Patient and health system factors associated with pretreatment loss to follow up among patients diagnosed with tuberculosis using Xpert\xae MTB/RIF testing in Uganda

Stella Zawedde-Muyanja,Barbara Castelnuovo,Yukari C Manabe,Adithya Cattamanchi,Achilles Katamba

doi:10.1186/s12889-020-09955-0

Abstract

BackgroundIn 2018, Uganda started only 65% of persons with incident tuberculosis on treatment. Pretreatment loss to follow up is an important contributor to suboptimal treatment coverage. We aimed to describe the patient and health facility-level characteristics associated with pretreatment loss to follow up among patients diagnosed with pulmonary tuberculosis at public health facilities in Uganda.MethodsAt ten public health facilities, laboratory register data was used to identify patients aged ≥ 15 years who had a positive Xpert®MTB/RIF test. Initiation on TB treatment was ascertained using the clinical register. Factors associated with not being initiated on TB treatment within two weeks of diagnosis were examined using a multilevel logistic regression model accounting for clustering by health facility.ResultsFrom January to June 2018, 510 patients (61.2% male and 31.5% HIV co-infected) were diagnosed with tuberculosis. One hundred (19.6%) were not initiated on TB treatment within 2 weeks of diagnosis. Not having a phone number recorded in the clinic registers (aOR 7.93, 95%CI 3.93–13.05); being HIV-infected (aOR 1.83; 95% CI: 1.09–3.26) and receiving care from a high volume health facility performing more than 12 Xpert tests per day (aOR 4.37, 95%CI 1.69–11.29) and were significantly associated with pretreatment loss to follow up.ConclusionIn public health facilities in Uganda, we found a high rate of pretreatment loss to follow up especially among TBHIV co-infected patients diagnosed at high volume health facilities. Interventions to improve the efficiency of Xpert® MTB/RIF testing, including monitoring of the TB care cascade should be developed and implemented.

Highlights

In 2018, Uganda started only 65% of persons with incident tuberculosis on treatment
Health facilities which do not have Xpert®MTB/RIF machines use sputum microscopy as the mainstay of diagnosis, but access Xpert® MTB/RIF testing for selected patient populations through a specimen referral system
In sensitivity analyses using multiple imputation, all significant associations were maintained (Supplementary Tables 1 & 2). In this retrospective study we examined patient and health facility factors associated with pretreatment Loss to follow-up (LFU) at public health facilities in Uganda; we found that about one in five patients diagnosed with TB experienced pretreatment LFU

Summary

Introduction

In 2018, Uganda started only 65% of persons with incident tuberculosis on treatment. The TB cascade of care, derived from the World Health Organization (WHO) Onion model [5] outlines the implementation steps for patients to achieve TB cure: they must recognize TB signs and symptoms; present to health facilities; be recognized by the healthcare system; receive a microbiological test for TB; be started on TB treatment and be retained in care for the entire duration of treatment. Previous studies have shown that a significant proportion of TB patients do not recognize the signs and symptoms of TB and do not present to the healthcare system [2, 6] Of those who present, only 20% of receive a microbiological test for TB [2, 7, 8]. Of those tested and diagnosed with TB, 20–25% never start treatment as a result of pretreatment loss to followup(LFU) [4, 7, 9]

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