Delays, behaviour and transmission: modelling the impact of effective private provider engagement on tuberculosis control in urban India

Abstract

2In India, the country with the world's largest burden of tuberculosis (TB), most patients first seek 3 care in the private healthcare sector, which is fragmented and unregulated. Ongoing initiatives 4 are demonstrating effective approaches for engaging with this sector, and form a central part of 5 India's recent National Strategic Plan: here we aimed to address their potential impact on TB 6 transmission in urban settings, when taken to scale. We developed a mathematical model of TB 7 transmission dynamics, calibrated to urban populations in Mumbai and Patna, two major cities 8 in India where pilot interventions are currently ongoing. 10We found that, when taken to sufficient scale to capture 75% of patient-provider interactions, the 11 intervention could reduce incidence by upto 21.3% (95% Bayesian credible interval (CrI) 13.0 -12 32.5%) and 15.8% (95% CrI 7.8 -28.2%) in Mumbai and Patna respectively, between 2018 and 13 2025. There is a stronger impact on TB mortality, with a reduction of up to 38.1% (95% CrI 20.0 14-55.1%) in the example of Mumbai. The incidence impact of this intervention alone may be 15 limited by the amount of transmission that has already occurred by the time a patient first 16 presents for care: model estimates suggest an initial patient delay of 4-5 months before first 17 seeking care, followed by a diagnostic delay of 1-2 months before ultimately initiating TB 18 treatment. Our results suggest that the transmission impact of such interventions could be 19 maximised by additional measures to encourage early uptake of TB services.