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

Abstract

Objectives: To describe the pre-diagnosis and pre-treatment loss to follow-up (LTFU) in the tuberculosis (TB) care cascade in Guruve (2015-16), a rural district in Zimbabwe. Design: Guruve has 19 rural health centres (RHCs) and one district hospital. In this cohort study, persons !15 years of age with presumptive pulmonary TB were tracked from the facility presumptive TB registers to the laboratory registers; if laboratory diagnosed, they were tracked to the district TB register (contains details of all TB patients registered for treatment). Each patient was tracked for 90 days after registration as presumptive TB and for 90 days after laboratory diagnosis. Environmental health technicians transported sputum specimens from the health facilities to the laboratories (n = 3). Results: Of 2974 persons with presumptive TB, pre-diagnosis LTFU occurred in 575 (19%, 95% confidence interval 18-21%). Associated factors included registration at a RHC, at a facility more than 2 km from the laboratory, and absence of an environmental health technician. Of 162 laboratory diagnosed pulmonary TB patients, pre-treatment LTFU occurred in 19 (12%, 95% confidence interval 8-18%). Conclusions: The presumptive TB register was helpful to assess the pre-diagnosis gaps beginning from presumption. Pre-diagnosis LTFU can be reduced by placement of an environmental health technician at all facilities.

Where are patients missed in the tuberculosis diagnostic cascade? A prospective cohort study in Ghana

“…In south-east Ghana, more than a quarter of presumptive TB patients never submitted a sputum, and non-submission of sputum was most strongly associated with longer distance to the laboratory. Studies from Zimbabwe, India and Tanzania have also reported high pre-diagnosis loss-to-follow, 25%, 30.4% and 44% respectively [16][17][18], and some studies, including one from Ghana, showed that attending rural health clinics and long travel distance were risk factors for delay or pre-diagnosis loss to follow-up [7,10,17,19]. In contrast, pre-diagnosis attrition was lower in South Africa and China (5% and 11% respectively) [20,21], perhaps because in South Africa, sputum specimens are transported free to a central laboratory for diagnosis.…”

“…There is a wealth of literature on health facility contribution to delayed or missed diagnosis of TB and pre-treatment loss-to-follow up [5][6][7][8][9]; however, most are cross-sectional studies involving TB patients already on treatment, thus excluding those who never started treatment, or retrospective reviews of secondary data [10]. To better understand losses from the care cascade, we conducted a prospective observational cohort study to identify where and when potential TB patients are missed in the diagnostic cascade.…”

The Growing Importance of Tuberculosis Preventive Therapy and How Research and Innovation Can Enhance Its Implementation on the Ground

“…Substantial delays from first symptoms to diagnosis are therefore often the norm. Large numbers of symptomatic individuals presenting to health facilities may also fail to be properly screened or investigated with appropriate microbiological or radiological tests and the diagnosis of TB therefore can be completely missed [7,8]. These problems of so-called "passive case finding" have plagued TB Control Programmes for decades and programmes frequently overlook the proportion of patients who suffer the fate of pre-diagnostic loss to follow-up.…”

Eliminating tuberculosis by 2035: tackling the financial barriers at all stages of the cascade of care

“…Two recent studies in Zimbabwe highlight the huge pre-diagnostic losses to follow-up that can occur between onset of symptoms, when patients are identified as having presumptive TB, and laboratory diagnosis. 2,3 The first study found that 55% of HIVinfected persons with presumptive TB who should have had a diagnostic Xpert w MTB/RIF assay (Cepheid, Sunnyvale, CA, USA) failed to have the test done, 2 and the second study conducted in Guruve (a rural district) found that 19% of nearly 3000 persons with presumptive TB failed to be investigated in a district laboratory. 3 In Guruve, an important risk factor was distance between the health facility that registered the presumptive TB patients and the laboratory tasked with analysing the specimens.…”

“…2,3 The first study found that 55% of HIVinfected persons with presumptive TB who should have had a diagnostic Xpert w MTB/RIF assay (Cepheid, Sunnyvale, CA, USA) failed to have the test done, 2 and the second study conducted in Guruve (a rural district) found that 19% of nearly 3000 persons with presumptive TB failed to be investigated in a district laboratory. 3 In Guruve, an important risk factor was distance between the health facility that registered the presumptive TB patients and the laboratory tasked with analysing the specimens. Other risk factors for pre-diagnostic loss to followup include TB-related stigma, direct non-medical costs (including food and transport), income loss and direct medical costs, including payments for laboratory tests, consultation fees and hospitalisation.…”