Journeys to tuberculosis treatment: a qualitative study of patients, families and communities in Jogjakarta, Indonesia

<p>Abstract</p> <p>Background</p> <p>Many tuberculosis (TB) patients in Indonesia are diagnosed late. We seek to document patient journeys toward TB diagnosis and treatment and factors that influence health care seeking behavior.</p> <p>Methods</p> <p>TB patients in Jogjakarta municipality (urban) and Kulon Progo district (rural) were recruited from health care facilities participating in the DOTS strategy and health care facilities not participating in the DOTS strategy, using purposive sampling methods. Data were collected through in-depth interviews with TB patients and members of their family and through Focus Group Discussions (FGD) with community members.</p> <p>Results</p> <p>In total, 67 TB patients and 22 family members were interviewed and 6 FGDs were performed. According to their care seeking behavior patients were categorized into National TB program's (NTP) dream cases (18%), 'slow-but-sure patients' (34%), 'shopaholics' (45%), and the NTP's nightmare case (3%). Care seeking behavior patterns did not seem to be influenced by gender, place of residence and educational level. Factors that influenced care seeking behavior include income and advice from household members or friends. Family members based their recommendation on previous experience and affordability. FGD results suggest that the majority of people in the urban area preferred the hospital or chest clinic for diagnosis and treatment of TB whereas in the rural area private practitioners were preferred. Knowledge about TB treatment being free of charge was better in the urban area. Many community members from the rural area doubted whether TB treatment would be available free of charge.</p> <p>Conclusion</p> <p>Most TB patients took over a month to reach a DOTS facility after symptoms appeared and had consulted a number of providers. Their income and advice from household members and friends were factors that influenced their care seeking behavior most.</p

Patients' perception regarding the influence of individual and social vulnerabilities on the adherence to tuberculosis treatment: a qualitative study

Background: Tuberculosis remains an important disease which mainly affects the majority of vulnerable individuals in society, who are subjected to poor living conditions and difficulties to access the services of public health. Under these circumstances, the present study aims to understand patients' perception in relation to the influence of individual and social vulnerabilities on the adherence to tuberculosis treatment. Methods: A qualitative descriptive cross sectional study was conducted in one large municipality at the state of Paraiba, Northeast of Brazil. The study subjects, who were residents of the study site, covered all tuberculosis cases diagnosed between March and June 2015. The sample was defined by the criteria of response saturation. All interviews were audio recorded, and data analysis was developed through the hermeneutic dialectic method and the theory of Generative Route Sense. The project was approved by the Research Ethics Committee of the University of Sao Paulo (USP). Results: A total of 13 individuals were interviewed and the responses were identified into two analytical categories: the difficulties they had and the enabling factors they could mention during their tuberculosis treatment. Patients brought up social exclusion as an obstacle to treatment adherence, which, along with stigmatization, weakened their link with family members and health professionals. Moreover, economic precariousness was a major hindrance to the maintenance of a proper diet and transportation access to health centers. However, social support and directly observed treatment helped to break down barriers of prejudice and to promote individual and family empowerment. Finally, patients also reported that their will to live and faith gave them the strength to continue with the treatment. Conclusions: According to patients in this study, social support and the strengthening of links with family members and health professionals may reduce social exclusion and other difficulties they face, thus encouraging them to the adhere to tuberculosis treatment.Univ Estadual Paraiba, Campina Grande, Paraiba, BrazilUniv Fed Rio Grande do Norte, Natal, RN, BrazilUniv Sao Paulo, Escola Enfermagem, Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Escola Paulista Enfermagem, Sao Paulo, BrazilFac Santa Maria, Cajazeiras, Paraiba, BrazilUniv Fed Sao Paulo, Escola Paulista Enfermagem, Sao Paulo, BrazilWeb of Scienc

Health care seeking among pulmonary tuberculosis suspects and patients in rural Ethiopia: a community-based study

<p>Abstract</p> <p>Background</p> <p>Health care seeking is a dynamic process that is influenced by socio-demographic, cultural and other factors. In Ethiopia, there are limited studies regarding the health seeking behaviour of tuberculosis (TB) suspects and TB patients. However, a thorough understanding of patients' motivation and actions is crucial to understanding TB and the treatment of disease. Such insights would conceivably help to reduce delay in diagnosis, improve treatment adherence and thereby reduce transmission of TB in the community. The objective of this study was to describe and analyze health care seeking among TB suspects and pulmonary TB (PTB) cases in a rural district of the Amhara Region in Ethiopia.</p> <p>Methods</p> <p>Study <it>kebeles </it>were randomly selected in a cross-sectional study design. House-to-house visits were conducted in which individuals aged 15 years and above in all households of the <it>kebeles </it>were included. Subjects with symptoms suggestive of TB were interviewed about their health seeking behaviour, socio-demographic and clinical factors using a semi-structured questionnaire. Logistics regression analysis was employed to assess associations between the independent and outcome variables.</p> <p>Results</p> <p>The majority, 787 (78%), TB suspects and 33 (82.5%) PTB cases had taken health care actions for symptoms from sources outside their homes. The median delay before the first action was 30 days. In logistics regression, women (AOR 0.8, 95% CI 0.6, 0.9) were found to be less likely to visit a medical health provider than men. Those with a long duration of cough (AOR 1.5, 95% CI 1.03, 2.1) and those with a previous history of TB (AOR 1.5, 95% CI 1.03, 2.3) were more likely to visit a medical health provider compared to those with a shorter duration of cough and with no history of TB.</p> <p>Conclusion</p> <p>The majority of TB suspects and PTB cases had already taken health care actions for their symptoms at the time of the survey. The availability of a simple and rapid diagnostic TB test for use at the lowest level of health care and the involvement of all health providers in case finding activities are imperative for early TB case detection.</p

Tuberculosis burden in an urban population: a cross sectional tuberculosis survey from Guinea Bissau

<p>Abstract</p> <p>Background</p> <p>Little is known about the prevalence of pulmonary tuberculosis (TB) in low income countries. We conducted a cross sectional survey for pulmonary TB and TB symptoms in Bissau, Guinea-Bissau, in an urban cohort with known HIV prevalence. TB surveillance in the area is routinely based on passive case finding.</p> <p>Methods</p> <p>Two cohorts were selected based on a previous HIV survey, but only 52.5% of those enrolled in the adult cohort had participated in the HIV survey. One cohort included all adults living in 384 randomly selected houses; in this cohort 8% (135/1687) were HIV infected. The other included individuals 50 years or older from all other houses in the study area; of these 11% (62/571) were HIV infected. Symptom screening was done through household visits using a standardised questionnaire. TB suspects were investigated with sputum smear microscopy and X-ray.</p> <p>Results</p> <p>In the adult cohort, we found 4 cases among 2989 individuals screened, giving a total TB prevalence of 134/100,000 (95% CI 36-342/100,000). In the >50 years cohort, we found 4 cases among 571 individuals screened, giving a total prevalence of 701/100,000 (191-1784/100.000). Two of the eight detected TB cases were unknown by the TB program. Of the total TB cases five were HIV uninfected while three had unknown HIV status. The prevalence of TB symptoms was 2.1% (63/2989) and 10.3% (59/571) in the two cohorts respectively.</p> <p>Conclusions</p> <p>In conclusion we found a moderately high prevalence of pulmonary TB and TB symptoms in the general population, higher among elderly individuals. By active case finding unknown cases were detected. Better awareness of TB and its symptoms needs to be promoted in low income settings.</p

Delay in diagnosis of tuberculosis in Rawalpindi, Pakistan

<p>Abstract</p> <p>Background</p> <p>Delay in diagnosis and treatment of tuberculosis (TB) may enhance the chances of morbidity and mortality and play a key role in continuous transmission of the bacilli. The objective of this study was to describe health care seeking behavior of suspected TB patients and initial diagnostic work up prior to consultation and diagnosis at National TB Center (NTC).</p> <p>Findings</p> <p>Interviews of 252 sputum smear positive patients were taken from NTC, Rawalpindi. The duration between on-set of symptoms and start of treatment was considered as the total delay and correlated with general characteristics of TB patients. The proportion of males and females were 49.6% and 50.4% with median age of 25 and 24 years respectively. A median delay of 56 days (8 weeks) was observed which was significantly associated with age, cough and fever. More than 50% of the current patients had a history of contact with previously diagnosed TB patients. The majority of patients (63%) visited health care providers within three weeks of appearance of symptoms but only thirty five percent were investigated for TB diagnosis.</p> <p>Conclusion</p> <p>Cough and fever are being ignored as likely symptoms of TB by patients as well as health care providers resulting in delay. Engaging private practitioners through public private mix (PPM) approach for expansion of TB diagnosis and increasing public awareness could be more beneficial to reduce delay.</p

Identification of Mycobacterium tuberculosis clinical isolates in Bangladesh by a species distinguishable multiplex PCR

<p>Abstract</p> <p>Background</p> <p>Species identification of isolates belonging to the <it>Mycobacterium tuberculosis </it>complex (MTC) seems to be important for the appropriate treatment of patients, since <it>M. bovis </it>is naturally resistant to a first line anti-tuberculosis (TB) drug, pyrazinamide, while most of the other MTC members are susceptible to this antimicrobial agent. A simple and low-cost differentiation method was needed in higher TB burden countries, such as Bangladesh, where the prevalence of <it>M. bovis </it>among people or cattle has not been investigated.</p> <p>Methods</p> <p>Genetic regions <it>cfp32</it>, RD9 and RD12 were chosen as targets for a species distinguishable multiplex PCR and the system was evaluated with twenty reference strains of mycobacterial species including non-tubercular mycobacteria (NTM). A total of 350 clinical MTC isolates obtained in Bangladesh were then analyzed with this multiplex PCR.</p> <p>Results</p> <p>All of the MTC reference strains gave expected banding patterns and no non-specific amplifications were observed in the NTM strains. Out of 350 clinical isolates examined by this method, 347 (99.1%) were positive for all of the <it>cfp32</it>, RD9 and RD12 and determined as <it>M. tuberculosis</it>. Two isolates lacked <it>cfp32 </it>PCR product and one lacked RD12, however, those three samples were further examined and identified as <it>M. tuberculosis </it>by the sequence analyses of <it>hsp65 </it>and <it>gyrB</it>.</p> <p>Conclusions</p> <p>The MTC-discrimination multiplex PCR (MTCD-MPCR) developed in this study showed high specificity and was thought to be very useful as a routine test because of its simplicity. In the current survey, all the 350 MTC isolates obtained from Bangladesh TB patients were determined as <it>M. tuberculosis </it>and no other MTC were detected. This result suggested the general TB treatment regimen including pyrazinamide to be the first choice in Bangladesh.</p

Management of pulmonary tuberculosis patients in an urban setting in Zambia: a patient's perspective

<p>Abstract</p> <p>Background</p> <p>Zambia continues to grapple with a high tuberculosis (TB) burden despite a long running Directly Observed Treatment Short course programme. Understanding issues that affect patient adherence to treatment programme is an important component in implementation of a successful TB control programme. We set out to investigate pulmonary TB patient's attitudes to seek health care, assess the care received from government health care centres based on TB patients' reports, and to seek associations with patient adherence to TB treatment programme.</p> <p>Methods</p> <p>This was a cross-sectional study of 105 respondents who had been registered as pulmonary TB patients (new and retreatment cases) in Ndola District between January 2006 and July 2007. We administered a structured questionnaire, bearing questions to obtain individual data on socio-demographics, health seeking behaviour, knowledge on TB, reported adherence to TB treatment, and health centre care received during treatment to consenting respondents.</p> <p>Results</p> <p>We identified that respondents delayed to seek treatment (68%) even when knowledge of TB symptoms was high (78%) or when they suspected that they had TB (73%). Respondent adherence to taking medication was high (77%) but low adherence to submitting follow-up sputum (47%) was observed in this group. Similarly, caregivers educate their patients more often on the treatment of the disease (98%) and drug taking (100%), than on submitting sputum during treatment (53%) and its importance (54%). Respondent adherence to treatment was significantly associated with respondent's knowledge about the disease and its treatment (p < 0.0001), and with caregiver's adherence to treatment guidelines (p = 0.0027).</p> <p>Conclusions</p> <p>There is a need to emphasise the importance of submitting follow-up sputum during patient education and counselling in order to enhance patient adherence and ultimately treatment outcome.</p

Molecular analysis of Mycobacterium isolates from extrapulmonary specimens obtained from patients in Mexico

<p>Abstract</p> <p>Background</p> <p>Little information is available on the molecular epidemiology in Mexico of <it>Mycobacterium </it>species infecting extrapulmonary sites in humans. This study used molecular methods to determine the <it>Mycobacterium </it>species present in tissues and body fluids in specimens obtained from patients in Mexico with extrapulmonary disease.</p> <p>Methods</p> <p>Bacterial or tissue specimens from patients with clinical or histological diagnosis of extrapulmonary tuberculosis were studied. DNA extracts from 30 bacterial cultures grown in Löwenstein Jensen medium and 42 paraffin-embedded tissues were prepared. Bacteria were cultured from urine, cerebrospinal fluid, pericardial fluid, gastric aspirate, or synovial fluid samples. Tissues samples were from lymph nodes, skin, brain, vagina, and peritoneum. The DNA extracts were analyzed by PCR and by line probe assay (INNO-LiPA MYCOBACTERIA v2. Innogenetics NV, Gent, Belgium) in order to identify the <it>Mycobacterium </it>species present. DNA samples positive for <it>M. tuberculosis </it>complex were further analyzed by PCR and line probe assay (INNO-LiPA Rif.TB, Innogenetics NV, Gent, Belgium) to detect mutations in the <it>rpo</it>B gene associated with rifampicin resistance.</p> <p>Results</p> <p>Of the 72 DNA extracts, 26 (36.1%) and 23 (31.9%) tested positive for <it>Mycobacterium species </it>by PCR or line probe assay, respectively. In tissues, <it>M. tuberculosis </it>complex and <it>M. genus </it>were found in lymph nodes, and <it>M. genus </it>was found in brain and vagina specimens. In body fluids, <it>M. tuberculosis </it>complex was found in synovial fluid. <it>M. gordonae</it>, <it>M. smegmatis</it>, <it>M. kansasii</it>, <it>M. genus</it>, <it>M. fortuitum/M. peregrinum </it>complex and <it>M. tuberculosis </it>complex were found in urine. <it>M. chelonae/M. abscessus </it>was found in pericardial fluid and <it>M. kansasii </it>was found in gastric aspirate. Two of <it>M. tuberculosis </it>complex isolates were also PCR and LiPA positive for the <it>rpo</it>B gene. These two isolates were from lymph nodes and were sensitive to rifampicin.</p> <p>Conclusion</p> <p>1) We describe the <it>Mycobacterium </it>species diversity in specimens derived from extrapulmonary sites in symptomatic patients in Mexico; 2) Nontuberculous mycobacteria were found in a considerable number of patients; 3) Genotypic rifampicin resistance in <it>M. tuberculosis </it>complex infections in lymph nodes was not found.</p

Factors associated with delayed diagnosis of tuberculosis in hospitalized patients in a high TB and HIV burden setting: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>The most essential components of TB control are early diagnosis and adequate treatment. Delay in the diagnosis and treatment of tuberculosis may result in more extensive disease and more complications, increase severity of the disease and is associated with higher risk of mortality. The purpose of this study was to identify factors associated with delayed diagnosis of TB in hospitalized patients.</p> <p>Methods</p> <p>We conducted a cross-sectional study in a general, tertiary care, university-affiliated hospital. Adult patients with TB that were hospitalized were identified retrospectively, and risk factors for delayed diagnosis were collected.</p> <p>Results</p> <p>The median delay until diagnosis was 6 days (IQR: 2-12 days). One hundred and sixty six (54.4%) patients were diagnosed ≤ 6 days, and 139 (45.6%) > 6 days after admission. The main factors associated with diagnostic delay (> 6 days) were extra-pulmonary TB and negative sputum smear.</p> <p>Conclusions</p> <p>Although hospitalization permits a rapid management of the patient and favors a faster diagnosis, we found an unacceptable time delay before the diagnosis of pulmonary TB was made. Future studies should focus on attempt to explain the reasons of diagnostic retard in the patients with the characteristics related to delay in this study.</p