Missed Opportunities for TB Investigation in Primary Care Clinics in South Africa: Experience from the XTEND Trial.

Violet N Chihota,Gavin Churchyard,Katherine Fielding,Kerrigan Mccarthy,Sibuse Ginindza,Alison D Grant,Tolu Oni

doi:10.1371/journal.pone.0138149

Violet N Chihota, Gavin Churchyard + Show 5 more

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https://doi.org/10.1371/journal.pone.0138149

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Abstract

Setting40 primary health clinics (PHCs) in four provinces in South Africa, June 2012 –February 2013.ObjectiveTo determine whether health care worker (HCW) practice in investigating people with TB symptoms was altered when the initial test for TB was changed from smear microscopy to Xpert MTB/RIF.DesignCross-sectional substudy at clinics participating in a pragmatic cluster randomised trial, Xpert for TB: Evaluating a New Diagnostic "XTEND", which evaluated the effect of Xpert MTB/RIF implementation in South Africa.MethodsConsecutive adults exiting PHCs reporting at least one TB symptom (defined as any of cough, weight loss, night sweats and fever) were enrolled. The main outcome was the proportion who self-reported having sputum requested by HCW during the clinic encounter just completed.Results3604 adults exiting PHCs (1676 in Xpert arm, 1928 in microscopy arm) were enrolled (median age 38 years, 71.4% female, 38.8% reported being HIV-positive, 70% reported cough). For 1267 participants (35.2%) the main reason for attending the clinic was TB symptom(s).Overall 2130/3604 (59.1%) said they reported their symptom(s) to HCW. 22.7% (818/3604) reported having been asked to give sputum for TB investigation. Though participants in the Xpert vs. microscopy arm were more likely to have sputum requested by HCW, this was not significantly different: overall (26.0% [436/1676] vs 19.8% [382/1928]; adjusted prevalence ratio [aPR] 1.31, [95% CI 0.78–2.20]) and when restricted to those presenting at clinics due to symptoms (49.1% [260/530] vs 29.9% [220/737]; aPR 1.38 [0.89–2.13]) and those reporting being HIV-positive (29.4% [190/647] vs 20.8% [156/749]; aPR 1.38[0.88–2.16]).Those attending clinic due to TB symptoms, were more likely to have sputum requested if they had increasing number of symptoms; longer duration of cough, unintentional weight loss and night sweats and if they reported symptoms to HCW.ConclusionsA large proportion of people exiting PHCs reporting TB symptoms did not get tested. Implementation of Xpert MTB/RIF did not substantially change the probability of testing for TB. Better systems are needed to ensure that opportunities to identify active TB among PHC attendees are not missed.

Highlights

The burden of tuberculosis (TB) remains high in South Africa, with an estimated prevalence of 715 per 100 000 population in 2013 [1]
To determine whether health care worker (HCW) practice in investigating people with TB symptoms was altered when the initial test for TB was changed from smear microscopy to Xpert MTB/RIF
Though participants in the Xpert vs. microscopy arm were more likely to have sputum requested by HCW, this was not significantly different: overall (26.0% [436/1676] vs 19.8% [382/1928]; adjusted prevalence ratio [aPR] 1.31, [95% confidence intervals (CIs) 0.78–2.20]) and when restricted to those presenting at clinics due to symptoms (49.1% [260/530] vs 29.9% [220/737]; aPR 1.38 [0.89–2.13]) and those reporting being human immunodeficiency virus (HIV)-positive (29.4% [190/647] vs 20.8% [156/749]; aPR 1.38[0.88– 2.16])

Summary

Introduction

The burden of tuberculosis (TB) remains high in South Africa, with an estimated prevalence of 715 per 100 000 population in 2013 [1]. To reduce the burden of TB the World Health Organization (WHO) recommends intensified case finding (ICF) for TB among human immunodeficiency virus (HIV) infected persons [2, 3] and has been recommended for all clinic attendees, regardless of HIV status [4]. Since 2011, South Africa has rolled out Xpert MTB/RIF as the first-line sputum test for diagnosis of TB across the country, replacing smear microscopy. Embedded within this roll out was the XTEND trial, an evaluation of the effect of Xpert MTB/RIF implementation on patient-relevant outcomes [8]. The primary outcome, mortality, was determined at six months among clinic attendees being investigated for TB

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Conclusion