Date Published: June 6, 2019
Publisher: Public Library of Science
Author(s): Winters Muttamba, Willy Ssengooba, Bruce Kirenga, Rogers Sekibira, Simon Walusimbi, Achilles Katamba, Moses Joloba, Philip C. Hill.
Tuberculosis (TB) is the 9th leading cause of death from a single infectious agent. Patients live in a complex health care system with both formal and informal providers, and it is important that a TB diagnosis is not missed at the first interaction with the health care system. In this study, we highlight the health seeking behavior of patients and missed opportunities for early TB diagnosis for which interventions could be instituted to ensure early TB diagnosis and prompt TB treatment initiation.
This study was nested in a cross-sectional study that assessed the accuracy of different Xpert MTB/Rif implementation strategies in programmatic settings at the referral hospitals in Uganda. We documented the symptom profile of presumptive TB patients and assessed the health seeking behavior of those with chronic cough by calculating proportion of patients that visited each type of health facility and further calculated the odds of being TB positive given the type of health facility initially visited for consultation.
A total of 1,863 presumptive TB patients were enrolled of which 979 (54.5%) were male, and 1795 (99.9%) had chronic cough. A total of 1352 (75.4%) had previously sought care for chronic cough, with 805 (59.6%) seeking care from a public health facility followed by private health facility (289; 21.4%). Up to 182 (13.5%) patients visited a drug store for chronic cough. Patients whose first contact was a private health facility were more likely to have a positive GeneXpert test (adjOR 1.4, 95% CI: 1.0–1.9; p = 0.047).
Chronic cough is a main symptom for many of the presumptive TB patients presenting at referral hospitals, with several patients having to visit the health system more than once before a TB diagnosis is made. This suggests the need for patients to be thoroughly evaluated at first interface with the health care system to ensure prompt diagnosis and treatment initiation. Improved TB diagnosis possibly with the GeneXpert test, at first contact with the health care system has potential to increase TB case finding and break the transmission cycle in the community.
Tuberculosis (TB) is the 9th leading cause of death from a single infectious agent, ranking above Human Immune deficiency virus (HIV) . The 2017 WHO global TB report lists Uganda as a high HIV/TB burden country. In 2016, Uganda notified 44816 TB cases , and data from the TB prevalence survey put the prevalence and incidence rates at 253/100,000 and 234/100,000 respectively . Uganda has a decentralized laboratory health system with laboratory services decentralized up to lower level health facilities. The country has up to 1,500 diagnostic and treatment units (DTUs) and as early as 2010, Xpert MTB/Rif technology was rolled out in the country, with up to 115 machines installed in 105 health facilities . Loop holes in the health care system are some of the reasons for delayed and missed TB diagnosis. Studies have shown that patients first identified as having TB in community surveys had previously attended health services on a number of occasions with symptoms but had never been diagnosed .
This study done among referral hospitals shows that a significant proportion of presumptive TB patients presents with chronic cough as one of the key symptoms. Despite the fact that these patients reside in a high burden setting, they are usually misdiagnosed for TB during their initial presentation at the heath facilities. Moreover, even with this attempt of care seeking given their chronic cough, most of them were not evaluated for TB during the initial care seeking visit. We document a significant number of these patients who end up being diagnosed with TB using the GeneXpert test at the referral health facilities. Our study further shows that a number of these participants had initially presented to at least one health facility with chronic cough before TB diagnosis was made. This presents a missed opportunity for early TB diagnosis in a high TB/HIV burden setting.
We were unable to document any other visits between the initial visit to the health care provider and the study site. This would have documented a complete pathway the study patients went through before a diagnosis was made. Furthermore, it would have helped us estimate the time between onset of cough and diagnosis to be able to document the magnitude of diagnostic delay. We were also unable to ascertain the level of the public health facility initially visited and also ascertain the test results for those patients that had been asked to provide a sputum sample on initial consultation. The level of the public health facility would have helped us understand whether the facility had the necessary diagnostics or not, while by understanding the results from the sputum, we would have been able to document whether a diagnostic test was done or not when sputum sample was requested.
Chronic cough is a main symptom for majority of the presumptive TB patients presenting at referral hospitals, with several patients having to visit the health system more than once before having a diagnosis. This suggests the need for patients to be thoroughly evaluated at first interface with the health care system to ensure prompt diagnosis and treatment initiation. Improved TB diagnosis possibly with the GeneXpert test, at first contact with the health care system has potential to increase TB case finding and break the transmission cycle in the community. Patients who first seek TB care from private facilities are 1.5 times more likely to have a positive sputum GeneXpert test result compared to those who first seek care in public health facilities. This stresses the need to strengthen the Public Private Partnerships in Uganda in order to improve TB control.