Where are patients missed in the tuberculosis diagnostic cascade? A prospective cohort study in Ghana

Abstract

BackgroundGhana's national prevalence survey showed higher than expected tuberculosis (TB) prevalence, indicating that many people with TB are not identified and treated. This study aimed to identify gaps in the TB diagnostic cascade prior to starting treatment. MethodsA prospective cohort study was conducted in urban and rural health facilities in south-east Ghana. Consecutive patients routinely identified as needing a TB test were followed up for two months to find out if sputum was submitted and/or treatment started. The causal effect of health facility location on submitting sputum was assessed before risk factors were investigated using logistic regression. ResultsA total of 428 persons (mean age 48 years, 67.3% female) were recruited, 285 (66.6%) from urban and 143 (33.4%) from rural facilities. Of 410 (96%) individuals followed up, 290 (70.7%) submitted sputum, among which 27 (14.1%) had a positive result and started treatment. Among those who visited an urban facility, 245/267(91.8%) submitted sputum, compared to 45/143 (31.5%) who visited a rural facility. Participants recruited at the urban facility were far more likely to submit a sputum sample (odds ratio (OR) 24.24, 95%CI 13.84-42.51). After adjustment for confounding, there was still a strong association between attending the urban facility and submitting sputum (adjusted OR (aOR) 9.52, 95%CI 3.87-23.40). Travel distance of >10 km to the laboratory was the strongest predictor of not submitting sputum (aOR 0.12, 95%CI 0.05-0.33). ConclusionThe majority of presumptive TB patients attending a rural health facility did not submit sputum for testing, mainly due to the long travel distance to the laboratory. Bridging this gap in the diagnostic cascade may improve case detection.

Barriers to tuberculosis case finding in primary and secondary health facilities in Ghana: perceptions, experiences and practices of healthcare workers

“…The main health system-related barrier was that the TB diagnostic laboratory was at the municipal hospital which is distant from most rural health facilities, and clients cannot afford the transport cost [ 18 ]. Limited access to diagnostic facilities, mostly in rural settings, and long travel distance were similar barriers experienced by presumed TB clients in other parts of the world [ 6 , 7 , 22 – 26 ].…”

“…Based on an initial assessment of health facilities in April 2018 before the start of data collection, we found that there were no TB case finding activities in the rural health facilities. This made it necessary to introduce the screening tool to HCWs who attended to patients in the consulting rooms of the study rural health facilities to facilitate enrolment for the cohort study [ 18 ] and also as an ethical obligation to help improve TB services. The HCWs were trained by the research team on how to use the screening tool and printed copies of the tool were provided to the rural health facilities.…”

“…This study was part of a larger project and qualitative research activities were conducted before and after quantitative components. Specifically, structured clinic observations were carried out before cohort and cross-sectional studies [ 17 , 18 ] and in-depth interviews were carried out as the final research activity of the project. The quantitative studies showed gaps which were health system- and HCW-related.…”

Surveying and mapping breast cancer services in Ghana: a cross-sectional pilot study in the Eastern Region

“…Open access services, so 10 km was established as our screening threshold. 28 In South Africa, women who lived greater than 20 km from a diagnostic hospital were more likely to have advanced disease at time of breast cancer diagnosis, so we established 25 km as our diagnosis threshold. 29 For surgical management, we established 45 km as our distance threshold to keep travel time typically less than 1 hour.…”

“It was difficult to offer same day results”: evaluation of community-based point-of-care testing for sexually transmitted infections among youth using the GeneXpert platform in Zimbabwe

“…However, this requires multiple steps between sample collection and treatment of a positive case, including a (correctly labelled) sample being sent to the laboratory, testing the sample, producing the result, sending the result back to the referring clinic, informing the patient, and the patient returning for treatment. Pre-treatment loss-to-follow-up (LTFU) in low-income countries is well documented for syphilis and other diseases including tuberculosis [7,8]. One strategy to reduce LTFU is to provide same day results through on-site STI testing.…”