Shewade Hemant Deepak, Kokane Arun M, Singh Akash Ranjan, Verma Manoj, Parmar Malik, Chauhan Ashish, Chahar Sanjay Singh, Tiwari Manoj, Khan Sheeba Naz, Gupta Vivek, Tripathy Jaya Prasad, Nagar Mukesh, Singh Sanjai Kumar, Mehra Pradeep Kumar, Kumar Ajay Mv
International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India, 110016.
Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, India.
BMC Health Serv Res. 2017 Apr 4;17(1):249. doi: 10.1186/s12913-017-2191-6.
Pre-diagnosis attrition needs to be addressed urgently if we are to make progress in improving MDR-TB case detection and achieve universal access to MDR-TB care. We report the pre-diagnosis attrition, along with factors associated, and turnaround times related to the diagnostic pathway among patient with presumptive MDR-TB in Bhopal district, central India (2014).
Study was conducted under the Revised National Tuberculosis Control Programme setting. It was a retrospective cohort study involving record review of all registered TB cases in Bhopal district that met the presumptive MDR-TB criteria (eligible for DST) in 2014. In quarter 1, Line Probe Assay (LPA) was used if sample was smear/culture positive. Quarter 2 onwards, LPA and Cartridge-based Nucleic Acid Amplification Test (CbNAAT) was used for smear positive and smear negative samples respectively. Pre-diagnosis attrition was defined as failure to undergo DST among patients with presumptive MDR-TB (as defined by the programme).
Of 770 patients eligible for DST, 311 underwent DST and 20 patients were diagnosed as having MDR-TB. Pre-diagnosis attrition was 60% (459/770). Among those with pre-diagnosis attrition, 91% (417/459) were not identified as 'presumptive MDR-TB' by the programme. TAT [median (IQR)] to undergo DST after eligibility was 4 (0, 10) days. Attrition was more than 40% across all subgroups. Age more than 64 years; those from a medical college; those eligible in quarter 1; patients with presumptive criteria 'previously treated - recurrent TB', 'treatment after loss-to-follow-up' and 'previously treated-others'; and patients with extra-pulmonary TB were independent risk factors for not undergoing DST.
High pre-diagnosis attrition was contributed by failure to identify and refer patients. Attrition reduced modestly with time and one factor that might have contributed to this was introduction of CbNAAT in quarter 2 of 2014. General health system strengthening which includes improvement in identification/referral and patient tracking with focus on those with higher risk for not undergoing DST is urgently required.
如果我们要在改善耐多药结核病病例发现方面取得进展并实现普遍获得耐多药结核病治疗，就需要紧急解决诊断前失访问题。我们报告了印度中部博帕尔地区（2014年）疑似耐多药结核病患者的诊断前失访情况、相关因素以及与诊断途径相关的周转时间。
该研究在修订后的国家结核病控制规划框架下进行。这是一项回顾性队列研究，涉及对2014年博帕尔地区所有符合疑似耐多药结核病标准（有资格进行药敏试验）的登记结核病病例的记录审查。在第一季度，如果样本涂片/培养呈阳性，则使用线性探针测定法（LPA）。从第二季度起，LPA和基于盒式核酸扩增试验（CbNAAT）分别用于涂片阳性和涂片阴性样本。诊断前失访定义为疑似耐多药结核病患者（按该规划定义）未接受药敏试验。
在770名有资格进行药敏试验的患者中，311人接受了药敏试验，20人被诊断为耐多药结核病。诊断前失访率为60%（459/770）。在诊断前失访的患者中，91%（417/459）未被该规划确定为“疑似耐多药结核病”。符合资格后进行药敏试验的周转时间[中位数（四分位间距）]为4（0，10）天。所有亚组的失访率均超过40%。年龄超过64岁；来自医学院的患者；第一季度符合资格的患者；具有“既往治疗 - 复发性结核病”“失访后治疗”和“既往治疗 - 其他”等疑似标准的患者；以及肺外结核病患者是未接受药敏试验的独立危险因素。
诊断前失访率高是由于未能识别和转诊患者。随着时间的推移，失访率略有下降，其中一个可能的原因是2014年第二季度引入了CbNAAT。迫切需要加强一般卫生系统，包括改善识别/转诊和患者追踪，重点关注未接受药敏试验风险较高的人群。
