Durations and Delays in Care Seeking, Diagnosis and Treatment Initiation in Uncomplicated Pulmonary Tuberculosis Patients in Mumbai, India.

Nerges Mistry,Sheela Rangan,Akshaya Patil,Shimoni Shah,Yatin Dholakia,Eunice Lobo,Daniela Flavia Hozbor

doi:10.1371/journal.pone.0152287

Nerges Mistry, Sheela Rangan + Show 5 more

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https://doi.org/10.1371/journal.pone.0152287

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Abstract

BackgroundTimely diagnosis and treatment initiation are critical to reduce the chain of transmission of Tuberculosis (TB) in places like Mumbai, where almost 60% of the inhabitants reside in overcrowded slums. This study documents the pathway from the onset of symptoms suggestive of TB to initiation of TB treatment and examines factors responsible for delay among uncomplicated pulmonary TB patients in Mumbai.MethodsA population-based retrospective survey was conducted in the slums of 15 high TB burden administrative wards to identify 153 self-reported TB patients. Subsequently in-depth interviews of 76 consenting patients that fit the inclusion criteria were undertaken using an open-ended interview schedule. Mean total, first care seeking, diagnosis and treatment initiation duration and delays were computed for new and retreatment patients. Patients showing defined delays were divided into outliers and non-outliers for all three delays using the median values.ResultsThe mean duration for the total pathway was 65 days with 29% of patients being outliers. Importantly the mean duration of first care seeking was similar in new (24 days) and retreatment patients (25 days). Diagnostic duration contributed to 55% of the total pathway largely in new patients. Treatment initiation was noted to be the least among the three durations with mean duration in retreatment patients twice that of new patients. Significantly more female patients experienced diagnostic delay. Major shift of patients from the private to public sector and non-allopaths to allopaths was observed, particularly for treatment initiation.ConclusionAchieving positive behavioural changes in providers (especially non-allopaths) and patients needs to be considered in TB control strategies. Specific attention is required in counselling of TB patients so that timely care seeking is effected at the time of relapse. Prioritizing improvement of environmental health in vulnerable locations and provision of point of care diagnostics would be singularly effective in curbing pathway delays.

Highlights

Every year approximately 1.5 million people die of Tuberculosis (TB) globally, and most of these occur in the developing countries. [1] India is one of the 22 TB high burden countries in the world; approximately 2.2 million cases in 2014 out of the estimated annual global incident cases of 9.6 million were reported from India. [2] Mumbai, the financial capital of India, with a population of approximately 14 million, 50–60% of whom live in overcrowded slums with extremely poor hygiene, sanitation and ventilation, [3, 4] is a hotspot for multi and extensive drug resistant TB in the country
Diagnosis and treatment initiation are critical to reduce the chain of transmission of Tuberculosis (TB) in places like Mumbai, where almost 60% of the inhabitants reside in overcrowded slums
Achieving positive behavioural changes in providers and patients needs to be considered in TB control strategies

Summary

Introduction

Every year approximately 1.5 million people die of Tuberculosis (TB) globally, and most of these occur in the developing countries. [1] India is one of the 22 TB high burden countries in the world; approximately 2.2 million cases in 2014 out of the estimated annual global incident cases of 9.6 million were reported from India. [2] Mumbai, the financial capital of India, with a population of approximately 14 million, 50–60% of whom live in overcrowded slums with extremely poor hygiene, sanitation and ventilation, [3, 4] is a hotspot for multi and extensive drug resistant TB in the country. [2] Mumbai, the financial capital of India, with a population of approximately 14 million, 50–60% of whom live in overcrowded slums with extremely poor hygiene, sanitation and ventilation, [3, 4] is a hotspot for multi and extensive drug resistant TB in the country This has been documented by numerous studies in the last decade. [15, 17, 18, 19] Most of these studies were conducted at facilities under the Revised National TB Control Programme (RNTCP) Such studies may be prone to respondent bias, and miss out patients seeking care in the heterogeneous private sector consisting of formal and non-formal providers, where more than 60% of patients in India seek health care.

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