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. 2020 Mar 19;15(3):e0230604.
doi: 10.1371/journal.pone.0230604. eCollection 2020.

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

Joyce B Der  1   2 , Daniel Grint  1 , Clement T Narh  2   3 , Frank Bonsu  4 , Alison D Grant  1   5   6
Affiliations

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

Joyce B Der et al. PLoS One. .

Abstract

Background: Ghana'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.

Methods: A 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.

Results: A 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).

Conclusion: The 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.

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Conflict of interest statement

The authors have declared that no competing interest exist.

Figures

Fig 1
Fig 1. Flowchart of study recruitment and follow up of people requested to give sputum for TB investigation in Ketu South Municipality, Ghana.
Fig 2
Fig 2. Cascade of TB care among people requested to give sputum for TB investigation in Ketu South Municipality, Ghana.
Fig 3
Fig 3. Time from test request to submitting sputum for people requested to give sputum for TB investigation in Ketu South Municipality, Ghana.
See this image and copyright information in PMC

References

    1. World Health Organization. Global tuberculosis report. Geneva: 2019 WHO/CDS/TB/2019.15.
    1. National Tuberculosis Control Program. Annual Report of the National TB Control Program, Ghana. 2015.
    1. National Tuberculosis Control Program. Annual Report of the National TB Control Program, Ghana. 2017.
    1. Ghana Health Service—National TB Control Program. Ghanaian National Population Based Tuberculosis Prevalence Survey in 2013. 2015.
    1. Ali SM, Naureen F, Noor A, Fatima I, Viney K, Ishaq M, et al. Loss-to-follow-up and delay to treatment initiation in Pakistan’s national tuberculosis control programme. BMC public health. 2018;18(1):335 Epub 2018/03/11. 10.1186/s12889-018-5222-2 . - DOI - PMC - PubMed

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