REVIEW ARTICLE |
https://doi.org/10.5005/jp-journals-11010-1115 |
A Short Narrative Review on the Delays in Tuberculosis Care in Odisha
School of Public Health, SRM Institute of Science and Technology, Chennai, Tamil Nadu, India
Corresponding Author: Janmejaya Samal, School of Public Health, SRM Institute of Science & Technology, Chennai, Tamil Nadu, India, Phone: +91 9438323843, e-mail: janmejas@srmist.edu.in
Received: 25 April 2024; Accepted: 21 May 2024; Published on: 18 June 2024
ABSTRACT
Early diagnosis and prompt treatment are definite steps toward tuberculosis (TB) elimination efforts; however, the same is greatly affected by delays in the TB care cascade. The delay, on the other hand, depends on the factors related to both sides of the health system, the supply and the demand side or the patient and the health system side. A review was carried out to understand different types, durations, and factors associated with delays in TB care among different population groups in Odisha. PubMed and Google Scholar search engines were used for searching relevant literature using the search string “Tuberculosis” AND “Delay” AND “Odisha.” Additionally, articles from cross-references were selected, with final inclusion of four studies for this review. Of the four studies, two articles each are based on secondary research and primary research. The secondary researches are based on Nikshay portal data, and primary researches are cross-sectional studies. Two studies were conducted in the tribal district of Rayagada, and one each included a sample from Cuttack to Mayurbhanj, with one pan-Odisha study. The retrospective observational registry-based cohort study among 47,831 TB cases across the state reported that 7.6% of cases were initiated on treatment after 14 days of diagnosis. The retrospective cohort study conducted in Cuttack and Rayagada district reported treatment delay of >15 days among 20% of the cases and median delay of treatment initiation of 14 days. The cross-sectional study in Rayagada reported that 62.2% of the patients reported to the designated microscopic centers (DMCs) after a month of the onset of symptoms. During recent days, the situation has improved; however, efforts must be directed toward improving knowledge and awareness about TB and its services among the tribal population, thereby improving health-seeking behavior and reducing delays.
How to cite this article: Samal J. A Short Narrative Review on the Delays in Tuberculosis Care in Odisha. Indian J Respir Care 2024;13(2):113–116.
Source of support: Nil
Conflict of interest: None
Keywords: Consultation delay, Diagnosis delay, Health system delay, Patient delay, Total delay, Treatment delay
INTRODUCTION
As per the World Health Organization’s estimations, the incidence of tuberculosis (TB) is 130 cases per 1,00,000 population worldwide,1 with India having 131 cases per 1,00,000 people.2 India (17%), Nigeria (11%), Indonesia (10%), Pakistan (8%), and the Philippines (7%), the five most populous nations, accounted for >50% of the global gap.1 The Global TB Report 2020 states that 26 and 27%, respectively, of TB cases in India are multidrug-resistant (MDR) and resistant to rifampin.3 Approximately 26% of incident cases and 31% of TB deaths globally were contributed by India.4 As part of the Union Budget 2017–2018, the Government of India announced its plan to end TB by 2025, with a goal to meet the 2030 Sustainable Development Goals (SDG) targets.5 On January 1, 2020, the Revised National TB Control Program (RNTCP) was renamed as the National TB Elimination Program (NTEP), which is India’s longest-running effort to fight TB. The National TB Control Program (NTCP) was launched in 1962 and was carried out in two phases between 1997 and 2019 under the name RNTCP.6 NTEP now serves as the technical and managerial aspects of the nation’s national anti-TB program and is an important component of the National Health Mission (NHM). One of the significant gaps in TB care is the “missing millions,” which refers to 3 in 10 people who contract TB worldwide that do not receive either diagnosis, treatment, or notification of the national TB program. This is one of the major gaps in TB control.7 Understanding the absolute number of patients finishing a stage of care during TB therapy as well as a gap is equally crucial.8,9 The diverse gaps in the TB care cascade have been identified both globally10-12 and in India.11 The concept of “cascade of care” can be used to assess how well a health system delivers care for a particular disease.12 The steps that each patient follows to help treat themselves or control their symptoms are referred to as the care cascade behavior.13 It is a very complex and cumbersome procedure that requires patients to analyze their symptoms, their health behavior and attitude, and then choose the appropriate course of therapy based on both the financial and physical accessibility.13 The delay in availing the services can occur at any of these points of the TB care cascade and can impact badly on the outcome of TB care.
With this background, this review was carried out to understand different factors and durations contributing to the delays associated with TB care among different population groups in the state of Odisha.
TUBERCULOSIS IN ODISHA
Odisha is better positioned in the country with reference to NTEP performance indicators. In 2022, Odisha was ranked as the second-best performing state among >50 lakhs (state population) population category. Total TB cases notified in 2022 were 60,372, which is 92.9% against the expected notification, amounting to 127.6 cases per lakh population, 74.2% pulmonary TB cases, 25.8% extrapulmonary TB cases, and 61% bacteriologically confirmed cases. The presumptive TB examination rate in 2022 in the state was 2,590 per lakh population, and the number needed to test was 44 through microscopy and 4 through nucleic acid amplification test (NAAT). Thirteen tribal districts of the state contributed 23,503 (38.93%) total TB cases in 2022. In 2022, through an active case-finding approach, 37,08,035 vulnerable individuals were screened for symptoms, of which 4.9% had identified TB symptoms, and 2% were diagnosed with TB.14
METHODS
The literature search was conducted during December 1st, 2023 to December 31st, 2023 using the PubMed and Google Scholar databases with search terms “Tuberculosis,” “Delays,” “Odisha.” The search string used for the literature search was “Tuberculosis” AND “Delay” AND “Odisha.” With the use of the above search string, only 4 articles were found through the PubMed search engine, while the same search string yielded 46 articles in Google Scholar with publication years ranging from 2000 to 2024. By the end of this search process, two articles from Google Scholar, one article from PubMed, and one article from cross-reference were selected for the review, which met the inclusion criteria.
The articles published in the English language from 2000 to 2024 that assessed the delays in TB care along with the factors in Odisha were selected for the narrative review. Studies on TB carried out in Odisha that did not explore the type, duration, and factors of delays of TB care and studies conducted in other parts of the country were excluded from the review.
Basic details of the published articles, such as the authors’ names, titles, study settings/districts where the studies were conducted, the study years, types of populations studied/participated, the sample sizes, and the study designs, were gathered in a table.
RESULTS
Four articles were selected for this review. Of these, two articles each are based on secondary research and primary research. Both secondary research articles are based on Nikshay portal data, while the primary research articles are cross-sectional studies, and 100% of these studies used TB cases as the study sample. Two studies were conducted in the Rayagada district, and one each included a sample from Cuttack to Mayurbhanj, with one pan-Odisha study. Both Rayagada and Mayurbhanj districts are predominantly tribal districts of the state. Table 1 shows the characteristics of the studies included in this review. Several factors related to delays in TB care have been found out and are presented as a word cloud in Figure 1.
| S. No. | Authors | Journal | Year of publication | Study year | District(s) covered | Sample size | Study population | Study designs |
|---|---|---|---|---|---|---|---|---|
| 1 | Giri et al.20 | Indian Journal of Tuberculosis | 2024 | 2019 | Pan-Odisha | 47,831 | TB cases | Retrospective observational registry-based cohort study |
| 2 | Ilangovan et al.21 | PLoS One | 2015 | 2013 | Cuttack and Rayagada | 1,800 | TB cases | Retrospective cohort study design |
| 3 | Basa and Venkatesh22 | Journal of Clinical and Diagnostic Research | 2016 | 2007 | Mayurbhanj | 261 | TB cases | Analytical cross-sectional study |
| 4 | Das and Dwibedi23 | International Journal of Mycobacteriology | 2016 | 2011–2013 | Rayagada | 634 | TB cases | Cross-sectional study |
Fig. 1: Word cloud showing the factors of delays associated with TB care in Odisha
DISCUSSION
The delay in TB care can occur at any phase of TB care pathway and can be related to the factors associated with the patients and the factors linked to the health system. These can also be called the demand side delays and supply side delays of the health system, and the combination of these two side delays is called the total delay.15Figure 2 depicts delays in the TB care cascade in which the consultation delay can also be synonymously used as the patient delay or the demand side delay of the health system and is the delay that occurs after the onset of the symptoms till the first consultation by the patient. Secondly, the diagnosis delay is the delay between the first consultation and the date of diagnosis. Some authorities consider the diagnosis delay from the onset of symptoms till the date of diagnosis. It is mostly agreed upon that for most TB patients, the total delay (the sum of the patient and healthcare delays) should not exceed 1 month, even though there is no universally approved time frame for this.16,17 A 4-week cutoff value is used to classify diagnostic delays, with 2 weeks each for acceptable patient and health system delays.18 Furthermore, there is a chance that the patient will put off getting help, and that the medical staff will take longer to identify and diagnose a TB case.19
Fig. 2: Delays in care cascade of TB patients
The retrospective observational registry-based (Nikshay portal, 2019 data) cohort study among 47,831 TB cases revealed that 77.4% of the cases were initiated on treatment within 7 days of diagnosis, 15% of cases were initiated on treatment within 7–14 days of diagnosis, and 7.6% of cases were initiated on treatment after 14 days of diagnosis.20 The study conducted among 3,192 TB patients in Cuttack and Rayagada district revealed the treatment delays in which 40% of the patients had treatment delay of >7 days, of which 20% had treatment delay of >15 days, in which the mean days of treatment initiation was 21 days and the median was 14 days.21 The study conducted across four TB units of Mayurbhanj district among 261 TB patients found that the median patient delay was 24 days with a mean of 36.5 days, 3 days of median health system delay with a mean delay of 11.59 days, and total median delay of 24 days, in which 97% of the patients had patient delay and 19.5% patients had health systems delay.22 The study conducted in Rayagada district of Odisha across 20 designated microscopic centers (DMCs) among 580 patients found that 62.2% of the patients reported to the DMCs after a month of the onset of the symptoms, in which 12.9% of the TB patients had diagnostic delay exceeding >2 months, 50% of them had high sputum grade.23 Several studies in India reported delays of varied duration in the past, one such study conducted in two Indian states of Jharkhand and Gujarat found 19 days of median total delay among the pulmonary TB cases and 23 days of median total delay among the extrapulmonary TB cases.10 Another systematic review reported patient delay, diagnostic delay, and treatment delay of 18.4, 31.0, and 2.5 days, respectively.24
The factors for delayed seeking care are related to both the patients as well as the health system, as depicted in these studies. The study in Cuttack and Rayagada district reported that a prior history of TB, diagnosis outside the district, human immunodeficiency virus (HIV)–TB coinfection, weak health system, difficult terrain, lack of adequate transport facilities, and poor referral of patients diagnosed outside the districts contribute to delay in TB care.21 The Mayurbhanj study reported poor awareness about TB, long distance from TB units or DMCs, poor socio-economic conditions, loss of wages, alcoholism, and the patient being the breadwinner of the family as the factors of delayed TB care in the district. The primary reasons for health system delay were administrative delays and lack of adequate human resources in the district.22 In addition to the above factors, several studies in India reported other factors such as social stigma, discrimination,25-27 and lack of family support28 as the contributing factors to delay in care-seeking across different population groups.
Since active TB cases have the potential to spread the disease to the neighboring communities, delays—at the patient and health system level—are critical from the public health standpoint. Therefore, to ensure successful TB control in a given population, early diagnosis and prompt treatment are utmost important. Additionally, delaying the diagnosis and treatment can make the patient’s condition worse, which could have a negative repercussion on the patient’s prognosis and even result in death.25 Because the health system and demand side factors differ greatly, it is important to document the delay attributes in various geographical contexts. To minimize delays in the TB care pathway and ultimately attain the larger objective of the end TB strategy, a comprehensive approach that considers each of these elements is strongly recommended.10 Program-level data on delays at various levels needs to be analyzed and reviewed with district TB units; however, this will rely on routine data collection on the number of providers seen prior to TB diagnosis, the length of the process, and patient costs; the data should include both public and private sectors. More study must be carried out to quantify the correlation between diagnostic delays and TB transmission and to estimate the number of secondary cases that may result from the lengthy treatment pathway.29
CONCLUSION
Understanding delays in TB care is very significant as strategies to reduce delays on both sides of the health system can help in early diagnosis and prompt treatment. This is further very important as the country is aiming to eliminate TB by 2025, 5 years ahead of the global target. Compared to earlier delays, the awareness among the general mass has increased a lot across different strata of the society, and the health system has also strengthened with the availability of required human resources, diagnostics and drugs, and other support services as well; however, the same is not universal across all the places in the country and in the context of the state as well. It is not unusual to have situations of stock out of medicines, diagnostics, and attrition of human resources in the program. Similarly, complete awareness about TB across tribal areas of the state does not stand true always and need incessant efforts to improve the knowledge and awareness of the tribal population. Furthermore, shopping behavior of many patients and not landing up in the right facility for diagnosis and treatment in the right time is another problem leading to drug-resistant TB. Hence, concerted efforts must be made to improve and strengthen both sides of the health system to reduce the delays in help-seeking behavior and to attain the overall objective of eliminating TB in the state.
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