Tuberculosis case fatality in India: a systematic review and meta-analysis

Abstract

IntroductionThe WHO End TB Strategy calls for a global reduction in the case fatality ratio (CFR) below 5%. India accounts for a third of global tuberculosis (TB) deaths. This systematic review estimated CFRs among Indian patients with TB both during and after treatment.MethodsWe systematically searched Medline, Embase and Global Health for eligible studies published between 1 January 2006 and 8 January 2019, including both cohort studies and intervention study control arms that followed Indian patients with TB for fatality either during treatment or post-treatment. From relevant studies we extracted CFRs in addition to study demographics. Study quality was assessed using modified Scottish Intercollegiate Guidelines Network cohort criteria. Sufficiently homogenous studies were pooled using a random effect generalised linear mixed model. A meta-regression was performed to associate study characteristics with resulting CFRs.Results218 relevant studies were identified, of which 211 provided treatment phase CFRs. Most patients (92.4%) were treated in the public sector. Quality concerns were identified in 74% of papers. We estimated a pooled treatment phase CFR of 5.16% (95% CI 4.20% to 6.34%) which fell to 3.78% (2.77% to 5.16%) when restricted to 52 high-quality studies. Treatment phase CFRs were higher for paediatric (n=27, 6.50% (2.65% to 10.36%)), drug-resistant (n=43, 14.06% (10.15% to 19.49%)) and HIV-infected (n=35, 10.91% (7.68% to 15.50%)) patients. Nineteen post-treatment CFR studies were too heterogeneous to pool except when restricting to three high-quality studies (2.69% (–0.79% to 6.18%)). Poor study quality (OR=2.27 (2.01 to 2.57)) and tertiary centres patients (OR=1.15 (1.03 to 1.28)) were significantly associated with increased treatment phase case fatality.ConclusionsCase fatality is a critical measure of the quality of TB care. While India’s treatment CFRs are in line with WHO targets, several key patient groups remain understudied and most studies suffer from methodological issues. Increased high-quality reporting on patient outcomes will help improve the evidence base on this topic.

India’s syndemic of tuberculosis and COVID-19

“…Even before the pandemic, the cascade of TB care in India has been leaky, 2 with long diagnostic delays, 3 complex care pathways, 4 poor quality of TB care in public as well as private health sectors 2 5 and high TB case fatality. 6 7 …”

Status and challenges for tuberculosis control in India – Stakeholders' perspective

“…Case fatality is a critical measure of the quality of TB care. Increased high-quality reporting on patient outcomes will help improve the evidence base on this topic 27 .…”

Case fatality and recurrent tuberculosis among patients managed in the private sector: A cohort study in Patna, India

“…In line with the WHO End TB strategy [ 2 ], the Indian national tuberculosis program has paid increasing attention to the quality of TB care in the country, especially in the largely unregulated private sector. However, there is insufficient data available in the currently available literature to form a reliable estimate of a key measure of the quality of care, the case fatality ratio, for privately treated TB patients in India [ 3 ]. Private healthcare dominates the Indian medical sector and it’s engagement is critical for ending TB in the country.…”

“…Half of all Indian TB patients are treated in the private sector where quality of care is generally low [ 4 , 5 ]. Unlike in the public sector, there is no systematic monitoring of privately treated TB patient and very few studies have addressed case fatality among Indian private sector TB patients [ 3 ]. One solution for improved quality of care in the private sector lies in Private Provider Interface Agencies (PPIAs) which have been successfully implemented in multiple regions in India [ 6 ].…”