Patient characteristics, health seeking and delays among new sputum smear positive TB patients identified through active case finding when compared to passive case finding in India

Abstract

BackgroundAxshya SAMVAD is an active tuberculosis (TB) case finding (ACF) strategy under project Axshya (Axshya meaning ‘free of TB’ and SAMVAD meaning ‘conversation’) among marginalized and vulnerable populations in 285 districts of India.ObjectivesTo compare patient characteristics, health seeking, delays in diagnosis and treatment initiation among new sputum smear positive TB patients detected through ACF and passive case finding (PCF) under the national TB programme in marginalized and vulnerable populations between March 2016 and February 2017.MethodsThis observational analytic study was conducted in 18 randomly sampled Axshya districts. We enrolled all TB patients detected through ACF and an equal number of randomly selected patients detected through PCF in the same settings. Data on patient characteristics, health seeking and delays were collected through record review and patient interviews (at their residence). Delays included patient level delay (from eligibility for sputum examination to first contact with any health care provider (HCP)), health system level diagnosis delay (from contact with first HCP to TB diagnosis) and treatment initiation delays (from diagnosis to treatment initiation). Total delay was the sum of patient level, health system level diagnosis delay and treatment initiation delays.ResultsWe included 234 ACF-diagnosed and 231 PCF-diagnosed patients. When compared to PCF, ACF patients were relatively older (≥65 years, 14% versus 8%, p = 0.041), had no formal education (57% versus 36%, p<0.001), had lower monthly income per capita (median 13.1 versus 15.7 USD, p = 0.014), were more likely from rural areas (92% versus 81%, p<0.002) and residing far away from the sputum microscopy centres (more than 15 km, 24% versus 18%, p = 0.126). Fewer patients had history of significant loss of weight (68% versus 78%, p = 0.011) and sputum grade of 3+ (15% versus 21%, p = 0.060). Compared to PCF, HCP visits among ACF patients was significantly lower (median one versus two HCPs, p<0.001). ACF patients had significantly lower health system level diagnosis delay (median five versus 19 days, p = 0.008) and the association remained significant after adjusting for potential confounders. Patient level and total delays were not significantly different.ConclusionAxshya SAMVAD linked the most impoverished communities to TB care and resulted in reduction of health system level diagnosis delay.

Active versus passive case finding for tuberculosis in marginalised and vulnerable populations in India: comparison of treatment outcomes

“…However, similar to the Myanmar study, the finding in our study allays fears that people with TB detected through ACF could have poor outcomes due to delay in treatment initiation, poor adherence and treatment completion as they are relatively healthier and the diagnosis is not patient-initiated [11]. Additionally, the treatment initiation delays in our cohort of people with TB were not significantly different in the ACF and PCF groups (published elsewhere) [22]. This warrants systematic adherence assessment studies and a qualitative systematic enquiry in India and similar high TB burden countries which can feed into interventions to ensure that early diagnosis through ACF translates into improved outcomes.…”

“…The 'Axshya SAMVAD study' was primarily designed to study the differences in total pre-treatment delay among ACF and PCF-diagnosed people with TB, with a sample size of 325 in each group [20][21][22]. Assessment of the relative difference in TB treatment outcomes was the secondary objective.…”

“…A baseline characteristic was considered as confounder if it was associated both with ACF (p < 0.05 or clinically significant difference of at least 5%) and unfavourable outcome (p < 0.2), after ruling out multicollinearity. Variables in the causal pathway like delay before diagnosis and treatment and catastrophic costs due to TB diagnosis were not considered as confounders [21,22,27]. HIV was positive only in one patient and therefore not included.…”

“…The ACF focussed on increasing the detection of people with new smear-positive pulmonary TB. It resulted in detection of a large number of persons with presumptive pulmonary TB and smearpositive pulmonary TB, reduced diagnosis delay, reduced costs due to TB diagnosis and prevalence of catastrophic costs due to TB diagnosis [19][20][21][22]. However, we do not know whether this translated into improved TB treatment outcomes.…”

Active Case Finding for Tuberculosis through TOUCH Agents in Selected High TB Burden Wards of Kolkata, India: A Mixed-methods Study on Outcomes and Implementation Challenges

“…Also, the studies have reported ACF to be beneficial in reducing delay in TB diagnosis, out of pocket expenditure, unsuccessful treatment outcomes and incidence of TB [3,7,8]. The benefits of community based ACF activity depends on selection of high risk group, prevalence of the TB in the selected group, incentives provided to healthcare workers, the diagnostic algorithm adopted, and support provided to patients in completing the cascade of TB diagnosis and treatment.…”