Pre-treatment delay and out of pocket expenses by notified new tuberculosis patients in an Indian mega city.

BACKGROUND: Study was carried out to find out delay from onset of symptoms and out of pocket expenditure (OOPE) until initiation of anti-TB treatment (ATT) by new Tuberculosis (TB) patients registered in public health facilities in Bengaluru. METHODS: Notified patients (N = 228) selected purposively were interviewed at initiation of ATT regarding number and type of facilities visited and delay in initiating ATT. OOPE was elicited separately for in- and out-patient visits, towards consultation, purchase of medicines, diagnostic tests, transportation, hospitalization and food. Dissaving or money borrowed was ascertained. RESULTS: Two-thirds of participants were 15-44 years of age and 56% were males, mean annual household income was $4357. About 75% first visited a private health facility; 68% and 87% respectively were diagnosed and started on ATT in public sector after visiting an average of three facilities and after a mean delay of 68 days; the median delay was 44 days. Of mean OOPE of $402, 54% was direct medical expenditure, 5% non-medical direct and 41% indirect. OOPE was higher for Extra-pulmonary TB compared to PTB and when number of health facilities visited before initiating treatment was >3 compared to those who visited ≤3 and when the time interval between onset of symptoms and treatment initiation (total delay) was >28 days compared to when this interval was ≤28 days. About 20% suffered catastrophic expenditure; 34% borrowed money and 37% sold assets. CONCLUSION: Concerted efforts are needed to reduce delay and OOPE in pre-treatment period and social protection to account for indirect expenditure.

Active tuberculosis case finding in India - The way forward.

Community based active case finding (ACF) for tuberculosis (TB) has seen resurrection in the current armamentarium of many TB managers in their fight toward eliminating TB. This article explores the accuracy and approximate cost of various ACF algorithms currently in vogue in India or those which could be useful, while inputting the sensitivity and specificity of screening and diagnostic tools as estimated from recently conducted community based surveys. This analysis informs that ACF may be prioritized to higher prevalence settings and the diagnostic algorithm for specific setting may be chosen taking into account the expected prevalence, estimated accuracy of the algorithm and resource availability. Further, chest X-ray cannot be used alone as a diagnostic tool and can be relied upon for this purpose when at least one of the three sputum specimen is smear positive. Accuracy of Xpert MTB/RIF as a diagnostic tool in community situations needs to be investigated further. The review brings out significant proportions of initial default and default during treatment among cases detected through ACF thus emphasizing the need for heightened efforts toward preventing the same. The article rounds off emphasizing priority to addressing barriers to speedy scale up of more sensitive diagnostic tools for health center based case finding including in private sector and ACF in high risk clinical groups for early and efficient case detection. It concludes by putting forth certain research areas that would strengthen future efforts.

Sub-national TB prevalence surveys in India, 2006-2012: Results of uniformly conducted data analysis.

SETTING: Community based tuberculosis (TB) prevalence surveys in ten sites across India during 2006-2012. OBJECTIVE: To re-analyze data of recent sub-national surveys using uniform statistical methods and obtain a pooled national level estimate of prevalence of TB. METHODS: Individuals ≥15 years old were screened by interview for symptoms suggestive of Pulmonary TB (PTB) and history of anti-TB treatment; additional screening by chest radiography was undertaken in five sites. Two sputum specimens were examined by smear and culture among Screen-positives. Prevalence in each site was estimated after imputing missing values to correct for bias introduced by incompleteness of data. In five sites, prevalence was corrected for non-screening by radiography. Pooled prevalence of bacteriologically positive PTB was estimated using Random Effects Model after excluding data from one site. Overall prevalence of TB (all ages, all types) was estimated by adjusting for extra-pulmonary TB and Pediatric TB. RESULTS: Of 769290 individuals registered, 715989 were screened by interview and 294532 also by radiography. Sputum specimen were examined from 50 852 individuals. Estimated prevalence of smear positive, culture positive and bacteriologically positive PTB varied between 108.4-428.1, 147.9-429.8 and 170.8-528.4 per 100000 populations in different sites. Pooled estimate of prevalence of bacteriologically positive PTB was 350.0 (260.7, 439.0). Overall prevalence of TB was estimated at 300.7 (223.7-377.5) in 2009, the mid-year of surveys. Prevalence was significantly higher in rural compared to urban areas. CONCLUSION: TB burden continues to be high in India suggesting further strengthening of TB control activities.

Sensitivity and specificity of screening tools and smear microscopy in active tuberculosis case finding.

SETTING: Community based five pulmonary tuberculosis (PTB) surveys among adults. OBJECTIVES: Estimate sensitivity and specificity of screening tools for PTB and sputum microscopy. METHODS: For each survey site, we estimated sensitivity and specificity of different screening criteria and microscopy against culture; pooled estimates were obtained using Random Effects Model. RESULTS: Sensitivity of cough alone, screening for any symptom (persistent cough ≥2 weeks, fever or chest pain ≥1 month, hemoptysis), any symptom or history of anti-TB treatment (h/o ATT) were 56.2%, 66% and 71.2% respectively; specificities were 95.3%, 93.8% and 92.7% respectively. X-ray when used alone for primary screening had sensitivity and specificity of 76.6% and 97.3% respectively. When used along with screening for cough, these figures were 94.3% and 93.1%, and 100% and 97.3% when used with any symptom and h/o ATT. When used for secondary screening, sensitivity and specificity of X-ray was 66.8% and 87.8% respectively after primary screening for cough, 65.0% and 89.8% after screening for any symptom, and 67.1% and 86.7% when used after screening for any symptom or h/o ATT. Pooled sensitivity and specificity of smear was 46.2% and 99.3% respectively. CONCLUSION: Program managers may use these estimates while evaluating algorithms for active case finding.

Tuberculosis diagnostic and treatment practices in private sector: Implementation study in an Indian city.

SETTING: Implementation study in private health facilities in an Indian metropolis. OBJECTIVES: Improve Tuberculosis (TB) care by private practitioners (PPs). METHODS: PPs from a defined city area were imparted short training in TB care and linkages made with public facilities; subsequent practices were recorded. RESULTS: Of 364 presumptive TB patient records, 70 (19.3%) did not conform to its definition. Of the conforming, 174 (59.2%) had presumptive pulmonary TB (PTB), 53 (18%) presumptive extra-pulmonary (EPTB) and 67 (24%) had both. Of conforming presumptive PTB, most underwent Chest X-ray and sputum examination in private laboratories. Tissue based diagnostics were not advised for most presumptive EPTB patients. Of 101 cases diagnosed with TB, 82% were new, 23% known diabetic and 4.7% human immune deficiency virus (HIV) reactive out of 64 tested. Most were notified and initiated treatment within 15 days of diagnosis. One-fourth was prescribed standard treatment regimen and treatment was not directly observed for most. One third was initial defaulters or lost during treatment; 62% of PTB and 46% EPTB cases initiated on treatment in private were successfully treated. Of successfully treated PTB cases, 61% had undergone follow-up sputum examination. CONCLUSION: Much intensified support mechanisms are needed to improve TB care in private sector.

Knowledge of private practitioners of Bangalore city in diagnosis, treatment of pulmonary tuberculosis and compliance with case notification.

One hundred and twenty-nine qualified private practitioners (PPs) were assessed on their knowledge in diagnosis of pulmonary tuberculosis (PTB), treatment of a new drug sensitive PTB case and practices of case notification, using semi-structured questionnaire. About 20% had adequate knowledge of diagnosis, 29% of treatment regimen, 54% the need for Direct Observation Treatment and 57% about role of sputum smear examination in monitoring treatment response. Of 85 (68%) PPs who had diagnosed any TB case during last two years, 54 (64%) had practised notification. These findings suggest the need for upgrading knowledge of PPs in TB diagnosis, treatment and notification.

A descriptive study of tuberculosis case finding in private health care facilities in a South Indian district.

SETTING: A South Indian district providing anti-tuberculosis services through the Revised National TB Control Programme (RNTCP) and private health care facilities. OBJECTIVE: To ascertain the profile of tuberculosis (TB) patients diagnosed and/or treated in private health care facilities. METHODS: Data on TB cases diagnosed and/or treated in all clinical departments of the medical college, 83 nursing homes and RNTCP health care facilities were collected prospectively. RESULTS: About 83% of new TB cases recorded in the private medical college, 47% in nursing homes and 24.5% in RNTCP TB registers were extra-pulmonary. The proportion of retreatment cases was respectively 5.5%, 9.6% and 19.8%. The proportion of males and those in the economically productive age group were similar in the three data sources. About 94% of cases diagnosed in the medical college and 55% in nursing homes were registered for treatment under the RNTCP. About 11% of the smear-positive patients diagnosed in RNTCP were initial defaulters. CONCLUSION: The proportion of extra-pulmonary cases was higher in the medical college and nursing homes and that of retreatment cases was lower than in the RNTCP.

Are registered sputum smear-negative tuberculosis patients in Karnataka, India, diagnosed by national algorithm?

SETTING: Four districts of Karnataka State, India, that have implemented the National Tuberculosis Control Programme (RNTCP). OBJECTIVE: To assess the proportion of patients diagnosed according to the nationally recommended algorithm among new smear-negative (NSN) PTB cases registered under the RNTCP. METHODS: Information on 201 registered NSN-PTB patients as regards date of initial sputum examination, repeat sputum examination and chest X-ray (CXR) if undertaken, treatment initiation and number of days of antibiotic treatment after initial sputum examination, were collected through record review and patient interviews. In patients with negative or unknown human immunodeficiency virus (HIV) status, the algorithm was considered completed if the patient underwent initial sputum examination, antibiotic trial for ⩾10 days, repeat sputum examination ⩾10 days after initial sputum examination, CXR after repeat sputum examination and anti-tuberculosis treatment ⩾10 days after initial sputum examination. In HIV-positive patients, the algorithm was considered completed if CXR was performed after or at the same time as initial sputum examination. RESULTS: Complete information was available for 170 patients. Of these, the algorithm was completed in 14 (8.2%, 95%CI 0.9-15.5): 1/140 patients with negative or unknown HIV status and 13/30 HIV-positive patients. CONCLUSION: The algorithm was not completed in most patients registered for treatment. Measures are needed to improve the diagnostic process for smear-negative PTB.

Implementation efficiency of a diagnostic algorithm in sputum smear-negative presumptive tuberculosis patients.

BACKGROUND: For the diagnosis of smear-negative pulmonary tuberculosis (PTB), India's Revised National Tuberculosis Control Programme (RNTCP) recommends a course of broad-spectrum antibiotics after negative smear on initial sputum examination, followed by repeat sputum examination and chest X-ray (CXR). OBJECTIVES: 1) To ascertain the proportion of presumptive PTB patients smear-negative on initial sputum examination who completed the diagnostic algorithm, and 2) to investigate barriers to the completion of the algorithm. METHODS: In Karnataka State, India, 256 study participants were interviewed in 2012 to ascertain the number of days antibiotics had been prescribed and consumed, the number of re-visits to health centre(s), whether repeat sputum examinations had been performed, whether or not CXR had been performed and when, and whether PTB had been diagnosed. In-depth interviews were conducted with 19 medical officers. RESULTS: The diagnostic algorithm was completed in 13 (5.1%) of 256 participants; three were diagnosed with PTB without completing the algorithm. Most medical officers were unaware of the algorithm, had trained 5-10 years previously, prescribed antibiotics for <10 days and advised CXR without repeat sputum examination, irrespective of the number of days of antibiotic treatment. Other main reasons for non-completion of algorithm were patients not returning to the health centres and a proportion switching to the private sector. CONCLUSION: Refresher training courses, raising patient awareness and active follow-up of patients to complete the algorithm are suggested.

Role of pre-Xpert® screening using chest X-ray in early diagnosis of smear-negative pulmonary tuberculosis.

In a sub-district level hospital in South India, the proportion of patients with abnormal chest X-ray (CXR) was evaluated among smear-negative, Xpert® MTB/RIF (Xpert) positive individuals with pulmonary tuberculosis (PTB) symptoms; 384 smear-negative PTB individuals with PTB symptoms and without a history of anti-tuberculosis treatment underwent CXR and Xpert testing of one sputum specimen. Of 378 individuals with both Xpert and CXR results available, 14 were positive for Mycobacterium tuberculosis. Of these, 13 (92.9%) had an abnormal CXR and one was normal. This study highlights the usefulness of CXR before Xpert testing, which needs further validation.

Treatment outcome of tuberculosis patients in a clinic of Bangalore.

A total of 112 cases (New = 101, previously treated = 11) were diagnosed as suffering from tuberculosis (TB) at a private clinic in Bangalore city. The clinic identified TB suspects, established diagnosis of TB, administered direct observation of treatment (DOT), maintained treatment cards and undertook defaulter retrieval actions as and when required. The Revised National Tuberculosis Control Programme (RNTCP) provided support in terms of sputum microscopy supply of patient-wise drug boxes and registration of patients. Ninety six (95.1%) of new cases and 10 (90.9%) of previously treated cases had successful treatment outcome. Most patients completed treatment within the prescribed period. No TB deaths were reported during the period of treatment.