Patient characteristics, health seeking and delays among new sputum smear positive TB patients identified through active case finding when compared to passive case finding in India

Abstract

Background: Axshya SAMVAD is an active tuberculosis (TB) case finding (ACF) strategy under project Axshya (Axshya meaning 'free of TB' and SAMVAD meaning 'conversation') among marginalized and vulnerable populations in 285 districts of India.

Objectives: To compare patient characteristics, health seeking, delays in diagnosis and treatment initiation among new sputum smear positive TB patients detected through ACF and passive case finding (PCF) under the national TB programme in marginalized and vulnerable populations between March 2016 and February 2017.

Methods: This observational analytic study was conducted in 18 randomly sampled Axshya districts. We enrolled all TB patients detected through ACF and an equal number of randomly selected patients detected through PCF in the same settings. Data on patient characteristics, health seeking and delays were collected through record review and patient interviews (at their residence). Delays included patient level delay (from eligibility for sputum examination to first contact with any health care provider (HCP)), health system level diagnosis delay (from contact with first HCP to TB diagnosis) and treatment initiation delays (from diagnosis to treatment initiation). Total delay was the sum of patient level, health system level diagnosis delay and treatment initiation delays.

Results: We included 234 ACF-diagnosed and 231 PCF-diagnosed patients. When compared to PCF, ACF patients were relatively older (≥65 years, 14% versus 8%, p = 0.041), had no formal education (57% versus 36%, p<0.001), had lower monthly income per capita (median 13.1 versus 15.7 USD, p = 0.014), were more likely from rural areas (92% versus 81%, p<0.002) and residing far away from the sputum microscopy centres (more than 15 km, 24% versus 18%, p = 0.126). Fewer patients had history of significant loss of weight (68% versus 78%, p = 0.011) and sputum grade of 3+ (15% versus 21%, p = 0.060). Compared to PCF, HCP visits among ACF patients was significantly lower (median one versus two HCPs, p<0.001). ACF patients had significantly lower health system level diagnosis delay (median five versus 19 days, p = 0.008) and the association remained significant after adjusting for potential confounders. Patient level and total delays were not significantly different.

Conclusion: Axshya SAMVAD linked the most impoverished communities to TB care and resulted in reduction of health system level diagnosis delay.

Fig 1. Map of India depicting the randomly sampled Axshya districts (n = 18) under Axshya SAMVAD study, India (2016–17) [24]*.

SAMVAD–sensitization and advocacy in marginalised and vulnerable areas of the district. Axshya SAMVAD–an active case finding strategy under project Axshya implemented by The Union, South East Asia office, New Delhi, India, across 285 districts of India. * Reprinted from Shewade HD et al [24] under a CC BY license, with permission from International Union Against Tuberculosis and Lung Disease (The Union), Copyright The Union 2017.

Fig 2. Conceptual framework on definitions of delay before treatment initiation among newly registered sputum postive TB patients, Axshya SAMVAD study, India (2016–17) * [28].

* Reprinted with modification from Sreeramareddy CT et al [28] under a CC BY license, with permission from International Union Against Tuberculosis and Lung Disease (The Union), Copyright The Union 2014. SAMVAD–sensitization and advocacy in marginalised and vulnerable areas of the district. Axshya SAMVAD–an active case finding strategy under project Axshya implemented by The Union, South East Asia office, New Delhi, India, across 285 districts of India. HCP–Health Care Providers.

Fig 3. Flow chart depicting study participant enrolment in Axshya SAMVAD study across 18 randomly sampled districts in India (2016–2017).

SAMVAD–sensitization and advocacy in marginalised and vulnerable areas of the district. Axshya SAMVAD–an active case finding strategy under project Axshya implemented by The Union, South East Asia office, New Delhi, India, across 285 districts of India. *32 were due to errors during record review (either patient turned out to be previously treated or sputum smear negative TB; 56 patients were recorded as new patients but turned out to be previously treated during patient interviews. ** due to patient non-availability during visit to residence.