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

Shewade, Hemant Deepak; Kokane, Arun; Singh, Akash Ranjan; Verma, Manoj Kumar; Parmar, Malik; Chahar, Sanjay Singh; Tiwari, Manoj Kumar; Khan, Sheeba Naz; Nagar, Mukesh; Singh, Saurabh; Mehra, Pradeep Kumar; Kumar, Ajay

doi:10.4236/jtr.2017.54025

Cited by 5 publications

(6 citation statements)

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“…14 Attrition in other settings with a genotypic DST facility were 21% in Bangladesh (2012-2014); respectively 12%, 13% and 38% in New Delhi (2011-2012), Bhopal (2014) and Chennai (2014), India; and 37% in South Africa (2011 and 2013). 10,18,23,26,29,30 While we are not sure of the reasons for this excellent performance, we speculate that it might be due to the decentralised initiation of MDR-TB treatment in the district hospital, instead of referring them for treatment to the DR-TB centre in accordance with RNTCP guidelines, particularly in the case of patients who were not severely ill.…”

Section: Interpretation Of Key Findingsmentioning

confidence: 93%

“…The cut-off of 6 months was arbitrary, as there is no prescribed cut-off, but the 6-month cut-off has been used previously. 18,23 Among those initiated on treatment, we calculated the median (interquartile range [IQR]) time in days to initiate treatment (from date of diagnosis). Log-binomial regression (enter method) and modified Poisson regression using robust variance estimates (enter method) were used for adjusted analysis of risk factors for pre-treatment attrition and delay (>7 days) in initiating treatment, respectively.…”

Section: Data Management and Statistical Analysismentioning

confidence: 99%

“…There is limited published literature on risk factors for pre-treatment attrition and delay in treatment initiation among MDR-TB patients from India, mostly due to limited sample size for a risk factor analysis. 10,12,13,18,19 Understanding the risk factors will help programme managers working at national and local levels to strengthen their PMDT services and bridge the diagnosis-treatment gap.…”

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confidence: 99%

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Delay and attrition before treatment initiation among MDR-TB patients in five districts of Gujarat, India

Shewade¹,

Shringarpure²,

Parmar

et al. 2018

public health action

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Setting: Gujarat, a state in west India. Background: Although treatment initiation has been improving among patients diagnosed with multidrug-resistant tuberculosis (MDR-TB) in programme settings, it has still not reached 100%. Objectives: To determine pre-treatment attrition (not initiated on treatment within 6 months of diagnosis), delay in treatment initiation (7 days from diagnosis) and associated factors among MDR-TB patients diagnosed in 2014 in five selected districts served by two genotypic drug susceptibility testing (DST) facilities and a drug-resistant TB centre in Gujarat. Design: This was a retrospective cohort study involving record review. Results: Among 257 MDR-TB patients, pre-treatment attrition was seen in 20 (8%, 95%CI 5-12). Patients with 'follow-up sputum-positive' as their DST criterion and sputum smear microscopy status 'unknown' at the time of referral for DST were less likely to be initiated on treatment. The median delay to treatment initiation was 8 days (interquartile range 6-13). Patients referred for DST from medical colleges were more likely to face delays in treatment initiation. Conclusion: The Gujarat TB programme is performing well in initiating laboratory-confirmed MDR-TB patients on treatment. However, there is further scope for reducing delay.

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Section: Interpretation Of Key Findingsmentioning

confidence: 93%

Section: Data Management and Statistical Analysismentioning

confidence: 99%

mentioning

confidence: 99%

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Delay and attrition before treatment initiation among MDR-TB patients in five districts of Gujarat, India

Shewade¹,

Shringarpure²,

Parmar

et al. 2018

public health action

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“…HDS and ARS were not programme staff. Both were part of the quantitative study that preceded this study [ 16 , 17 ]. ARS had prior interaction with the staff as he and his institution worked in close collaboration with the TB programme in the district.…”

Section: Methodsmentioning

confidence: 99%

“…The turnaround times were satisfactory for those who completed the care pathway. Most of the pre-diagnosis attrition was contributed by failure to refer eligible patients for molecular DST by programme staff [ 16 , 17 ]. Despite being in contact and engaged with the TB programme (these ‘high risk’ patients were already diagnosed or registered for treatment within the programme), all eligible TB patients did not undergo DST as per guidelines.…”

Section: Introductionmentioning

confidence: 99%

Provider reported barriers and solutions to improve testing among tuberculosis patients ‘eligible for drug susceptibility test’: A qualitative study from programmatic setting in India

et al. 2018

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BackgroundIn a study conducted in Bhopal district (a setting with facility for molecular drug susceptibility testing (DST)) located in central India in 2014–15, we found high levels of pre-diagnosis attrition among patients with presumptive multi drug-resistant tuberculosis (MDR-TB)–meaning TB patients who were eligible for DST, were not being tested.ObjectivesIn this study, we explored the health care provider perspectives into barriers and suggested solutions for improving DST.MethodsThis was a descriptive qualitative study. One to one interviews (n = 10) and focus group discussions (n = 2) with experienced key informants involved in programmatic management of DR-TB were conducted in April 2017. Manual descriptive thematic analysis was performed.ResultsThe key barriers reported were a) lack of or delay in identification of patients eligible for DST because of using treatment register as the source for identifying patients b) lack of assured specimen transport after patient identification and c) lack of tracking. Extra pulmonary TB patients were not getting identified as eligible for DST. Solutions suggested by the health care providers were i) generation of unique identifier at identification in designated microscopy center (DMC), immediate intimation of unique identifier to district and regular monitoring by senior TB laboratory and senior treatment supervisors of patients eligible for DST that were missed; ii) documentation of unique identifier at each step of cascade; iii) use of human carriers/couriers to transport specimen from DMCs especially in rural areas; and iv) routine entry of all presumptive extra-pulmonary TB specimen, as far as possible, in DMC laboratory register.ConclusionLack of assured specimen transport and lack of accountability for tracking patient after identification and referral were the key barriers. The identification of patients eligible for DST among microbiologically confirmed TB at the time of diagnosis and among clinically confirmed TB at the time of treatment initiation is the key. Use of unique identifier at identification and its use to ensure cohort wise tracking has to be complemented with specimen transport support and prompt feedback to the DMC. The study has implications to improve detection of MDR-TB among diagnosed/notified TB patients.

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Pre-treatment loss to follow-up among patients with rifampicin-resistant tuberculosis in Baluchistan, Pakistan, 2012-17: a retrospective cohort study

Aziz

Wali

Fatima³

et al. 2018

F1000Res

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Background: Patients with rifampicin-resistant TB (RR-TB) pretreatment loss to follow-up continue to be a global health challenge. Although the accuracy of diagnosis significantly increased with the implementation of Xpert MTB/RIF assay, which is a rapid molecular based test and more sensitive than conventional microscopy which detects MTB even present in small limit of 136 MTB/ml of sputum, but still data suggest a wide treatment initiation gap among diagnosed. This study was done to assess the proportion of patients with RR-TB pretreatment lost to follow-up and the socio-demographic factors associated with this in Balochistan, Pakistan. Methods: This was a retrospective cohort study based on review of the routinely managed program records. The data included all patients with RR-TB detected at Fatima Jinnah Chest & General Hospital Quetta and District Head Quarter Hospital Loralai, Xpert sites and enrolled at programmatic management of drug resistant TB (PMDT) sites during 2012-2017. Data collected was double-entered, validated and analyzed using EpiData. Results: Of the 396 patients with RR-TB detected during 2012-17, 78 (19.8%) underwent pre-treatment lost to follow-up. The mean age of those detected with RR-TB was 37 years (SD ±16.98); 189 (48%) were of age group 15-34, while 60% were female. Among 84 individuals referred out to other facilities, only 6 started treatment. Almost half of the ‘pretreatment lost to follow-up’ patients were from age group 15-34, while 43 were from within the Quetta and Loralai districts. Conclusions: The high proportion of patients with RR-TB that were pre-treatment lost to follow-up in Balochistan needs immediate strategies to establish linkages between Xpert and PMDT sites for the timely management of patients to prevent the spread of RR-TB infection.

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

Cited by 5 publications

References 5 publications

Delay and attrition before treatment initiation among MDR-TB patients in five districts of Gujarat, India

Delay and attrition before treatment initiation among MDR-TB patients in five districts of Gujarat, India

Provider reported barriers and solutions to improve testing among tuberculosis patients ‘eligible for drug susceptibility test’: A qualitative study from programmatic setting in India

Pre-treatment loss to follow-up among patients with rifampicin-resistant tuberculosis in Baluchistan, Pakistan, 2012-17: a retrospective cohort study

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