Early mortality in tuberculosis patients initially lost to follow up following diagnosis in provincial hospitals and primary health care facilities in Western Cape, South Africa.

Muhammad Osman,Karen Du Preez,Rory Dunbar,Arne Von Delft,Pren Naidoo,Florian M Marx,Alex Welte,Anneke C Hesseling,Andrew Boulle,Sue-Ann Meehan,Richard John Lessells

doi:10.1371/journal.pone.0252084

Abstract

In South Africa, low tuberculosis (TB) treatment coverage and high TB case fatality remain important challenges. Following TB diagnosis, patients must link with a primary health care (PHC) facility for initiation or continuation of antituberculosis treatment and TB registration. We aimed to evaluate mortality among TB patients who did not link to a TB treatment facility for TB treatment within 30 days of their TB diagnosis, i.e. who were "initial loss to follow-up (ILTFU)" in Cape Town, South Africa. We prospectively included all patients with a routine laboratory or clinical diagnosis of TB made at PHC or hospital level in Khayelitsha and Tygerberg sub-districts in Cape Town, using routine TB data from an integrated provincial health data centre between October 2018 and March 2020. Overall, 74% (10,208/13,736) of TB patients were diagnosed at PHC facilities and ILTFU was 20.0% (2,742/13,736). Of ILTFU patients, 17.1% (468/2,742) died, with 69.7% (326/468) of deaths occurring within 30 days of diagnosis. Most ILTFU deaths (85.5%; 400/468) occurred in patients diagnosed in hospital. Multivariable logistic regression identified increasing age, HIV positive status, and hospital-based TB diagnosis (higher in the absence of TB treatment initiation and being ILTFU) as predictors of mortality. Although hospitals account for a modest proportion of diagnosed TB patients they have high TB-associated mortality. A hospital-based TB diagnosis is a critical opportunity to identify those at high risk of early and overall mortality. Interventions to diagnose TB before hospital admission, improve linkage to TB treatment following diagnosis, and reduce mortality in hospital-diagnosed TB patients should be prioritised.

Highlights

In 2019, 10 million people developed tuberculosis (TB) and 1.4 million people (14%) with TB died [1]
We defined “initial loss to follow-up (ILTFU)” as TB patients who did not link to a TB treatment facility (primary health care (PHC) facility or TB hospital) for TB treatment within 30 days of their TB diagnosis having been made
We identified all TB patients diagnosed in hospital and at PHC facilities and activated a system of linking patients to PHC facilities using a cascade of short message services, telephone calls, and community-based tracing of patients

Summary

Introduction

In 2019, 10 million people developed tuberculosis (TB) and 1.4 million people (14%) with TB died [1]. Gaps in TB treatment coverage have highlighted the burden of undiagnosed and untreated TB, with only 71% of incident TB cases being registered and reported, globally [1]. In a systematic review and meta-analysis of data from high burden TB settings in Africa, pre-treatment loss to follow up, defined predominantly as the gap between diagnosed TB patients and those recorded in TB treatment registers, was 18% [3]. TB patients may die or be lost before linking to TB care with or without having initiated TB treatment. These patients may remain unreported or return to health services for repeated testing and may eventually be included in treatment cohorts. We defined “initial loss to follow-up (ILTFU)” as TB patients who did not link to a TB treatment facility (primary health care (PHC) facility or TB hospital) for TB treatment within 30 days of their TB diagnosis having been made

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