Tuberculosis Care In India Research Articles

Integrating health planning and primary care infrastructure for COVID-19 and tuberculosis care in India: Challenges and opportunities.

Tuberculosis (TB) is the leading cause of death from a single infectious agent worldwide. The COVID‐19 pandemic has overburdened healthcare services around the world especially in resource constrained settings. It has shaken already unstable foundation of TB control programs in India and other high burden states. A 25% decline is expected in TB detection while estimates suggest 13% increase in TB deaths due to the impact of the pandemic. However, the significant intersections between the two diseases perhaps offer potential opportunities for consolidating the efforts to tackle both. The widespread implementation and acceptance of universal masking and social distancing in India has helped limit transmission of both diseases. Integrating the capacity building strategies for the two diseases, optimizing the existing the surveillance and monitoring systems which have been achieved over the years will result in a single vertically integrated national program addressing both, rather than multiple parallel program which utilize the already sparse primary care manpower and infrastructure. In this article, we explore the impact of the COVID‐19 pandemic on tuberculosis in India and offer suggestions on how effective health planning can efficiently integrate infrastructure and manpower at primary level to provide care for both COVID‐19 and tuberculosis.

'We are not aware of notification of tuberculosis': A mixed-methods study among private practitioners from western India.

Implementing the Standards for tuberculosis care in India (STCI) guidelines in the private sector is vital. This study attempted to estimate the knowledge and practices regarding STCI guidelines among private practitioners and to explore the reasons and solutions for low tuberculosis (TB) notification rates. We conducted a cross-sectional study for assessing the knowledge and practices of the STCI guidelines among 100 full-time allopathic private practitioners in Bhavnagar (in western part of India) from September 2018 to January 2019. Knowledge and practice were categorised as good or poor by assigning scores to the responses to a questionnaire based on the STCI guidelines. It was followed by two focus group discussions to explore the reasons and solutions for low notification rates of TB as perceived by private practitioners. Among the 100 private practitioners, 55% had good knowledge, and 41% had good practice regarding the STCI guidelines; 69% knew about the gazette notification of mandatory notification of TB, and 58% were notifying TB cases to the government. Lack of awareness about the process as well as incentives for notification, time constraints and infrequent visits by health workers were the main reasons perceived by private practitioners for not notifying TB cases to the government. The critical solutions suggested by them were creating awareness regarding the notification process as well as incentives, increasing health worker visits and use of social media for notification. Only about half of private practitioners follow the STCI guidelines for TB care, and the notification rates are low in our setting. Regular sensitisation programs need to be arranged for private practitioners to create awareness on TB notification.

Tuberculosis, a preventable pandemic through sensitization programme

The focus of India's tuberculosis control measure has shifted to improving education, understanding symptoms, eliminating transmission, and trying to influence healthcare seeking behavior among both tuberculosis patients and the general public. Tuberculosis is the leading cause of death from an infectious disease worldwide, and drug-resistant strains pose a significant threat to global health security. Sensitization programmes regarding Tuberculosis Disease, Early Detection, Vaccination, Screening, Treatment Compliance, Cough Etiquette & Disposal of Sputum, National Health Programmes, Nutrition, Home & Environment Control can create patient awareness of tuberculosis can promote infection prevention and treatment adherence. Tuberculosis can be reduced by using measures like protecting one's mouth while coughing or sneezing and safely dispose of sputum. Besides that, appropriate sputum disposal will dramatically reduce disease transmission. In tuberculosis patients, knowledge and understanding of touch sensitivity to droplet infection is understood to influence their behavior and assess the frequency and level of transmission in their contacts. Early diagnosis of pulmonary tuberculosis patients and treatment with a complete course of anti-tuberculosis medications are important for TB management. As a result, any reported TB symptomatics with a cough lasting more than two weeks should be referred for TB assessment. Following that, proper treatment necessitates adherence to World Health Organization-recommended treatment guidelines as well as other relevant TB care requirements such as the International Standards for TB Care (ISTC) and the Standards for TB Care in India. Tuberculosis (TB) is still prevalent in many parts of the world, including India, and needs monitoring, clinical assessment, examination, touch tracking, proof of diagnosis, and treatment regimens that are either monitored or unsupervised for successful eradication.

Measuring and Understanding Delays in Multidrug-Resistant Tuberculosis Care in India

Background: India carries 27% of the global tuberculosis (TB) burden with a regional increase in multidrug-resistance (MDR) over the last decade. We aimed to characterize MDR-TB patient risk factors, delays in care and pathways to diagnosis and treatment in Pune, India. Methods: Between Jan-2018 and Sep-2019, we conducted structured and unstructured interviews with patients (>=15 years age) registered with the National TB Elimination Program (NTEP) for MDR (n=128) and non-MDR TB (n=269) treatment. We collected treatment record and GeneXpert-TB/RIF resistance probe binding data. Findings: MDR-TB was associated with continuous residence in a crowded locality [adjusted-OR (aOR) =2.02, 95%CI 1.12-3.63] and young age (aOR= 0.71, 95%CI 0.57-0.89 per 10-year increase). GeneXpert binding patterns demonstrated low diversity with 72.5% (n=233) of MDR isolates losing Probe-E binding. Median time from symptom onset to diagnosis was longer for MDR than non-MDR-TB (90 days, IQR 60-180 vs. 60 days IQR 30-90, Wilcoxon P<0.01). Pathways to care were complex with a median number of encounters of 4 (IQR 3-5) and 3 (IQR 2-4) for MDR and non-MDR respectively. The majority, 68% and 72% respectively, first sought care in the private sector and this was associated with a larger number of subsequent healthcare encounters and high out of pocket expenses. Only 9% received their MDR diagnosis in the private sector. Interpretation: The association of MDR-TB with younger age and crowding in Pune, along with low genotypic diversity of MDR isolates raises concerns of ongoing MDR transmission. Pathways analysis revealed points of intervention including the need to expedite patient referral to and improve retention in the NTEP. Funding Statement: Harvard-Dubai Centre for Global Health Delivery (MF, SA). Boston Children’s Hospital Global Health Program (AD). Declaration of Interests: None to declare. Ethics Approval Statement: We secured approvals from the Indian Ministry of Health and Family Welfare, Central TB Division, the State and local NTEP, Harvard Medical School’s Institutional Review Board and the institutional ethics committee of Dr. D.Y. Patil Vidyapeeth.

TB care for women and Covid-A double health crisis in the offing?

The COVID-19 pandemic and its health, economic and social aftermath has currently overshadowed every other health concern throughout the world. There are numerous ways in which this will impact existing public health issues. In this article we aim to examine and reflect on the interactions between COVID-19 and tuberculosis (TB) another scourge which has long been the world’s leading infectious killer. There are potentially grave consequences for existing and undiagnosed TB patients globally, particularly in low and middle income countries like India where TB is endemic and health services poorly equipped. TB control programmes are likely to be strained due to diversion of resources, and an inevitable loss of health system focus. This is likely to lead to a reduction in quality of TB care and worse outcomes. The symptoms of TB and COVID-19 can be similar, for instance symptoms like cough and fever. Not only can this create diagnostic confusion, but it could worsen the stigmatization of TB patients especially in LMICs, given the fear of COVID-19. Women with TB in India are a vulnerable group as gender disparities play a significant role in how men and women access healthcare in the public and private sectors. They are especially likely to suffer as part of the “collateral damage” and also experience the impact of the double stigma disproportionately. In this paper the researchers examine the impact of Covid 19 on women seeking TB care in India.

Direct and indirect patient costs of tuberculosis care in India.

To synthesise the evidence for estimating the direct and indirect patient costs of drug-sensitive and drug-resistant tuberculosis care in India. PubMed, Embase, Web of Science, IndMED and Google Scholar were searched for studies conducted in India between 2000 and 2018 and published in English. The search terms were "tuberculosis" AND "costs" (cost Analysis, economics, cost of illness, health care costs, health expenditures, direct service costs, catastrophic cost) AND "India". The cost of TB care was from the patient's perspective. Data regarding costs were extracted, indexed to the year 2018 using cumulative inflation rate and converted to US dollars at the exchange rate of 2018. Thirteen studies were included in this review. The mean (unweighted) total cost incurred by patients being treated for drug-sensitive TB in a public health facility was $ 235.00 (SD- 222.10), and the median of means was $ 170.60 (range - 43.70-718.40). The mean direct cost was 45.5% of the total cost. Only one study, which was conducted in a private facility, reported the mean total cost for drug-resistant TB as $ 7778.04. Catastrophic cost (total cost≥20% of the total annual household income) was experienced by 7% to 32.4% of drug-sensitive TB patients and by 68% of drug-resistant TB patients. Despite free diagnostic and treatment services provided under the Revised National Tuberculosis Control Programme, the patient cost of tuberculosis care is high. Relevant studies vary widely in methodology and cost reporting.

Universal health coverage and tuberculosis care in India in the times of Covid-19: Aligning Ayushman Bharat (National Health Assurance Scheme) to improve case detection, reduce deaths and catastrophic health expenditure.

India has the largest global burden of new cases of tuberculosis (TB) and deaths due to TB. These occur predominantly in the poor who suffer catastrophic costs during diagnosis and treatment. The National Tuberculosis Elimination Programme has ambitious goals of 80% reduction of incidence of TB, 90% reduction in mortality due to TB by 2025 and 0% occurrence of catastrophic costs to households affected by TB by 2020. The Covid-19 pandemic and the resulting disruption to TB services are expected to worsen the situation. There are gaps in case finding at the peripheral level and access to care at the higher level for patients with TB. An estimated 32% patients with active TB do not access diagnostic services, while catastrophic costs associated with hospitalization are a barrier to access for seriously ill patients. Deaths due to TB in India occur largely at home and not in medical facilities, and are preventable with appropriate inpatient care. The Ayushman Bharat scheme with its Health and Wellness Centres (HWCs) and coverage for inpatient care under the Pradhan Mantri Jan Arogya Yojana (PM-JAY) can facilitate, the achievement of the goals of TB elimination. The HWCs provide an opportunity to close the case-finding gap as first point of contact by enabling sputum transport services to the designated microscopy centres. This will facilitate case detection, reduce diagnostic delays, and decrease community transmission and the incidence of TB. The benefit package of PM-JAY can cover patients with pulmonary TB, inpatient evaluation for other forms of TB, enhance the allocation for treatment and cover management of comorbid conditions such as severe undernutrition, anaemia, HIV and diabetes.

Mobile phone access and comfort: implications for HIV and tuberculosis care in India and South Africa.

SETTING: India and South Africa shoulder the greatest burden of tuberculosis (TB) and human immunodeficiency virus (HIV) infection respectively, but care retention is suboptimal.OBJECTIVE: We conducted a study in Pune, India, and Matlosana, South Africa, 1) to identify the factors associated with mobile phone access and comfort of use, 2) to assess access patterns.DESIGN: A cross-sectional study assessed mobile phone access, and comfort; a longitudinal study assessed access patterns.RESULTS: We enrolled 261 participants: 136 in India and 125 in South Africa. Between 1 week and 6 months, participant contact decreased from 90% (n = 122) to 57% (n = 75) in India and from 93% (n = 116) to 70% (n = 88) in South Africa. In the latter, a reason for a clinic visit for HIV management was associated with 63% lower odds of contact than other priorities (e.g., diabetes mellitus, maternal health, TB). In India, 57% (n = 78) reported discomfort with texting; discomfort was higher in the unemployed (adjusted OR [aOR] 4.97, 95%CI 1.12-22.09) and those aged ≥35 years (aOR 1.10, 95%CI 1.04-1.16) participants, but lower in those with higher education (aOR 0.04, 95% CI 0.01-1.14). In South Africa, 91% (n = 114) reported comfort with texting.CONCLUSION: Mobile phone contact was poor at 6 months. While mHealth could transform TB-HIV care, alternative approaches may be needed for certain subpopulations.

In the eye of the multiple beholders: Qualitative research perspectives on studying and encouraging quality of TB care in India

This paper outlines insights qualitative research brings to the study of quality of care. It advocates understanding care as sequential, interpersonal action aimed at improving health and documenting the networks in which care occurs. It assesses the strengths and weakness of contemporary quantitative and qualitative approaches to examining quality of care for tuberculosis (TB) before outlining three qualitative research programs aimed at understanding quality of TB in India. Three case studies focus on the diagnosis level in the cascade of TB care and use qualitative research to examine the clinical use of pharmaceuticals as diagnostics, the development of diagnostic tests, and the role of care providers in the utilization of diagnostic services. They show that 1) care must be understood as part of relationships over time, 2) the presence or absence of technologies does not always imply their expected use in care, 3) physicians’ provision of care is often inflected by their perceptions of patient desires, and 4) effective care is not always perfectly aligned with global health priorities. Qualitative methods with a networked perspective on care provide novel findings that can and have been used when developing quality of care improvement interventions for TB.

428. Mobile Phone Access and Comfort: Implications for HIV and Tuberculosis Care in India and South Africa

BackgroundIndia and South Africa shoulder the greatest global burden of TB and HIV, but care retention in these countries is suboptimal. Integration of mHealth into the health system has potential to strengthen retention. We conducted a study in two high burden yet disparate settings, Pune, India and Matlosana, South Africa, to (1) identify factors associated with mobile phone access, comfort of use and (2) understand long-term behavioral patterns of mobile phone access.MethodsWe conducted a cross-sectional study to assess demographics, mobile phone access, and comfort of use, followed by a longitudinal study to determine long-term access among adult participants (≥18 years) from 2014 to 2016. Participants were recruited from the TB clinic at Sassoon Government hospital in Pune and from four public clinics serving the general population in Matlosana. Univariate odds ratios compared characteristics of participants with discomfort texting to those who expressed comfort, as well as those unable to be contacted at six months vs. those contacted. We included variables significantly associated at the univariate level (P < 0.10), and those determined of importance a priori, in a multivariable logistic regression.ResultsWe enrolled a total of 261 participants; 136 in India, 125 in South Africa. The ability to contact participants steadily decreased from 90% (n = 122) contacted at week one to 57% (n = 75) contacted at six months in India and 93% (n = 116) at week one and 70% (n = 88) at six months in South Africa (Figure 1). For India, adjusted analysis revealed that texting discomfort was significantly higher in unemployed (OR 4.97, 95% CI: 1.12, 22.09) and 35+ year old (OR 1.10, 95% CI: 1.04, 1.16) participants, while significantly lower in those with higher education (OR 0.04, 95% CI: 0.01, 0.14). In South Africa, 91% of participants (n = 114) reported comfort with text messaging.ConclusionThe ability to maintain contact with participants by mobile phone in India and South Africa was poor at the 6 month timepoint. While mHealth has the potential to transform HIV and TB care in endemic countries, alternative approaches may be needed for certain subpopulations, including those who are older, unemployed and with lower education.Figure 1.mHealth CallbacksDisclosures All authors: No reported disclosures.

Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities.

BackgroundIndia has the highest burden of tuberculosis (TB). Although most patients with TB in India seek care from the private sector, there is limited evidence on quality of TB care or its correlates. Following our validation study on the standardized patient (SP) method for TB, we utilized SPs to examine quality of adult TB care among health providers with different qualifications in 2 Indian cities.Methods and findingsDuring 2014–2017, pilot programs engaged the private health sector to improve TB management in Mumbai and Patna. Nested within these projects, to obtain representative, baseline measures of quality of TB care at the city level, we recruited 24 adults to be SPs. They were trained to portray 4 TB “case scenarios” representing various stages of disease and diagnostic progression. Between November 2014 and August 2015, the SPs visited representatively sampled private providers stratified by qualification: (1) allopathic providers with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees or higher and (2) non-MBBS providers with alternative medicine, minimal, or no qualifications.Our main outcome was case-specific correct management benchmarked against the Standards for TB Care in India (STCI). Using ANOVA, we assessed variation in correct management and quality outcomes across (a) cities, (b) qualifications, and (c) case scenarios. Additionally, 2 micro-experiments identified sources of variation: first, quality in the presence of diagnostic test results certainty and second, provider consistency for different patients presenting the same case.A total of 2,652 SP–provider interactions across 1,203 health facilities were analyzed. Based on our sampling strategy and after removing 50 micro-experiment interactions, 2,602 interactions were weighted for city-representative interpretation. After weighting, the 473 Patna providers receiving SPs represent 3,179 eligible providers in Patna; in Mumbai, the 730 providers represent 7,115 eligible providers. Correct management was observed in 959 out of 2,602 interactions (37%; 35% weighted; 95% CI 32%–37%), primarily from referrals and ordering chest X-rays (CXRs). Unnecessary medicines were given to nearly all SPs, and antibiotic use was common. Anti-TB drugs were prescribed in 118 interactions (4.5%; 5% weighted), of which 45 were given in the case in which such treatment is considered correct management.MBBS and more qualified providers had higher odds of correctly managing cases than non-MBBS providers (odds ratio [OR] 2.80; 95% CI 2.05–3.82; p < 0.0001). Mumbai non-MBBS providers had higher odds of correct management than non-MBBS in Patna (OR 1.79; 95% CI 1.06–3.03), and MBBS providers’ quality of care did not vary between cities (OR 1.15; 95% CI 0.79–1.68; p = 0.4642). In the micro-experiments, improving diagnostic certainty had a positive effect on correct management but not across all quality dimensions. Also, providers delivered idiosyncratically consistent care, repeating all observed actions, including mistakes, approximately 75% of the time. The SP method has limitations: it cannot account for patient mix or care-management practices reflecting more than one patient–provider interaction.ConclusionsQuality of TB care is suboptimal and variable in urban India’s private health sector. Addressing this is critical for India’s plans to end TB by 2025. For the first time, we have rich measures on representative levels of care quality from 2 cities, which can inform private-sector TB interventions and quality-improvement efforts.

Preferred Healthcare Destination for Tuberculosis Care among the Slum Dwellers in Chhattisgarh: An Exploratory Study

Background: Health seeking behavior for tuberculosis (TB) among Indian population varies greatly with different indicators like habitation, gender, socioeconomic status, and literacy. Studies reveal that a substantial portion of Indian population seeks medical care at private health facilities, despite TB being a centrally sponsored program. Objective: The main objective of this study was to assess the health seeking behavior for TB among the slum dwellers in Chhattisgarh, India. Materials and Methods: A cross-sectional study was carried out using a structured questionnaire to collect information regarding the preference of health facilities and reasons for not approaching government health facility for TB care among 100 households in a slum area in Chhattisgarh. Results: Of the 100 families, 25, 69, 01, and 05% of the families reported to approach private practitioners, government health facilities, traditional practitioners, and adopt self-medication, respectively, for common health problems. Similarly, of 100 families, 44, 54, 01, and 01% families reported to approach private practitioners, government health facilities, traditional practitioners, and adopt self-medication, respectively, for TB care. In addition, several factors were identified for not approaching the government health facilities for TB care. Of 100 households, 13, 01, 20, 19, and 25% households, respectively, reported the following factors “there is long queue in govt. hospital, the Govt. medicines are not of good quality, in Govt. hospital nobody takes care of us, there is no communication facility, my home is far away from Govt. health facility.” In addition, 21% households reported to accept government health facility for TB care. Conclusion: As a centrally sponsored program, TB care in India is free of cost and quality in diagnosis, and treatment is assured. Thus, communities should be mobilized to access TB care at public health facilities to prevent poverty trap, and other problems owing to private sector TB care.

Ways and Means to Utilize Private Practitioners for Tuberculosis Care in India.

The growing interest of utilizing the private practitioners in improving the outreach of public health services including Tuberculosis (TB) control programme stemmed out of people's preference for private health facilities in situations where public health facilities fail to meet the expectations. In different parts of India, many models of Public Private Partnership have been tried and tested and proved successful in providing quality TB care in the concerned community. In this paper, several ways and means have been proposed to effectively utilize private practitioners for TB care in India. These strategies are discussed under different headings: (1) identification of potential private practitioners: (2) orientation of private practitioners: (3) networking of private practitioners with patients and Directly Observed Treatment Short course (DOTS) provider: (4) follow-up and sensitization of patients by private practitioners: (5) let the word of mouth work: and (6) evaluation of the involvement of private practitioners in TB care. However the following points must be addressed before utilizing the private practitioners for TB care: time constraints in notifying the disease, adherence to DOTS regime/alternative to DOTS regime, referral of patients to public health facilities for diagnosis and treatment, follow-up and sensitization of the patients and behaviour change communication and awareness in the community by the private practitioners. Few of these are mandatory for the private practitioners; most are practicable. With the effective utilization of private practitioners many problems can be sorted out that are currently plaguing the system such as irrational and excessive use of certain drugs, over reliance on chest X-ray for diagnosis, under use of sputum microscopy, lack of knowledge regarding standard treatment protocols and varied prescription practices.

Treatment of childhood tuberculosis in India.

With a quarter of the global burden of tuberculosis (TB) occurring in India, children in this country are at high risk of tuberculous infection and TB disease. India's Revised National Tuberculosis Control Programme provides free diagnosis and treatment for children with TB using quality assured, weight-based individual drug boxes. Guidelines have recently been revised, updating both the diagnostic algorithm and shifting to a daily regimen with World Health Organization recommended dosages using child-friendly, fixed-dose combination pills. Active case finding is practised in households of TB patients as well as among human immunodeficiency virus infected and malnourished children. More attention needs to be paid to the provision of preventive therapy for household contacts aged <6 years as well as to the detection of multidrug-resistant TB among children. Case notification and the use of the Standards of TB Care in India are being strengthened in the private sector.

Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study

Existing studies of the quality of tuberculosis care have relied on recall-based patient surveys, questionnaire surveys of knowledge, and prescription or medical record analysis, and the results mostly show the health-care provider's knowledge rather than actual practice. No study has used standardised patients to assess clinical practice. Therefore we aimed to assess quality of care for tuberculosis using such patients. We did a pilot, cross-sectional validation study of a convenience sample of consenting private health-care providers in low-income and middle-income areas of Delhi, India. We recruited standardised patients in apparently good health from the local community to present four cases (two of presumed tuberculosis and one each of confirmed tuberculosis and suspected multidrug-resistant tuberculosis) to a randomly allocated health-care provider. The key objective was to validate the standardised-patient method using three criteria: negligible risk and ability to avoid adverse events for providers and standardised patients, low detection rates of standardised patients by providers, and data accuracy across standardised patients and audio verification of standardised-patient recall. We also used medical vignettes to assess providers' knowledge of presumed tuberculosis. Correct case management was benchmarked using Standards for Tuberculosis Care in India (STCI). Between Feb 2, and March 28, 2014, we recruited and trained 17 standardised patients who had 250 interactions with 100 health-care providers, 29 of whom were qualified in allopathic medicine (ie, they had a Bachelor of Medicine & Surgery [MBBS] degree), 40 of whom practised alternative medicine, and 31 of whom were informal health-care providers with few or no qualifications. The interactions took place between April 1, and April 23, 2014. The proportion of detected standardised patients was low (11 [5%] detected out of 232 interactions among providers who completed the follow-up survey), and standardised patients' recall correlated highly with audio recordings (r=0·63 [95% CI 0·53-0·79]), with no safety concerns reported. The mean consultation length was 6 min (95% CI 5·5-6·6) with a mean of 6·18 (5·72-6·64) questions or examinations completed, representing 35% (33-38) of essential checklist items. Across all cases, only 52 (21% [16-26]) of 250 were correctly managed. Correct management was higher among MBBS-qualified doctors than other types of health-care provider (adjusted odds ratio 2·41 [95% CI 1·17-4·93]; p=0·0166). Of the 69 providers who completed the vignette, knowledge in the vignettes was more consistent with STCI than their actual clinical practice-eg, 50 (73%) ordered a chest radiograph or sputum test during the vignette compared with seven (10%) during the standardised-patient interaction; OR 0·04 (95% CI 0·02-0·11); p<0·0001. Standardised patients can be successfully implemented to assess tuberculosis care. Our data suggest a big gap between private provider knowledge and practice. Additional work is needed to substantiate our pilot data, understand the know-do gap in provider behaviour, and to identify the best approach to measure and improve the quality of tuberculosis care in India. Grand Challenges Canada, the Bill & Melinda Gates Foundation, Knowledge for Change Program, and the World Bank Development Research Group.

Quality of tuberculosis care in India: a systematic review.

While Indian studies have assessed care providers' knowledge and practices, there is no systematic review on the quality of tuberculosis (TB) care. We searched multiple sources to identify studies (2000-2014) on providers' knowledge and practices. We used the International Standards for TB Care to benchmark quality of care. Of the 47 studies included, 35 were questionnaire surveys and 12 used chart abstraction. None assessed actual practice using standardised patients. Heterogeneity in the findings precluded meta-analysis. Of 22 studies evaluating provider knowledge about using sputum smears for diagnosis, 10 found that less than half of providers had correct knowledge; 3 of 4 studies assessing self-reported practices by providers found that less than a quarter reported ordering smears for patients with chest symptoms. In 11 of 14 studies that assessed treatment, less than one third of providers knew the standard regimen for drug-susceptible TB. Adherence to standards in practice was generally lower than correct knowledge of those standards. Eleven studies with both public and private providers found higher levels of appropriate knowledge/practice in the public sector. Available evidence suggests suboptimal quality of TB care, particularly in the private sector. Improvement of quality of care should be a priority for India.

Quality of tuberculosis care in India: A systematic review

Quality of tuberculosis care in India: A systematic review

Costs and Consequences of Using Interferon-γ Release Assays for the Diagnosis of Active Tuberculosis in India.

BackgroundThere is growing concern that interferon-γ release assays (IGRAs) are being used off-label for the diagnosis of active tuberculosis (TB) disease in many high-burden settings, including India, where the background prevalence of latent TB infection is high. We analyzed the costs and consequences of using IGRAs for the diagnosis of active TB in India from the perspective of the Indian TB control sector.Methods and FindingsWe constructed a decision analytic model to estimate the incremental cost and effectiveness of IGRAs for the diagnosis of active TB in India. We compared a reference scenario of clinical examination and non-microbiological tests against scenarios in which clinical diagnosis was augmented by the addition of either sputum smear microscopy, IGRA, or Xpert MTB/RIF. We examined costs (in 2013 US dollars) and consequences from the perspective of the Indian healthcare sector. Relative to sputum smear microscopy, use of IGRA for active TB resulted in 23,700 (95% uncertainty range, UR: 3,800 – 38,300) additional true-positive diagnoses, but at the expense of 315,700 (95% UR: 118,300 – 388,400) additional false-positive diagnoses and an incremental cost of US$49.3 million (95% UR: $34.9 – $58.0 million) (2.9 billion Indian Rupees). Relative to Xpert MTB/RIF (including the cost of treatment for drug resistant TB), use of IGRA led to 400 additional TB cases treated (95% UR: [-8,000] – 16,200), 370,600 (95% UR: 252,200 – 441,700) more false-positive diagnoses, 70,400 (95% UR: [-7,900] – 247,200) fewer disability-adjusted life years averted, and US$14.6 million (95%UR: [-$7.2] – $28.7 million) (854 million Indian Rupees) in additional costs.ConclusionUsing IGRAs for diagnosis of active TB in a setting like India results in tremendous overtreatment of people without TB, and substantial incremental cost with little gain in health. These results support the policies by WHO and Standards for TB Care in India, which discourage the use of IGRAs for the diagnosis of active TB in India and similar settings.