10 research outputs found
What 'outliers' tell us about missed opportunities for tuberculosis control: a cross-sectional study of patients in Mumbai, India
BACKGROUND: India's Revised National Tuberculosis Control Programme (RNTCP) is deemed highly successful in terms of detection and cure rates. However, some patients experience delays in accessing diagnosis and treatment. Patients falling between the 96th and 100th percentiles for these access indicators are often ignored as atypical 'outliers' when assessing programme performance. They may, however, provide clues to understanding why some patients never reach the programme. This paper examines the underlying vulnerabilities of patients with extreme values for delays in accessing the RNTCP in Mumbai city, India. METHODS: We conducted a cross-sectional study with 266 new sputum positive patients registered with the RNTCP in Mumbai. Patients were classified as 'outliers' if patient, provider and system delays were beyond the 95th percentile for the respective variable. Case profiles of 'outliers' for patient, provider and system delays were examined and compared with the rest of the sample to identify key factors responsible for delays. RESULTS: Forty-two patients were 'outliers' on one or more of the delay variables. All 'outliers' had a significantly lower per capita income than the remaining sample. The lack of economic resources was compounded by social, structural and environmental vulnerabilities. Longer patient delays were related to patients' perception of symptoms as non-serious. Provider delays were incurred as a result of private providers' failure to respond to tuberculosis in a timely manner. Diagnostic and treatment delays were minimal, however, analysis of the 'outliers' revealed the importance of social support in enabling access to the programme. CONCLUSION: A proxy for those who fail to reach the programme, these case profiles highlight unique vulnerabilities that need innovative approaches by the RNTCP. The focus on 'outliers' provides a less resource- and time-intensive alternative to community-based studies for understanding the barriers to reaching public health programmes
Strains of Mycobacterium tuberculosis from Western Maharashtra, India, Exhibit a High Degree of Diversity and Strain-Specific Associations with Drug Resistance, Cavitary Disease, and Treatment Failure βΏ β
We performed spoligotyping of Mycobacterium tuberculosis isolates from 833 systematically sampled pulmonary tuberculosis (TB) patients in urban Mumbai, India (723 patients), and adjacent rural areas in western India (110 patients). The urban cohort consisted of two groups of patients, new cases (646 patients) and first-time treatment failures (77 patients), while only new cases were recruited in the rural areas. The isolates from urban new cases showed 71% clustering, with 168 Manu1, 62 CAS, 22 Beijing, and 30 EAI-5 isolates. The isolates from first-time treatment failures were 69% clustered, with 14 Manu1, 8 CAS, 8 Beijing, and 6 EAI-5 isolates. The proportion of Beijing strains was higher in this group than in urban new cases (odds ratio [OR], 3.29; 95% confidence limit [95% CL], 1.29 to 8.14; P = 0.003). The isolates from rural new cases showed 69% clustering, with 38 Manu1, 7 CAS, and 1 EAI-5 isolate. Beijing was absent in the rural cohort. Manu1 was found to be more common in the rural cohort (OR, 0.67; 95% CL, 0.42 to 1.05; P = 0.06). In total, 71% of isolates were clustered into 58 spoligotypes with 4 predominant strains, Manu1 (26%), CAS (9%), EAI-5 (4%), and Beijing (4%), along with 246 unique spoligotypes. In the isolates from urban new cases, we found Beijing to be associated with multidrug resistance (MDR) (OR, 3.40; 95% CL, 1.20 to 9.62; P = 0.02). CAS was found to be associated with pansensitivity (OR, 1.83; 95% CL, 1.03 to 3.24; P = 0.03) and cavities as seen on chest radiographs (OR, 2.72; 95% CL, 1.34 to 5.53; P = 0.006). We recorded 239 new spoligotypes yet unreported in the global databases, suggesting that the local TB strains exhibit a high degree of diversity
Alarming levels of drug-resistant tuberculosis in HIV-infected patients in metropolitan Mumbai, India.
BACKGROUND: Drug-resistant tuberculosis (DR-TB) is a looming threat to tuberculosis control in India. However, no countrywide prevalence data are available. The burden of DR-TB in HIV-co-infected patients is likewise unknown. Undiagnosed and untreated DR-TB among HIV-infected patients is a major cause of mortality and morbidity. We aimed to assess the prevalence of DR-TB (defined as resistance to any anti-TB drug) in patients attending public antiretroviral treatment (ART) centers in greater metropolitan Mumbai, India. METHODS: A cross-sectional survey was conducted among adults and children ART-center attendees. Smear microscopy, culture and drug-susceptibility-testing (DST) against all first and second-line TB-drugs using phenotypic liquid culture (MGIT) were conducted on all presumptive tuberculosis patients. Analyses were performed to determine DR-TB prevalence and resistance patterns separately for new and previously treated, culture-positive TB-cases. RESULTS: Between March 2013 and January 2014, ART-center attendees were screened during 14135 visits, of whom 1724 had presumptive TB. Of 1724 attendees, 72 (4%) were smear-positive and 202 (12%) had a positive culture for Mycobacterium tuberculosis. Overall DR-TB was diagnosed in 68 (34%, 95% CI: 27%-40%) TB-patients. The proportions of DR-TB were 25% (29/114) and 44% (39/88) among new and previously treated cases respectively. The patterns of DR-TB were: 21% mono-resistant, 12% poly-resistant, 38% multidrug-resistant (MDR-TB), 21% pre-extensively-drug-resistant (MDR-TB plus resistance to either a fluoroquinolone or second-line injectable), 6% extensively drug-resistant (XDR-TB) and 2% extremely drug-resistant TB (XDR-TB plus resistance to any group-IV/V drug). Only previous history of TB was significantly associated with the diagnosis of DR-TB in multivariate models. CONCLUSION: The burden of DR-TB among HIV-infected patients attending public ART-centers in Mumbai was alarmingly high, likely representing ongoing transmission in the community and health facilities. These data highlight the need to promptly diagnose drug-resistance among all HIV-infected patients by systematically offering access to first and second-line DST to all patients with 'presumptive TB' rather than 'presumptive DR-TB' and tailor the treatment regimen based on the resistance patterns
Demographic and clinical factors associated with drug-resistant tuberculosis in HIV-infected tuberculosis patients, Mumbai, India.
<p>ART: Antiretroviral treatment, CI; Confidence Intervals <sup>+</sup>Patients with recorded family income, Nβ=β162* Patients with available information about CD4 count, last visit Nβ=β185** Patients on ART with available information about ART initiation date, Nβ=β126<sup>a</sup> aOR; adjusted Odds ratios (calculated by binary logistic regression using multiple imputation for CD4 missing data).</p><p>Demographic and clinical factors associated with drug-resistant tuberculosis in HIV-infected tuberculosis patients, Mumbai, India.</p
Demographic and clinical factors associated with multidrug-resistant tuberculosis in HIV-infected tuberculosis patients, Mumbai, India.
<p>ART: Antiretroviral treatment, CI; Confidence Intervals <sup>+</sup>Patients with recorded family income, Nβ=β140* Patients with available information about CD4 count, last visit Nβ=β164** Patients on ART with available information about ART initiation date, Nβ=β126<sup>a</sup>aOR; adjusted Odds ratios (calculated by binary logistic regression using multiple imputation for CD4 missing data).</p><p>Demographic and clinical factors associated with multidrug-resistant tuberculosis in HIV-infected tuberculosis patients, Mumbai, India.</p
Drug-resistant tuberculosis among HIV-infected patients with presumptive tuberculosis, Mumbai, India.
<p>Drug-resistant tuberculosis among HIV-infected patients with presumptive tuberculosis, Mumbai, India.</p
Demographic and clinical characteristics of HIV-infected patients with presumptive TB, Mumbai, India.
<p>ART: Antiretroviral treatment* Patients on ART with available information about ART initiation date, Nβ=β1370.</p><p>Demographic and clinical characteristics of HIV-infected patients with presumptive TB, Mumbai, India.</p
Demographic and clinical factors associated with culture-positive tuberculosis in HIV-infected patients, Mumbai, India.
<p>ART: Antiretroviral treatment, IQR: Inter-quartile range, CI; Confidence Intervals <sup>+</sup>Patients with recorded family income, Nβ=β1452* Patients with available information on CD4, last visit, Nβ=β1582** Patients on ART with available information about ART initiation date, Nβ=β1370<sup>a</sup> aPR; adjusted Prevalence Ratios (calculated by Poisson regression using multiple imputation for CD4 missing data).</p><p>Demographic and clinical factors associated with culture-positive tuberculosis in HIV-infected patients, Mumbai, India.</p
Resistance profile (first and second-line) for all drug-resistant tuberculosis patients, Mumbai, India.
<p>H-isoniazid, R-rifampicin, E-ethambutol, Eto-ethionamide, Km-kanamycin, Cm-capreomycin, Ofx-ofloxacin, Mfx-Moxifloxacin, Lin- Linezolid, PAS- para-aminosalicylic acid.</p><p>Resistance profile (first and second-line) for all drug-resistant tuberculosis patients, Mumbai, India.</p