title: High pre-diagnosis attrition among patients with presumptive MDR-TB: an operational research from Bhopal district, India.
abstract: Pre-diagnosis attrition needs to be addressed urgently if we are to make progress in improving MDR-TB case detection and achieve universal access to MDR-TB care. We report the pre-diagnosis attrition, along with factors associated, and turnaround times related to the diagnostic pathway among patient with presumptive MDR-TB in Bhopal district, central India (2014).
  
  
  
  Study was conducted under the Revised National Tuberculosis Control Programme setting. It was a retrospective cohort study involving record review of all registered TB cases in Bhopal district that met the presumptive MDR-TB criteria (eligible for DST) in 2014. In quarter 1, Line Probe Assay (LPA) was used if sample was smear/culture positive. Quarter 2 onwards, LPA and Cartridge-based Nucleic Acid Amplification Test (CbNAAT) was used for smear positive and smear negative samples respectively. Pre-diagnosis attrition was defined as failure to undergo DST among patients with presumptive MDR-TB (as defined by the programme).
  
  
  
  Of 770 patients eligible for DST, 311 underwent DST and 20 patients were diagnosed as having MDR-TB. Pre-diagnosis attrition was 60% (459/770). Among those with pre-diagnosis attrition, 91% (417/459) were not identified as 'presumptive MDR-TB' by the programme. TAT [median (IQR)] to undergo DST after eligibility was 4 (0, 10) days. Attrition was more than 40% across all subgroups. Age more than 64 years; those from a medical college; those eligible in quarter 1; patients with presumptive criteria 'previously treated - recurrent TB', 'treatment after loss-to-follow-up' and 'previously treated-others'; and patients with extra-pulmonary TB were independent risk factors for not undergoing DST.
  
  
  
  High pre-diagnosis attrition was contributed by failure to identify and refer patients. Attrition reduced modestly with time and one factor that might have contributed to this was introduction of CbNAAT in quarter 2 of 2014. General health system strengthening which includes improvement in identification/referral and patient tracking with focus on those with higher risk for not undergoing DST is urgently required.
authors.affiliation: International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India, 110016. hemantjipmer@gmail.com.
authors.forename: Hemant Deepak
authors.initials: HD
authors.lastname: Shewade
authors.affiliation: Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, India.
authors.forename: Arun M
authors.initials: AM
authors.lastname: Kokane
authors.affiliation: Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, India.
authors.forename: Akash Ranjan
authors.initials: AR
authors.lastname: Singh
authors.affiliation: State TB cell, Department of Health and Family Welfare, Bhopal, India.
authors.forename: Manoj
authors.initials: M
authors.lastname: Verma
authors.affiliation: World Health Organization, Country Office in India, New Delhi, India.
authors.forename: Malik
authors.initials: M
authors.lastname: Parmar
authors.affiliation: Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, India.
authors.forename: Ashish
authors.initials: A
authors.lastname: Chauhan
authors.affiliation: Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, India.
authors.forename: Sanjay Singh
authors.initials: SS
authors.lastname: Chahar
authors.affiliation: Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, India.
authors.forename: Manoj
authors.initials: M
authors.lastname: Tiwari
authors.affiliation: State TB cell, Department of Health and Family Welfare, Bhopal, India.
authors.forename: Sheeba Naz
authors.initials: SN
authors.lastname: Khan
authors.affiliation: Department of Community Ophthalmology, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
authors.forename: Vivek
authors.initials: V
authors.lastname: Gupta
authors.affiliation: International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India, 110016.
authors.forename: Jaya Prasad
authors.initials: JP
authors.lastname: Tripathy
authors.affiliation: Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, India.
authors.forename: Mukesh
authors.initials: M
authors.lastname: Nagar
authors.affiliation: Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, India.
authors.forename: Sanjai Kumar
authors.initials: SK
authors.lastname: Singh
authors.affiliation: Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences (AIIMS), Bhopal, India.
authors.forename: Pradeep Kumar
authors.initials: PK
authors.lastname: Mehra
authors.affiliation: International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India, 110016.|International Union Against Tuberculosis and Lung Disease, Paris, France.
authors.forename: Ajay Mv
authors.initials: AM
authors.lastname: Kumar
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000995:Antitubercular Agents / Q000627:therapeutic use; D042241:Early Diagnosis; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000187:drug effects / Q000302:isolation & purification; D009874:Operations Research; D010342:Patient Acceptance of Health Care; D012189:Retrospective Studies; D018088:Tuberculosis, Multidrug-Resistant / Q000175:diagnosis* / Q000188:drug therapy / Q000517:prevention & control; D055815:Young Adult
chemical_list: D000995:Antitubercular Agents
keywords: Attrition; Diagnosis and treatment pathway; Diagnosis, delayed; India; Operational research; Tuberculosis, multidrug-resistant/diagnosis; Tuberculosis, multidrug-resistant/prevention and control