Date Published: March 13, 2019
Publisher: Public Library of Science
Author(s): Hemant Deepak Shewade, Vivek Gupta, Srinath Satyanarayana, Prabhat Pandey, U. N. Bajpai, Jaya Prasad Tripathy, Soundappan Kathirvel, Sripriya Pandurangan, Subrat Mohanty, Vaibhav Haribhau Ghule, Karuna D. Sagili, Banuru Muralidhara Prasad, Sudhi Nath, Priyanka Singh, Kamlesh Singh, Ramesh Singh, Gurukartick Jayaraman, P. Rajeswaran, Binod Kumar Srivastava, Moumita Biswas, Gayadhar Mallick, Om Prakash Bera, K. N. Sahai, Lakshmi Murali, Sanjeev Kamble, Madhav Deshpande, Naresh Kumar, Sunil Kumar, A. James Jeyakumar Jaisingh, Ali Jafar Naqvi, Prafulla Verma, Mohammed Salauddin Ansari, Prafulla C. Mishra, G Sumesh, Sanjeeb Barik, Vijesh Mathew, Manas Ranjan Singh Lohar, Chandrashekhar S. Gaurkhede, Ganesh Parate, Sharifa Yasin Bale, Ishwar Koli, Ashwin Kumar Bharadwaj, G. Venkatraman, K. Sathiyanarayanan, Jinesh Lal, Ashwini Kumar Sharma, Raghuram Rao, Ajay M. V. Kumar, Sarabjit Singh Chadha, Matthew J. Saunders.
Axshya SAMVAD is an active tuberculosis (TB) case finding (ACF) strategy under project Axshya (Axshya meaning ‘free of TB’ and SAMVAD meaning ‘conversation’) among marginalized and vulnerable populations in 285 districts of India.
To compare patient characteristics, health seeking, delays in diagnosis and treatment initiation among new sputum smear positive TB patients detected through ACF and passive case finding (PCF) under the national TB programme in marginalized and vulnerable populations between March 2016 and February 2017.
This observational analytic study was conducted in 18 randomly sampled Axshya districts. We enrolled all TB patients detected through ACF and an equal number of randomly selected patients detected through PCF in the same settings. Data on patient characteristics, health seeking and delays were collected through record review and patient interviews (at their residence). Delays included patient level delay (from eligibility for sputum examination to first contact with any health care provider (HCP)), health system level diagnosis delay (from contact with first HCP to TB diagnosis) and treatment initiation delays (from diagnosis to treatment initiation). Total delay was the sum of patient level, health system level diagnosis delay and treatment initiation delays.
We included 234 ACF-diagnosed and 231 PCF-diagnosed patients. When compared to PCF, ACF patients were relatively older (≥65 years, 14% versus 8%, p = 0.041), had no formal education (57% versus 36%, p<0.001), had lower monthly income per capita (median 13.1 versus 15.7 USD, p = 0.014), were more likely from rural areas (92% versus 81%, p<0.002) and residing far away from the sputum microscopy centres (more than 15 km, 24% versus 18%, p = 0.126). Fewer patients had history of significant loss of weight (68% versus 78%, p = 0.011) and sputum grade of 3+ (15% versus 21%, p = 0.060). Compared to PCF, HCP visits among ACF patients was significantly lower (median one versus two HCPs, p<0.001). ACF patients had significantly lower health system level diagnosis delay (median five versus 19 days, p = 0.008) and the association remained significant after adjusting for potential confounders. Patient level and total delays were not significantly different. Axshya SAMVAD linked the most impoverished communities to TB care and resulted in reduction of health system level diagnosis delay.
Tuberculosis (TB) is the world’s leading cause of death among infectious diseases. In 2017, there were an estimated 10 million new patients and 1.6 million deaths due to TB . World Health Organization’s ‘End TB strategy’ emphasizes on early diagnosis and treatment which is vital for effective TB management [2,3]. Delays in diagnosis and treatment initiation can result in severe clinical presentation, increased disease transmission and unfavourable outcomes including death [4–9]. Therefore, finding patients early has the potential to reduce TB transmission.
Project Axshya was implemented on a very large scale (around half of the districts in India) among marginalised and vulnerable populations in India. Axshya SAMVAD, an active case finding strategy under the project, was successful in identifying patients who were comparatively more marginalized and vulnerable and relatively less sick when compared to PCF. Axshya SAMVAD reduced delays in diagnosis which was probably mediated through reducing the number of HCPs visited.
This study adds to the evidence base favouring active case finding for TB among those with poor access. Axshya SAMVAD, an active case finding strategy in community settings among marginalized and vulnerable populations conducted over a large scale in India, provided healthcare equity for vulnerable groups and reduced the diagnosis delay when compared to passive case finding. Project Axshya may take steps to further reduce the diagnosis delay through assisted referral and/or SCT without the need for a documented failed referral.