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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 25  |  Issue : 1  |  Page : 19-22

Delay in starting therapy in drug-resistant tuberculosis – An insight


1 Department of Respiratory Medicine, King George Medical University, Lucknow, Uttar Pradesh; Department of Pulmonary, Critical Care and Sleep Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
2 Department of Respiratory Medicine, King George Medical University, Lucknow, Uttar Pradesh, India
3 Department of Pulmonary, Critical Care and Sleep Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission20-Mar-2019
Date of Acceptance04-Sep-2019
Date of Web Publication14-Apr-2020

Correspondence Address:
Dr. Pranav Ish
B1, Green Park Extension, New Delhi - 110 016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmgims.jmgims_18_19

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  Abstract 


Introduction: The Revised National Tuberculosis Control Programme (RNTCP) ensures a prompt diagnosis and effective treatment of all tuberculosis (TB) patients with drug-resistant TB via decentralized drug sensitivity testing (DST). This study was taken in to find out the cause of delays in initiation of treatment. Material and Methods: This cross-sectional observational study included a questionnaire-based interview and retrospective analysis of records of the concerned patients with an aim to explore the reasons associated with this delay. Results: A delay was arbitrarily defined as a time period of more than 15 days from the date of sputum collection for DST to the date of admission. It considered of two parts, one due to lapse in system regarding implementation of program and other due to the lapses in the part of the patient. Out of 402 patients enrolled in the study, 252 (62.7%) sought treatment after the prescribed period and were categorized as delayed and comprised the Group I of study. The remaining 150 (37.3%) were those who sought treatment within the prescribed period and were and were termed in-time treatment seekers and thus comprised Group II of study. Delay in communication of results to DOTS centre and in-patient tracing was the most common reason for delay while unwillingness to avail treatment against the expectation was the least common reason. Conclusions: Undefined time for communication of DST results and patient tracing in PMDT services are the major cause of delay. Strengthening the communication skills of the care providers through expanding DST services at sub-district levels, regular training of care providers, setting district level information cells, creating mobile apps, and involving volunteers who are representatives of the local community is the need of the hour.

Keywords: Communication, delay, drug-resistant tuberculosis


How to cite this article:
Joshi A, Kant S, Kushwaha RS, Ish P. Delay in starting therapy in drug-resistant tuberculosis – An insight. J Mahatma Gandhi Inst Med Sci 2020;25:19-22

How to cite this URL:
Joshi A, Kant S, Kushwaha RS, Ish P. Delay in starting therapy in drug-resistant tuberculosis – An insight. J Mahatma Gandhi Inst Med Sci [serial online] 2020 [cited 2020 Oct 20];25:19-22. Available from: https://www.jmgims.co.in/text.asp?2020/25/1/19/282349




  Introduction Top


Multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant TB (XDR-TB) continue to pose an overwhelming threat to the control of TB since the past two decades.[1],[2] According to the programmatic management for drug-resistant tuberculosis (PMDT),[3] national programs are failing to diagnose and treat MDR-TB effectively. The curse persists despite cost-effective management of MDR-TB[4] although treatment of MDR-TB and XDR-TB is feasible even in patients who are infected with HIV.[5],[6]

The Revised National Tuberculosis Control Program (RNTCP), through its PMDT Vision, ensures a prompt diagnosis and effective treatment of all TB patients with drug-resistant TB through decentralized drug sensitivity testing (DST) and PMDT services as a component of RNTCP. Drug-resistant TB centers (DRTBC) have envisaged various functions in PMDT, and some important ones are to initiate treatment, follow-up, and manage complications. As per the PMDT guidelines published in 2012, the methodologies for DRTB testing:

  • Begins with transferring sputum from designated microscopy center to DST center
  • Followed by sputum testing, generation of the report, and communicating to respective District Tuberculosis Officers (DTOs) through electronic mails and short messenger service on phone to be followed by
  • Tracing the patient and his/her counseling regarding MDR-TB, and finally,
  • Reporting by the patient to our department (DRTBC) for admission.


Minimum of anywhere between 10 and 15 days period is required for the above-described methodology. This study was taken in to find the cause of such delays in the initiation of treatment, statistically, so that steps could be taken to cut short the delay and hence subsequently establishing faith in PMDT services in future.


  Materials and Methods Top


A single-centered, cross-sectional, observational study was done during a period of 1 year in the Department of Respiratory Medicine, King George's Medical University (KGMU), Lucknow. A questionnaire-based interview and retrospective analysis of records were undertaken after taking verbal consents of the concerned patients with an aim to explore the reasons associated with this delay. A total of 402 cases of MDR-TB proven by LPA or cartridge-based nucleic acid amplification test (CBNAAT) from Government/Government-accredited setup to the Department of Pulmonary Medicine KGMU for the initiation of treatment under PMDT were included in the study. Ethical approval was taken from the Ethical Committee of the University.

The statistical analysis was done using SPSS (Statistical Package for Social Sciences) Version 15.0 statistical Analysis Software (SPSS Inc., Chicago, IL, USA). The following statistical formulas were used: mean, standard deviation (SD), and Chi-square test (χ2). The values were represented in number (%) and mean ± SD.

Definition of delay

A delay was arbitrarily defined as a time period of more than 15 days from the date of sputum collection for DST to the date of admission. It consisted of two parts, one due to lapse in the system regarding implementation of program and other due to the lapses in the part of the patient.

Programmatic causes for delay

As given in PMDT guidelines, the time taken for the LPA is 3 days and for CBNAAT is 3 hours and after considering the remote areas, the transportation facilities, and workforce available at such centers along with consensus of many governmental personnel and medical officers involved in RNTCP, a time period of 7 days was considered sufficient enough from date of sputum collection to its transfer to DST laboratory under cold chain, putting sputum for LPA and declaration of result. During this first half, it is the whole and sole responsibility of health-care system. If any delay in DST results occurs, it will fall under the programmatic causes of delay.

Delay in the part of the patient

The next 8 days were given for the tracing of patient, followed by his/her counseling and his/her travel time. Hence, this is shared by health-care system as well as patient. The causes for delay in this period were sorted out on the basis of interviews with patients and telephonic conversations with respective DTOs/health centers regarding tracing of patients and their counseling for further confirmation. If, in these 8 days, delay is due to patient's factors than this delay is assigned in the part of patient, else it is supposed to be due to delay in tracing/counselling part of the RNTCP program and falls under programmatic causes.


  Results Top


[Table 1] shows the distribution of cases according to the time of reporting to the health-care facility. Of 402 patients enrolled in the study, 252 (62.7%) sought treatment after the prescribed period and were categorized as delayed and comprised the Group I study. Remaining 150 (37.3%) were those who sought treatment within the prescribed period and were termed in time treatment seekers and thus comprised the Group II of study. Overall, as well as in both the groups, majority of patients were male. However, proportion of females in Group II (39.3%) (P = 0.016 by Chi-square test) was significantly higher, suggesting female patients were more predisposed to delay. Delay in communication of results to DOTS center and in-patient tracing was the most common reason for delay while unwillingness to avail treatment against the expectation was the least common reason [Table 2].
Table 1: Distribution of patients in two groups

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Table 2: Distribution of patients according to causes of delay in initiation of treatment

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  Discussion Top


A delay was arbitrarily assumed if >15 days were taken from the date of sputum collection for DST to the date of reporting to the department for admission. This 15-day period consisted of the time taken for transfer of sputum for DST followed by communicating results to respective DTOs, tracing the patient and counseling regarding MDR–TB, and finally, the time taken by the patient to report to our department for admission. It comprised two parts: due to program and due to the patient. This time period was set after considering various factors in the state such as transportation facilities, patient's attitude toward his/her illness, literacy level, socioeconomic and cultural background, inaccessible remote areas, and the workforce available at DOTS center for tracing the patient and with consensus of various DOTS providers, supervisors, and medical officers involved in this program.

Delay of the DST results was seen in 97 patients, which were exclusively on the part of the health-care systems. Delay of >3 days in-between date of sputum collection at DOTS center and date of sputum received at DST laboratory was observed.

Delay in communication of results to DOTS center and in tracing of patients was present in 187 patients. It was the most common reason and unfortunately is a correctable yet under-addressed issue. For a start, health-care support staff can be trained regarding PMDT guidelines in India, and need for early referral can be stressed on. Communication should be more efficient, easily accessible, and easily understandable. Guidelines for specifying time delays and penalties for such delays need to be specified.

Most of the patients attending the DRTB center for initiation were from the rural background. During interview, 89 (22.1%) were unaware regarding the free pretreatment evaluation. Sixty-seven patients (26.6%) of these reported with delay. These patients because of unawareness wasted time in arranging money for the pretreatment investigations. This calls for urgent need to spread public awareness, especially for the illiterate that the ministry and program provide nearly everything for a smooth and rapid start of the treatment.

Ill health leading to immobilization was seen in 109 (27.1%) patients. Ninety-nine of them (39.3%) presented with delay because of high-grade fever, generalized weakness, pain in abdomen, breathlessness on exertion, etc., Thus, addressing symptomatic treatment for increasing patient mobility is a dormant field to be developed.

Unwillingness for the treatment was almost exclusive seen among patients who came with delay. Twenty-eight of 29 patients who were unwilling for treatment belonged to the delayed group. This was attributed to the previous history of anti-tubercular treatment intake, rude behavior of DOTs provider, interrupted supply of medications, lack of motivation, lack of interest in travelling from remote areas, and side effects such as pain in abdomen, vomiting, pain at the site of injections, lack of symptomatic relief, and unwillingness for hospitalization. This is similar to previous studies which found the above-mentioned cause of the same.[7],[8]

Being out of station was an important cause for delay and was seen in 47 (18.7%) patients. Patients were out of stations during the tracing period for daily earnings. This sometimes can be both an avoidable and sometimes unavoidable depending on the local job opportunities and proper patient education during the time of sputum collection. The concept of monetary rehabilitation of such patients is underway in the national program with a provision of 500 rupees/month. However, the long-term utility of such schemes needs to be stringently monitored.


  Conclusion Top


Based on our study, we arrived at the following conclusions:

  • Undefined time for communication of DST results and patient tracing in PMDT services are the major causes of delay
  • Lack of awareness, good communication skills, and the importance of PMDT services among service providers are other areas involved in programmatic causes of delay which can be corrected through proper training
  • Patient factors responsible for delay are indirectly influenced by the past or present experiences and interaction of the patient with service providers, and to mitigate this, proper counseling is the need of the hour
  • Strengthening the communication skills of the care providers through expanding DST services at subdistrict levels, regular training of the care providers, setting district level information cells, creating mobile apps, and involving volunteers who are representatives of the local community can help in reducing or preventing this delay.
  • Maintaining record at DRTB centers regarding causes of delay and to discuss on monthly or quarterly basis with DTOs can serve as a check point for the same.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Multidrug and Extensively Drug-Resistant TB (M/XDR-TB): 2010 Global Report on Surveillance and Response. World Health Organization; 2010. Available from: http://whqlibdoc.who.int/publications/2010/9789241599191_eng.pdf. [Last accessed on 2018 Sep 07].  Back to cited text no. 1
    
2.
Raviglione MC, Smith IM. XDR tuberculosis – implications for global public health. N Engl J Med 2007;356:656-9.  Back to cited text no. 2
    
3.
Revised National Tuberculosis Control Programme. Guidelines on Programmatic Management of Drug Resistant TB (PMDT) in India. Revised National Tuberculosis Control Programme; 2012. Available from: http://www.tbcindia.nic.in/documents.html. [Last accessed on 2015 Jun 20].  Back to cited text no. 3
    
4.
Tupasi TE, Gupta R, Quelapio MI, Orillaza RB, Mira NR, Mangubat NV, et al. Feasibility and cost-effectiveness of treating multidrug-resistant tuberculosis: A cohort study in the Philippines. PLoS Med 2006;3:e352.  Back to cited text no. 4
    
5.
Orenstein EW, Basu S, Shah NS, Andrews JR, Friedland GH, Moll AP, et al. Treatment outcomes among patients with multidrug-resistant tuberculosis: Systematic review and meta-analysis. Lancet Infect Dis 2009;9:153-61.  Back to cited text no. 5
    
6.
Sotgiu G, Ferrara G, Matteelli A, Richardson MD, Centis R, Ruesch-Gerdes S, et al. Epidemiology and clinical management of XDR-TB: A systematic review by TBNET. Eur Respir J 2009;33:871-81.  Back to cited text no. 6
    
7.
Institute of Medicine (US). Facing the Reality of Drug-Resistant Tuberculosis in India: Challenges and Potential Solutions: Summary of a Joint Workshop by the Institute of Medicine, the Indian National Science Academy, and the Indian Council of Medical Research. Washington (DC): National Academies Press (US); 2012.  Back to cited text no. 7
    
8.
Joseph P, Desai VB, Mohan NS, Fredrick JS, Ramachandran R, Raman B, et al. Outcome of standardized treatment for patients with MDR-TB from Tamil Nadu, India. Indian J Med Res 2011;133:529-34.  Back to cited text no. 8
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