Initial default among tuberculosis patients diagnosed in selected medical colleges of Puducherry: issues and possible interventions

Abstract

Background: India accounts for one-fourth of the global incident tuberculosis (TB) case load and tops the list of highburden countries. Initial default and loss to follow-up are important challenges in achieving the objectives of the Revised National TB Control Programme (RNTCP). Objective: A study was carried out to estimate the proportion of initial defaulters, reasons for initial default, and recommendations to reduce initial default. Materials and Methods: A record-based study was carried out to identify the initial defaulters among new sputumpositive TB patients diagnosed during 1 year (2013) in four medical colleges of Puducherry. On the basis of the completeness of recorded residential address and availability of the patients, 38 patients were contacted and enrolled in the study. A pretested and predesigned questionnaire was used to interview the patients and open-ended questions were used to elicit the reason for initial default. Results: The proportion of initial default among all the four medical colleges was 15.3%. Patient-related factors for initial default were long distance to the health facility, lack of support from the family members, being advised against alcohol consumption while taking treatment, monetary constraints, job constraints, not convinced about results by the health facility, stigma related to TB, and lack of awareness regarding TB. Health system-related factors were unpleasant experience with the health system, lack of dissemination of adequate information regarding further course of action to the patients, and nonavailability of the laboratory staff. Conclusion: The magnitude of initial default was found to be high in Puducherry and most of the reasons for initial default found in this study were preventable. Systematic methods to prevent initial default need to be chalked out by program managers in collaboration with various medical colleges under the RNTCP.

The Tuberculosis Cascade of Care in India’s Public Sector: A Systematic Review and Meta-analysis

“…Of these, 14 contain relevant data on pretreatment loss to follow-up of smear-positive TB patients [44–46,60,62–71], and two studies contain data on pretreatment loss to follow-up of MDR TB patients [47,48]. …”

“…Three of these studies provide specific information on the proportion of pretreatment loss to follow-up patients who are lost during the referral process. These studies report that 98/120 (81.6%) [44], 62/63 (98.4%) [45], and 75/145 (51.7%) [46] of pretreatment loss to follow-up among smear-positive patients occurred during referral, for a pooled prevalence of 235/328 (71.6%, 95%CI: 66.5%–76.3%). The pooled prevalence of the two studies of MDR TB patients shows a pretreatment loss to follow-up rate of 23.0% (95%CI: 21.8%–24.3%) (Table H in S3 Text).…”

“…Improving care at public sector facilities may help to retain these patients—by increasing case detection (e.g., through use of more sensitive and rapid molecular tests), accelerating the time to treatment initiation, improving linkage of diagnosed patients to care, and making TB services more patient-friendly. In addition, since most diagnosed patients in Gap 2 are lost during the process of referral from TB microscopy centers to local DOT centers [44–46], strengthening patient tracking and improving the accountability of the health system for these patients may help address this gap.…”

“…The studies of smear-positive pretreatment loss to follow-up identified in this systematic review suggest that most patients are lost to follow-up during the process of referral from government TB microscopy centers to DOT centers. Specifically, three of the studies in the review provide specific information on patient losses during the referral process, and we used the findings of these studies to estimate the proportion of all pretreatment loss to follow-up patients who are lost during the referral process [44–46]. …”

It’s complicated: why do tuberculosis patients not initiate or stay adherent to treatment? A qualitative study from South Africa

“…They found that high indirect costs, the anticipated/real side effects of TB treatment and the non-acceptance of TB diagnoses were major inhibitors to treatment initiation and therefore initial LTFU. Two studies from India [9, 10] both used semi-structured interviews for patients enrolled in the Revised National Tuberculosis Control Programme and found alcoholism, TB-related stigma, lack of TB awareness, lack of support and the fact that patients were busy with “other jobs” main contributors to initial LTFU. Therefore the reasons for initial LTFU appear varied and context specific, with extensive gaps remaining in understanding why it occurs and what the possible enablers and inhibitors are to having patients initiate treatment.…”