Solutions proposed by patients and health care providers to reduce diagnosis delay among adult new leprosy patients in Maharashtra, India (2013–15).

<p>Solutions proposed by patients and health care providers to reduce diagnosis delay among adult new leprosy patients in Maharashtra, India (2013–15).</p

“I Wasted 3 Years, Thinking It’s Not a Problem”: Patient and Health System Delays in Diagnosis of Leprosy in India: A Mixed-Methods Study

<div><p>Background</p><p>Worldwide, leprosy is one of the major causes of preventable disability. India contributes to 60% of global leprosy burden. With increasing numbers of leprosy with grade 2 disability (visible disability) at diagnosis, we aimed to determine risk factors associated with grade 2 disability among new cases and explore patients and providers’ perspectives into reasons for late presentation.</p><p>Methodology/Principal Findings</p><p>This was an explanatory mixed-methods study where the quantitative component, a matched case-control design, was followed by a qualitative component. A total of 70 cases (grade 2 disability) and 140 controls (grade 0) matched for age and sex were randomly sampled from new patients registered between January 2013-January 2015 in three districts of Maharashtra (Mumbai, Thane and Amaravati) and interviewed using a structured close ended questionnaire. Eight public health care providers involved in leprosy care and 7 leprosy patients were purposively selected (maximum variation sampling) and interviewed using a structured open-ended interview schedule. Among cases, overall median (IQR) diagnosis delay in months was 17.9(7–30); patient and health system delay was 7(4–16.5) and 5.5(0.9–12.5) respectively; this was significantly higher than the delay in controls. Reasons for delayed presentation identified by the quantitative and qualitative data were: poor awareness of leprosy symptoms, first health care provider visited being private practitioners who were not aware about provision of free leprosy treatment at public health care facilities, reduced engagement and capacity of the general health care system in leprosy control.</p><p>Conclusions</p><p>Raising awareness in communities and health care providers regarding early leprosy symptoms, engagement of private health care provider in early leprosy diagnosis and increasing capacity of general health system staff, especially targeting high endemic areas that are hotspots for leprosy transmission may help in reducing diagnosis delays.</p></div

Risk factors associated with grade 2 disability at diagnosis among adult new leprosy patients registered in Maharashtra, India (2013–15).

<p>Risk factors associated with grade 2 disability at diagnosis among adult new leprosy patients registered in Maharashtra, India (2013–15).</p

Diagnosis delay in months and its association with grade 2 disability at diagnosis among adult new leprosy patients registered in Maharashtra, India (2013–15).

<p>Diagnosis delay in months and its association with grade 2 disability at diagnosis among adult new leprosy patients registered in Maharashtra, India (2013–15).</p

Patient pathway in Maharashtra, India (2013–15)—Themes associated with leprosy diagnosis delay.

<p>Patient pathway in Maharashtra, India (2013–15)—Themes associated with leprosy diagnosis delay.</p

Data collection sites for the study in Maharashtra, India (2013–15): Mumbai, Thane & Palghar and Amaravati.

<p>Data collection sites for the study in Maharashtra, India (2013–15): Mumbai, Thane & Palghar and Amaravati.</p

Reasons for not consulting doctor at a public health facility immediately after notice of first symptom among new leprosy patients (grade 2 and grade 0 disability at diagnosis) registered in Maharashtra, India (2013–15).

<p>Reasons for not consulting doctor at a public health facility immediately after notice of first symptom among new leprosy patients (grade 2 and grade 0 disability at diagnosis) registered in Maharashtra, India (2013–15).</p

Reasons for not seeking care immediately after notice of first symptom among adult new leprosy patients with grade 2 disability at diagnosis registered in Maharashtra, India (2013–15).

<p>Reasons for not seeking care immediately after notice of first symptom among adult new leprosy patients with grade 2 disability at diagnosis registered in Maharashtra, India (2013–15).</p

Summary of risk of bias in included studies assessed using New Castle Ottawa quality assessment scale for cohort studies [37].

<p>Summary of risk of bias in included studies assessed using New Castle Ottawa quality assessment scale for cohort studies [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0186697#pone.0186697.ref037" target="_blank">37</a>].</p

Effect of glycemic control and type of diabetes treatment on unsuccessful TB treatment outcomes among people with TB-Diabetes: A systematic review

<div><p>Background</p><p><b>S</b>tringent glycemic control by using insulin as a replacement or in addition to oral hypoglycemic agents (OHAs) has been recommended for people with tuberculosis and diabetes mellitus (TB-DM). This systematic review (PROSPERO 2016:CRD42016039101) analyses whether this improves TB treatment outcomes.</p><p>Objectives</p><p>Among people with drug-susceptible TB and DM on anti-TB treatment, to determine the effect of i) glycemic control (stringent or less stringent) compared to poor glycemic control and ii) insulin (only or with OHAs) compared to ‘OHAs only’ on unsuccessful TB treatment outcome(s). We looked for unfavourable TB treatment outcomes at the end of intensive phase and/or end of TB treatment (minimum six months and maximum 12 months follow up). Secondary outcomes were development of MDR-TB during the course of treatment, recurrence after 6 months and/or after 1 year post successful treatment completion and development of adverse events related to glucose lowering treatment (including hypoglycemic episodes).</p><p>Methods</p><p>All interventional studies (with comparison arm) and cohort studies on people with TB-DM on anti-TB treatment reporting glycemic control, DM treatment details and TB treatment outcomes were eligible. We searched electronic databases (EMBASE, PubMed, Google Scholar) and grey literature between 1996 and April 2017. Screening, data extraction and risk of bias assessment were done independently by two investigators and recourse to a third investigator, for resolution of differences.</p><p>Results</p><p>After removal of duplicates from 2326 identified articles, 2054 underwent title and abstract screening. Following full text screening of 56 articles, nine cohort studies were included. Considering high methodological and clinical heterogeneity, we decided to report the results qualitatively and not perform a meta-analysis. Eight studies dealt with glycemic control, of which only two were free of the risk of bias (with confounder-adjusted measures of effect). An Indian study reported 30% fewer unsuccessful treatment outcomes (aOR (0.95 CI): 0.72 (0.64−0.81)) and 2.8 times higher odds of ‘no recurrence’ (aOR (0.95 CI): 2.83 (2.60−2.92)) among patients with optimal glycemic control at baseline. A Peruvian study reported faster culture conversion among those with glycemic control (aHR (0.95 CI): 2.2 (1.1,4)). Two poor quality studies reported the effect of insulin on TB treatment outcomes.</p><p>Conclusion</p><p>We identified few studies that were free of the risk of bias. There were limited data and inconsistent findings among available studies. We recommend robustly designed and analyzed studies including randomized controlled trials on the effect of glucose lowering treatment options on TB treatment outcomes.</p></div