Tuberculosis patients in an Indian mega-city: Where do they live and where are they diagnosed?

Abstract

ObjectiveTuberculosis (TB) is a major source of mortality in urban India, with many structural challenges to optimal care delivery. In the government TB program in Chennai, India’s fourth most populous city, there is a 49% gap between the official number of smear-positive TB patients diagnosed and the official number registered in TB treatment within the city in 2014. We hypothesize that this “urban registration gap” is partly due to rural patients temporarily visiting the city for diagnostic evaluation.MethodsWe collected data for one month (May 2015) from 22 government designated microscopy centers (DMCs) in Chennai where 90% of smear-positive TB patients are diagnosed and coded patient addresses by location. We also analyzed the distribution of chest symptomatics (i.e., patients screened for TB because of pulmonary symptoms) and diagnosed smear-positive TB patients for all of Chennai’s 54 DMCs in 2014.ResultsAt 22 DMCs in May 2015, 565 of 3,543 (15.9%) chest symptomatics and 71 of 412 (17.2%) diagnosed smear-positive patients had an address outside of Chennai. At the city’s four high patient volume DMCs, 54 of 270 (20.0%) smear-positive patients lived out-of-city. At one of these high-volume DMCs, 31 of 59 (52.5%) smear-positive patients lived out-of-city. Out of 6,135 smear-positive patients diagnosed in Chennai in 2014, 3,498 (57%) were diagnosed at the four high-volume DMCs. The 32 DMCs with the lowest patient volume diagnosed 10% of all smear-positive patients.ConclusionsTB case detection in Chennai is centralized, with four high-volume DMCs making most diagnoses. One-sixth of patients are from outside the city, most of whom get evaluated at these high-volume DMCs. This calls for better coordination between high-volume city DMCs and rural TB units where many patients may take TB treatment. Patient mobility only partly explains Chennai’s urban registration gap, suggesting that pretreatment loss to follow-up of patients who live within the city may also be a major problem.

Understanding pretreatment loss to follow-up of tuberculosis patients: an explanatory qualitative study in Chennai, India

“…While we cannot be sure how the absence of these patients biassed our findings, it is possible that some of these patients represent individuals with greater distrust of the health system, as implied from their hesitation to engage with HCWs and our research team. It is also possible that some untrackable patients represent individuals with greater mobility (eg, truck drivers, migrant labourers) or who temporarily visited Chennai from nearby districts to access medical care 15. Another study limitation is the small number of women in our sample, which limits our ability to draw conclusions regarding how sex influences PTLFU.…”

“…HCWs also did not have administrative tools, such as information on DOT centre addresses, to provide patients with accurate referral information. Navigational challenges could potentially be addressed through interventions to improve communication and coordination, including short messaging service (SMS) notifications of test results to patients,28 29 electronic health records with real-time availability of patient information across facilities,15 29 paper-based or electronic directories with instructions to facilitate referral to other facilities or employment of patient navigators (individuals tasked with helping patients traverse the health system) 30. Similarly, other barriers in pathway 1 are potentially rectifiable through practical health system changes, including hiring of more personnel, providing greater material support to HCWs (for phone calls, etc) and reducing administrative hurdles for patients.…”

“…City TB services follow guidelines of India’s Revised National TB Control Programme (RNTCP). The current study followed patients at 22 of Chennai’s RNTCP-designated microscopy centres (DMCs), which accounted for 90% of smear-positive TB patients diagnosed in the public sector in 2014 13 15. Four DMCs, located in specialised TB facilities or tertiary hospitals, diagnosed more than half of the city’s smear-positive patients;15 we refer to these four as ‘high-volume DMCs’ and to the remaining 18 as ‘moderate-volume or low-volume DMCs’.…”

Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care

“…We studied methods used in the South African cascade for further insights [11]. Our prior research is relevant for estimating different cascade stages, including the number of individuals with TB in the population (NA, VC) [26,27], the diagnostic gap (MP, RN) [28–30], pretreatment loss to follow-up (PTLFU; RS, SS, VC, MP) [31–35], and post-treatment disease recurrence (VC) [36]. Our team also includes an expert in the HIV care cascade (KM) [37–40].…”

“…Patients may be lost to follow-up after starting therapy but before official treatment registration [32]. Second, patients may get diagnosed in one location (e.g., a city) but start treatment elsewhere (e.g., a rural area), making follow-up difficult, especially since unique identification numbers are uncommon in many countries [31,32,73]. Third, missing or illegible contact information often makes patient tracking difficult, especially in settings using paper records [31–33,73,74].…”