High pre-diagnosis attrition among patients with presumptive MDR-TB: an operational research from Bhopal district, India

Abstract

BackgroundPre-diagnosis attrition needs to be addressed urgently if we are to make progress in improving MDR-TB case detection and achieve universal access to MDR-TB care. We report the pre-diagnosis attrition, along with factors associated, and turnaround times related to the diagnostic pathway among patient with presumptive MDR-TB in Bhopal district, central India (2014).MethodsStudy was conducted under the Revised National Tuberculosis Control Programme setting. It was a retrospective cohort study involving record review of all registered TB cases in Bhopal district that met the presumptive MDR-TB criteria (eligible for DST) in 2014. In quarter 1, Line Probe Assay (LPA) was used if sample was smear/culture positive. Quarter 2 onwards, LPA and Cartridge-based Nucleic Acid Amplification Test (CbNAAT) was used for smear positive and smear negative samples respectively. Pre-diagnosis attrition was defined as failure to undergo DST among patients with presumptive MDR-TB (as defined by the programme).ResultsOf 770 patients eligible for DST, 311 underwent DST and 20 patients were diagnosed as having MDR-TB. Pre-diagnosis attrition was 60% (459/770). Among those with pre-diagnosis attrition, 91% (417/459) were not identified as ‘presumptive MDR-TB’ by the programme. TAT [median (IQR)] to undergo DST after eligibility was 4 (0, 10) days. Attrition was more than 40% across all subgroups. Age more than 64 years; those from a medical college; those eligible in quarter 1; patients with presumptive criteria ‘previously treated – recurrent TB’, ‘treatment after loss-to-follow-up’ and ‘previously treated-others’; and patients with extra-pulmonary TB were independent risk factors for not undergoing DST.ConclusionHigh pre-diagnosis attrition was contributed by failure to identify and refer patients. Attrition reduced modestly with time and one factor that might have contributed to this was introduction of CbNAAT in quarter 2 of 2014. General health system strengthening which includes improvement in identification/referral and patient tracking with focus on those with higher risk for not undergoing DST is urgently required.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2191-6) contains supplementary material, which is available to authorized users.

Where, when, and how many tuberculosis patients are lost from presumption until treatment initiation? A step by step assessment in a rural district in Zimbabwe

“…To understand the losses before TB diagnosis, it is important to study the care cascade in detail from presumption to the availability of test results. Pre-diagnosis LTFU among people with presumptive TB and its associated factors have been studied in presumptive multidrug-resistant TB (MDR-TB) but not in drugsusceptible TB (Chadha et al, 2011;Khann et al, 2013;Li et al, 2014;Shewade et al, 2016Shewade et al, , 2017. In South Africa, the care cascade was studied among persons with presumptive drug-susceptible TB during the diagnostic process (from sputum receipt in the laboratory to testing) but not in the period before sputum receipt in the laboratory (Botha et al, 2008).…”

Treatment Initiation among Patients with Multidrug Resistant Tuberculosis in Bhopal District, India

“…Previously, we found 60% pre-diagnosis loss to follow-up among patients with presumptive MDR-TB in 2014 in Bhopal, largely contributed by failure to refer patients for DST [3]. Considering the minimal pre-diagnosis loss to follow-up at the level of NRL [3] and the low pre-treatment loss to follow-up identified in this study, we can infer that performance of the diagnostic and treatment pathway was satisfactory once the sample reached the NRL.…”

“…Considering the minimal pre-diagnosis loss to follow-up at the level of NRL [3] and the low pre-treatment loss to follow-up identified in this study, we can infer that performance of the diagnostic and treatment pathway was satisfactory once the sample reached the NRL.…”

“…India has highest burden of multidrug-resistant/rifampicin-resistant tuberculosis [3]. Here, we report the pre-treatment loss to follow-up (between confirmed MDR-TB and treatment initiation) and time from diagnosis to treatment initiation.…”

Overcoming the health system barriers to early diagnosis and management of multidrug-resistant tuberculosis in a rural setting in North India

“…The case detection rate for MDR-TB was 22%, as only 28 876 cases were notified against an estimated 130 000 MDR-TB cases in 2015, and a total of 24 396 (84%) of the diagnosed cases were put on treatment 4 11. Many studies have raised concerns over the high rates of prediagnosis and pretreatment attrition and/or delays in the diagnosis and treatment pathway for MDR-TB 12–22. Prompt identification of patients with presumptive MDR-TB (one who is eligible for DST), diagnosis of MDR-TB and initiation of treatment are crucial to preventing disease transmission and reducing the high morbidity and mortality 9…”