title: Is physical access an impediment to tuberculosis diagnosis and treatment? A study from a rural district in North India.
abstract: METHODS
  All designated microscopy centres (DMCs) in Fatehgarh Sahib District, Punjab, India.
  
  
  OBJECTIVE
  To study the association of distance (physical access) to DMCs with loss to follow-up (LTFU) of presumptive tuberculosis (TB) cases while undergoing diagnostic sputum examination and failure to initiate treatment among smear-positive TB patients after diagnosis.
  
  
  METHODS
  A cross-sectional, record-based study was undertaken to analyse patient records from routine laboratory registers in all DMCs from January to June 2012.
  
  
  RESULTS
  More than 50% of presumptive TB cases had to travel >7 km to reach the DMC, totalling >28 km for two sputum examinations for the evaluation of an episode. The distance (>10 km) to the diagnostic facility was found to be significantly associated (P < 0.01), both with LTFU during diagnosis and with a delay (>7 days) in initiating treatment after diagnosis. There was a significant correlation (r = 0.7) between distance to the DMC and time to initiate treatment among smear-positive TB cases.
  
  
  CONCLUSIONS
  Distance from the nearest facility represents a significant risk for LTFU during diagnosis and delayed initiation of treatment after diagnosis. Further decentralisation of TB care services to the community level is required by expanding the network of DMCs or by organising sputum collection and transportation.
authors.affiliation: School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
authors.forename: J P
authors.initials: JP
authors.lastname: Tripathy
authors.affiliation: International Union Against Tuberculosis and Lung Disease, New Delhi, India.
authors.forename: S
authors.initials: S
authors.lastname: Srinath
authors.affiliation: Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.
authors.forename: P
authors.initials: P
authors.lastname: Naidoo
authors.affiliation: REACH, Chennai, India.
authors.forename: R
authors.initials: R
authors.lastname: Ananthakrishnan
authors.affiliation: Revised National Tuberculosis Control Programme, District Fatehgarh Sahib, Punjab, India.
authors.forename: R
authors.initials: R
authors.lastname: Bhaskar
keywords: India; RNTCP; TB diagnosis; physical access