Magnitude and Reasons for Gaps in Tuberculosis Diagnostic Testing and Treatment Initiation: An Operational Research Study from Dakshina Kannada, South India.

BACKGROUND: In India, ensuring all Persons with Presumptive TB (PPTB) undergo TB diagnostic tests and initiating all diagnosed TB patients on treatment are two major implementation challenges. OBJECTIVES: In a coastal district of Karnataka state, South India, to (1) determine the number and proportion of PPTB who did not undergo any TB diagnostic test, and the number and proportion of TB patients who were not initiated on treatment (2) explore the facilitators and barriers in TB diagnostic testing and treatment initiation from health care providers' perspective. METHODS: For objective-1, we used a cross-sectional design involving review of data of PPTB enrolled for care during January-March 2019 and for objective-2, we used a qualitative design involving key informant interviews of health care providers. RESULTS: Of 8822 PPTB patients enrolled for evaluation of TB, 767 (9%) had not undergone any TB diagnostic test. In those who had undergone any TB diagnostic test, a total of 822 were diagnosed with TB and of them, 26 (3%) were not initiated on treatment. Cartridge-based nucleic acid amplification tests was used as a diagnostic test only among 1188 (13.5%) PPTB patients. The gaps in diagnostic testing were due to: non-availability of doctors/lab-technicians, inadequate knowledge about TB diagnostic tests among health care providers, reluctance of patients to undergo the TB diagnostic tests due to stigma/confidentiality issues and sub-optimal engagement of private health facilities for TB control. CONCLUSION: About 9% of PPTB not undergoing any test for TB and 3% of the TB patients not initiated on treatment are of major concern. Revised National TB Control Programme needs to address the identified barriers to improve the process of TB diagnosis and treatment initiation.

Are they there yet? Linkage of patients with tuberculosis to services for tobacco cessation and alcohol abuse - a mixed methods study from Karnataka, India.

BACKGROUND: Tobacco use and alcohol abuse are associated with higher risk of tuberculosis (TB) infection, progression to active TB and adverse treatment outcomes among patients with TB. Revised National Tuberculosis Control Programme (RNTCP) treatment guidelines (2016) require the documentation of tobacco and alcohol use among patients with TB and their linkage to tobacco and alcohol abuse treatment services. This study aimed to assess the extent of documentation of tobacco and alcohol usage data in the TB treatment card and to explore in-depth, the operational issues involved in linkage. METHODS: A convergent parallel mixed methods study was conducted. All new TB treatment cards of adult patients registered under RNTCP between January and June 2017 in Dakshina Kannada district were reviewed to assess documentation. Document review was done to understand the process of linkage (directing patients to tobacco and alcohol abuse treatment services). In-depth interview of health care providers (n = 7) and patients with TB (n = 5) explored into their perspectives on linkage. RESULTS: Among 413 treatment cards reviewed, tobacco use was documented in 322 (78%), of whom 86 (21%) were documented as current tobacco users. Sixteen (19%) out of these 86 patients were linked to tobacco cessation services. Alcohol usage status was documented in 319 (77%) cards of whom 71(17%) were documented as alcohol users. Eleven (16%) out of these 71 patients were linked to alcohol abuse treatment services. The questions in the treatment card lacked clarity. Guidelines on eliciting history of substance abuse and criteria for linkage were not detailed. Perceived enablers for linkage included family support, will power of the patients and fear of complications. Challenges included patient's lack of motivation, financial and time constraints, inadequate guidelines and lack of co-ordination mechanisms between TB programme and tobacco/alcohol abuse treatment services. CONCLUSION: Documentation was good but not universally done. Clear operational guidelines on linkage and treatment guidelines for health care providers to appropriately manage the patients with comorbidities are lacking. Lack of coordination between the TB treatment programme and tobacco cessation as well as alcohol treatment services was considered a major challenge in effective implementation of the linkage services.