Operational Challenges in Diagnosing Multi-Drug Resistant TB and Initiating Treatment in Andhra Pradesh, India

Abstract

BackgroundRevised National TB Control Programme (RNTCP), Andhra Pradesh, India. There is limited information on whether MDR-TB suspects are identified, undergo diagnostic assessment and are initiated on treatment according to the programme guidelines.ObjectivesTo assess i) using the programme definition, the number and proportion of MDR-TB suspects in a large cohort of TB patients on first-line treatment under RNTCP ii) the proportion of these MDR-TB suspects who underwent diagnosis for MDR-TB and iii) the number and proportion of those diagnosed as MDR-TB who were successfully initiated on treatment.MethodsA retrospective cohort analysis, by reviewing RNTCP records and reports, was conducted in four districts of Andhra Pradesh, India, among patients registered for first line treatment during October 2008 to December 2009.ResultsAmong 23,999 TB patients registered for treatment there were 559 (2%) MDR-TB suspects (according to programme definition) of which 307 (55%) underwent diagnosis and amongst these 169 (55%) were found to be MDR-TB. Of the MDR-TB patients, 112 (66%) were successfully initiated on treatment. Amongst those eligible for MDR-TB services, significant proportions are lost during the diagnostic and treatment initiation pathway due to a variety of operational challenges. The programme needs to urgently address these challenges for effective delivery and utilisation of the MDR-TB services.

Screening retreatment tuberculosis patients for drug resistance in mid-west Nepal: how well are we doing?

“…6 A study in China showed that less than one third of patients who should have undergone CDST actually did so. 4 In India, only 55% of MDR-TB suspects had positive culture results, 5 and in a recent study in presumptive MDR-TB patients in Cambodia, less than 50% were examined for culture and only 21% had positive M. tuberculosis cultures. 15 How do we begin to improve the system?…”

“…The logistics of getting sputum samples to a central reference laboratory (CRL), as is the case in Nepal, is not easy, and this has proved difficult in other countries. [3][4][5][6] We therefore carried out a retrospective study to determine how the CDST process worked among retreatment patients in the mid-west region of Nepal, the results of CDST when specimens did successfully reach the CRL, and the time taken for all procedures to be performed.…”

Comparative Study of Led Fluorescent Microscopy With the Conventional Zn Based Microscopy for Diagnosis of Microbiologically Confirmed Tb Cases.

“…Under Revised National TB Control Programme (RNTCP), we have one designated microscopy centre (DMC) for every 100,000 population [22]. These DMCs are responsible for detection of all the new TB cases and hence the improvement in case detection is directly related with the improvement in microscopy.…”

MDR-TB screening in a setting with molecular diagnostic techniques: Who got tested, who didn’t and why?

“…First, about 10% of patients with presumptive MDR-TB were not identified or referred for testing, an aspect missed by most of the other studies on this issue, and similar to an existing study from Andhra Pradesh, India. 9 Attrition at this stage was mainly seen among previously treated patients with EPTB (categorised as 'retreatment others'). This was predominantly due to a lack of clarity among the programme staff with respect to whether EPTB patients need to be referred.…”

“…2 Studies from around the world have raised concerns over the high pre-diagnostic and pre-treatment attrition in MDR-TB diagnosis and treatment pathways (DTP). [3][4][5][6][7][8][9] Most of these studies were conducted in settings with the capacity for phenotypic diagnostic techniques, with a long turnaround time (TAT). A study from New Delhi, India, identified a significant decrease in TAT and pre-treatment loss to follow-up in 2014 after the introduction of line probe assay (LPA) technology, mainly attributed to a decrease in laboratory diagnostic time, although other operational issues were still of concern.…”