Tuberculosis treatment discontinuation and symptom persistence: an observational study of Bihar, India’s public care system covering >100,000,000 inhabitants

Abstract

BackgroundThe effectiveness of India’s TB control programs depend critically on patients completing appropriate treatment. Discontinuing treatment prior to completion can leave patients infectious and symptomatic. Developing strategies to reduce early discontinuation requires characterizing its patterns and their link to symptom persistence.MethodsThe 2011 BEST-TB survey (360 clusters, 11 districts) sampled patients (n = 1007) from Bihar’s public healthcare system who had initiated treatment >6 months prior to being interviewed, administering questionnaires to patients about TB treatment duration and symptoms, prior treatment, and sociodemographic characteristics. Multivariate logistic regression models estimated the risk of treatment discontinuation for these characteristics. Similar models estimated probabilities of symptom persistence to 25 weeks post-treatment initiation adjusting for the same predictors and treatment duration. All models included district fixed effects, robust standard errors, and adjustments for the survey sampling design. Treatment default timing and symptom persistence relied solely on self-report.Results24% of patients discontinued treatment prior to 25 weeks. Higher likelihood of discontinuation occurred in those who had failed to complete previous TB treatment episodes (aOR: 4.77 [95% CI: 1.98 – 11.53]) and those seeing multiple providers (3.67 per provider [1.94 – 6.95]). Symptoms persisted in 42% of patients discontinuing treatment within 5 weeks versus 28% for completing 25 weeks of treatment. Symptom persistence was more likely for those with prior TB treatment (aOR: 5.05 [1.90 – 13.38]); poorer patients (2.94 [1.51 – 5.72]); and women (1.79 [1.07 – 2.99]). Predictors for treatment discontinuation prior to 16 weeks were similar.ConclusionsPremature TB treatment discontinuation and symptom persistence is particularly high among individuals who have failed to complete treatment for a prior episode. Strategies to identify and promote treatment completion in this group appear promising. Likewise, effective TB regimens of shortened duration currently in trials may eventually help to achieve higher treatment completion rates.

Providers' knowledge of diagnosis and treatment of tuberculosis using vignettes: evidence from rural Bihar, India

“…In a framework where providers with higher knowledge could charge higher fees, one possible explanation for our finding that knowledge is not adequately priced could be due to substantial asymmetric information: patients cannot directly assess providers' knowledge and cannot infer it from outcomes (either theirs or of other patients) due to variations in case-mix and infrequent experience. However, another explanation might be that knowledge might be only very loosely related to performance, 13 which is what ultimately matters for the patient.…”

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Understanding the drug exposure–response relationship of bedaquiline to predict efficacy for novel dosing regimens in the treatment of multidrug‐resistant tuberculosis

“…had other TB therapy within a month of starting BDQ in study C209, exhibited slower clearance of the bacteria. One possible explanation is that after receiving some TB therapy, multiplying bacteria are already cleared whereas nonmultiplying bacteria or persisters remain, being then more difficult to clear from the body . Other possible explanations are bias from patient selection, different effectiveness of the background TB regimen, or a multiphasic mechanism of bacterial clearance not captured by the model.…”

Tuberculosis patients not covered by treatment in public health services: findings from India's National Family Health Survey 2015–16

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