Chest Radiography and Xpert MTB/RIF® Testing in Persons with Presumptive Pulmonary TB: Gaps and Challenges from a District in Karnataka, India

Abstract

Background. In India, as per the latest diagnostic algorithm, all persons with presumptive pulmonary TB (PPTB) are required to undergo sputum smear examination and chest radiography (CXR) upfront. Those with sputum smear positive, sputum smear negative, but CXR lesions suggestive of TB or those with strong clinical suspicion of TB are expected to undergo Xpert MTB/RIF® assay test (also known as CB-NAAT (cartridge-based nucleic acid amplification test)). Objective. To assess what proportion of PPTB who are undergoing sputum smear examination at microscopy centers of public health facilities have undergone CXR and CB-NAAT. To explore the barriers for uptake of CXR and CB-NAAT from the public health care provider's perspective. Methods. We conducted a sequential explanatory mixed-methods study in Chikkaballapur district of Karnataka State, South India. The quantitative component involved a review of records of PPTB who had undergone sputum smear examination in a representative sample of seven microscopy centers. The qualitative component involved key informant interviews with four medical officers and group interviews with 9 paramedical staff. Results. In February and March 2019, about 732 PPTB had undergone smear examination. Of these, 301 (41%) had undergone CXR and 49 (7%) had undergone CB-NAAT. The proportion of PPTB who had undergone CXR varied across the seven microscopy centers (0% to 89%). CB-NAAT was higher in PPTB from urban areas when compared to rural areas (8% vs. 3%) and in those who were smear positive when compared to smear negative (65% vs. 2%). The major barriers for CXR and CB-NAAT were nonavailability of these tests at all microscopy centers and patients' reluctance to travel to the facilities where CXR and CB-NAAT services are available. Conclusions. CXR and CB-NAAT of PPTB are suboptimal. RNTCP should undertake measures to address these gaps in implementing its latest diagnostic algorithm.

A synthesis of qualitative evidence of barriers and facilitators in implementing guidelines for TB testing in healthcare settings

“…Eight studies were from lower-middle-income countries [ 9 , 31 , 36 , 37 , 40 , 41 , 43 , 46 ], five were from upper-middle-income countries [ 6 , 33 , 34 , 39 , 45 ], six were from high-income countries [ 7 , 8 , 32 , 38 , 47 , 48 ] and two were from low-income countries [ 35 , 42 ]. Four studies had representatives from a mix of countries with different income levels [ 5 , 29 , 30 , 44 ].…”

Barriers to engagement by people with active tuberculosis in the care cascade in India: a systematic review of two decades of quantitative research

“…For example, providers missed identifying patients who met criteria to undergo NAAT (up to 54%) [51], particularly patients who were not already taking TB treatment and experiencing treatment failure. While algorithms for TB evaluation, including NAAT, have evolved since some of these studies were published [47], our findings suggest that algorithms that target advanced diagnostic testing to patient subgroups run the risk of excluding eligible patients. Communication gaps were also a problem, with many patients not completing the workup because they were not informed they were undergoing sputum testing or chest X-ray due to concern for TB [44,48,56].…”

“…c Of these 15 studies, 3 reported on non-pursual of diagnostic workup despite referral [40][41][42], 4 reported on non-completion of sputum microscopy evaluation [43][44][45][46], 2 reported on chest X-ray non-completion [47,48], and 6 reported on non-completion of NAAT, line probe assay, or mycobacterial culture [47,[49][50][51][52][53].…”

“…Patients who had not been informed a chest X-ray was needed for their diagnostic workup had higher adjusted odds of non-completion. Appendix) [47,[49][50][51][52][53]. One study also found that drug susceptibility testing (DST) noncompletion was higher before the rollout of line probe assay in an unadjusted analysis [53].…”

“…The denominator for all percentages only includes individuals who had not sought care for TB symptoms in population-based surveys. CI, confidence interval; TB, tuberculosis.workup despite referral[40][41][42]; 4 reported on non-completion of sputum microscopy evaluation[43][44][45][46]; 2 reported on chest X-ray non-completion[47,48]; and 6 reported on noncompletion of NAAT, line probe assay, or mycobacterial culture among people at higher risk for drug-resistant TB[47,[49][50][51][52][53]. 10 studies described reasons for not completing the diagnostic workup, of which 2 reported on non-completion of sputum microscopy evaluation from patient interviews[44,54], 2 reported on chest X-ray non-completion from patient interviews[55,56], and 6 reported on NAAT non-completion from evaluation of health records[49][50][51][52]57,58] (Table C in S2 Appendix).Factors associated with non-pursual of the TB diagnostic workup despite referralFindings varied regarding factors associated with non-pursual of the diagnostic workup despite referral (Fig3).…”