysis include the lack of available data on the cascade of care in the private sector and substantial uncertainty regarding the 1-y period prevalence of TB in India. CONCLUSIONS Increasing case detection is critical to improving outcomes in India's TB cascade of care, especially for smear-negative and MDR TB patients. For new smear-positive patients, pretreatment loss to follow-up and post-treatment TB recurrence are considerable points of attrition that may contribute to ongoing TB transmission. Future multisite studies providing more accurate information on key steps in the public sector TB cascade and extension of this analysis to private sector patients may help to better target interventions and resources for TB control in India.
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