Abstract
Background. A significant proportion of tuberculosis (TB) patients globally make their initial visit for medical care to either an informal provider or a private practitioner, and many are not formally notified. Involvement of private practitioners (PPs) in a public-private mix for TB (TB-PPM) provides an opportunity for improving TB control. However, context-specific interventions beyond public-private agreements and mandatory notification are needed. In this study we will evaluate whether a tailored intervention package can increase TB notifications from PPs in Indonesia. Methods. This is a cluster-randomized trial of a multi-component public health intervention. 36 community health centre (CHC) areas will be selected as study locations and randomly allocated to intervention and control arms (1:1). PPs in the intervention areas will be identified using a mapping exercise and recruited into the study if they are eligible and consent. They will receive a tailored intervention package including in-person education about TB management along with bimonthly electronic refreshers, context-specific selection of referral pathways, and access to a TB-reporting app developed in collaboration with the National TB programme. The primary hypothesis is that the intervention package will increase the TB notification rate. The primary outcome will be measured by collecting notification data from the CHCs in intervention and control arms at the end of a 1-year observation period and comparing with the 1-year pre-intervention. The primary analysis will be intention-to-treat at the cluster level, using a generalised mixed model with repeated measures of TB notifications for 1 year pre- and 1 year post-intervention. Discussion. The results from this study will provide evidence on whether a tailored intervention package is effective in increasing the number of TB notifications, and whether the PPs refer presumptive TB cases correctly. The study results will guide policy in the development of TB-PPM in Indonesia and similar settings.
Highlights
Tuberculosis (TB) is the leading infectious disease cause of global mortality
An analysis of TB patient pathways in five low-middle income countries (LMICs) demonstrated that, on average, 26% of TB patients first sought care at primary care clinics, of whom only 13% of patients were tested with appropriate TB diagnostics, and only 7% were notified to the National TB Programme (NTP).[3]
To our knowledge, the use of a randomized controlled trial to evaluate the effect of intervention to increase private practitioners (PPs) involvement in TB control has been reported just once in the past ten years.[16]
Summary
Tuberculosis (TB) is the leading infectious disease cause of global mortality. In 2018, an estimated 10 million people had TB and, including those living with HIV, 1.4 million died from the illness. Approximately 3 million new TB cases are estimated to not be notified to health authorities, 2 million of which reside in the 20 high-burden countries that contribute 70% of the total global TB incidence.[1] Case notification plays an important role in disease surveillance by identifying cases as potential sources of new infections and their contacts, measuring the disease burden, and prompting the implementation of timely curative treatment. PPs in the intervention areas will be identified using a mapping exercise and recruited into the study if they are eligible and consent.
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