RESUMEN
BACKGROUND: Diagnosis, notification and timely initiation of treatment is an important cornerstone for the elimination of tuberculosis (TB). The referral and feedback mechanism under National Tuberculosis Programme of India has been changed from paper-based to web-based electronic system (Nikshay) since 2018. The current study was carried out to assess the effect of Nikshay in referral and receipt of feedback on treatment initiation and to understand the early implementation challenges. METHODS: A mixed-methods study was conducted in a medical college referral unit (MCRU) of Delhi, India. The electronic TB notification data for July 2018-March 2019 were abstracted from Nikshay portal and analysed. Unadjusted and adjusted relative risk (aRR) was calculated to assess the factors associated with the receipt of feedback. Themes and subthemes were generated from qualitative data obtained through key-informant interviews of healthcare providers. RESULTS: Of the total 4395 patients handled by MCRU during the study period, 3315 (75.4%) were referred out within and outside Delhi for treatment. Feedback was received among 797 (24.0%) of the patients who were referred out. Patients with extrapulmonary TB (aRR: 1.3, confidence interval (CI): 1.1-1.8), previously treated (aRR: 1.2, CI: 1.2-1.3) and registered for drug-resistant TB care (aRR: 1.4, CI: 1.1-1.8), had high chance of receiving feedback. Four broad themes emerged, namely, (a) awareness of programme and Nikshay; (b) tracking of patients; (c) user-friendly portal and (d) workload. CONCLUSION: The low feedback on treatment initiation of patients with TB needs further research after health system-level quality improvement interventions. Real-time tracking of patients is the need of the hour towards the path for TB elimination.
RESUMEN
BACKGROUND: Diagnosis of pulmonary tuberculosis (PTB) in children is challenging due to difficulties in obtaining good quality sputum specimens as well as the paucibacillary nature of disease. Globally a large proportion of pediatric tuberculosis (TB) cases are diagnosed based only on clinical findings. Xpert MTB/RIF, a highly sensitive and specific rapid tool, offers a promising solution in addressing these challenges. This study presents the results from pediatric groups taking part in a large demonstration study wherein Xpert MTB/RIF testing replaced smear microscopy for all presumptive PTB cases in public health facilities across India. METHODS: The study covered a population of 8.8 million across 18 programmatic sub-district level tuberculosis units (TU), with one Xpert MTB/RIF platform established at each study TU. Pediatric presumptive PTB cases (both TB and Drug Resistant TB (DR-TB)) accessing any public health facilities in study area were prospectively enrolled and tested on Xpert MTB/RIF following a standardized diagnostic algorithm. RESULTS: 4,600 pediatric presumptive pulmonary TB cases were enrolled. 590 (12.8%, CI 11.8-13.8) pediatric PTB were diagnosed. Overall 10.4% (CI 9.5-11.2) of presumptive PTB cases had positive results by Xpert MTB/RIF, compared with 4.8% (CI 4.2-5.4) who had smear-positive results. Upfront Xpert MTB/RIF testing of presumptive PTB and presumptive DR-TB cases resulted in diagnosis of 79 and 12 rifampicin resistance cases, respectively. Positive predictive value (PPV) for rifampicin resistance detection was high (98%, CI 90.1-99.9), with no statistically significant variation with respect to past history of treatment. CONCLUSION: Upfront access to Xpert MTB/RIF testing in pediatric presumptive PTB cases was associated with a two-fold increase in bacteriologically-confirmed PTB, and increased detection of rifampicin-resistant TB cases under routine operational conditions across India. These results suggest that routine Xpert MTB/RIF testing is a promising solution to present-day challenges in the diagnosis of PTB in pediatric patients.