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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 13-17

Unite to end Tuberculosis – The need for public–private collaboration


1 Department of Internal Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
2 Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India

Date of Submission16-Jan-2021
Date of Decision18-Jan-2021
Date of Acceptance20-Jan-2021
Date of Web Publication19-Feb-2021

Correspondence Address:
Dr. Abel K Samuel Johnson
Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla - 689 103, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmrp.cmrp_9_21

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  Abstract 


Background: Despite effective diagnostic tools and drugs for tuberculosis , the disease still remains a public health threat. Financial insecurity, Social stigma, food insecurity, distance to nearest health facility and psychological stress play as hurdles in the diagnosis and completion of tuberculosis treatment. Early diagnosis and completion of treatment plays a key role in controlling tuberculosis. The public and the private sector in India together is trying hard to control this menace. The public sector in India has a wide network of institutions with uniform standardized treatment for TB treatment under the National tuberculosis program. The private sector is heterogeneous with limited or no extension centers in the peripheries. This makes it difficult for the private sector to follow up the patient. So the national program has extended the arms to join with the private partners to eliminate TB. This article attempts to highlight the need of collaborating with the national program to eliminate tuberculosis.
Materials and Methods : All the tuberculosis patients diagnosed at a private institution prior to partnership with the national program were followed up to understand the treatment outcomes and understand the importance of public private collaboration.
Results: A total of 131 patients were diagnosed with tuberculosis from the health facility during the study period. Out of the 131 patients, 30% (n = 39) could not be traced. Among the patients who were contacted, treatment interruption was observed in 6 (7%) patients. More than 1/4th of the traced patients (n = 62) completed their treatment. Death occurred to 08 (9%) traced patients.
Conclusion: This study reiterate the need for Private public coordination in the treatment of TB. It is the responsibility of the health care professionals in the private sector to collaborate with the national tuberculosis program to make tuberculosis elimination a reality.

Keywords: Elimination, partnership, private, public, treatment outcomes, tuberculosis


How to cite this article:
Koshy J, Samuel Johnson AK, Babu BP, Joseph MR. Unite to end Tuberculosis – The need for public–private collaboration. Curr Med Res Pract 2021;11:13-7

How to cite this URL:
Koshy J, Samuel Johnson AK, Babu BP, Joseph MR. Unite to end Tuberculosis – The need for public–private collaboration. Curr Med Res Pract [serial online] 2021 [cited 2021 Mar 4];11:13-7. Available from: http://www.cmrp.org/text.asp?2021/11/1/13/309923




  Introduction Top


Tuberculosis (TB) is a multisystem disease with myriad presentations and manifestations. India is the country with the highest burden of TB.[1] As per the Global TB report 2017, the estimated incidence of TB in India was approximately 2,800,000 accounting for about a quarter of the world's TB cases. This huge number of TB patients is managed by the government and private health institutions.[1] Global burden of TB is showing a declining trend, but India still holds more than a quarter (27%) of the global burden. There has been a steady increase in the notification of TB cases from around the World. Around 5.7–5.8 million new cases were reported annually, mainly due to the increased reporting of detected cases by the private sector in India. However still, a staggering one million TB cases are missing from notification,[2] most of them being diagnosed and treated in private sector.[3] Studying the burden of TB in the private sector remains crucial for understanding and managing the overall burden of TB in India.

Being tertiary care medical centers, the number of TB patients managed at medical school hospitals is substantially more across the country.[4] In Kerala, tertiary care institutions are preferred to reconfirm the diagnosis and receive TB care to avoid the stigma and bypass the confidentiality issues associated with the disease.[5] Medical schools play an important role in TB care through service delivery, advocacy, training and operational research. With advancement in TB care, the medical schools are supporting case management of drug-resistant TB patients, pharmaco vigilance and private sector engagement.[6],[7]

Collaborative efforts between the public and private sectors have shown to improve the case detection and treatment outcomes of TB.[8] The combined positives of private healthcare providers and the public health sector when joined can be used to provide a service that will bring high rates of treatment success and increased rates of patient notification.[9] Over the years, the partnership with the National TB Control Programme has opened avenues for the tertiary care centres in improving the quality of TB services, provision of specialised services for seriously ill TB patients or complicated cases like those TB patients co-infected with HIV and multi-drug resistant TB, research and advocacy and social mobilisation.[6],[7],[10]

The public sector has a wide network of institutions with uniform standardised treatment for TB treatment under Revised National TB Control Programme (RNTCP) implemented all throughout the network. The private sector is heterogeneous with no extension centers in the peripheries. This makes it difficult to follow up the patient and understand treatment outcomes, even though studies from Kerala have shown that the prescribing pattern is reasonable for TB management among the private sector doctors.[11]

Most of the medical schools in Kerala have joined hands with medical schools to implement a Directly Observed Treatment Short Course Chemotherapy (DOTS). The effectiveness of DOTS for TB treatment in medical schools has been established by various studies.[5],[6],[7],[12]

This article is an attempt to highlight the importance of collaborating with the national program to eliminate TB.


  Materials and Methods Top


The present study was conducted from January 2015 to December 2017 at a tertiary care institute in Central Travancore. All the patients above the age of 18 years diagnosed with TB were included in the study.

The hospital registration number of all the TB patients diagnosed in our hospital was obtained using the Hospital Information and Management system software platform. With the hospital registration number, the medical records of the patients diagnosed with TB were retrieved from the medical records division. The details about their TB treatment including the demographic profile, diagnosis, the type of TB, department to which they presented, the treatment taken and their outcome along with the contact address were obtained from the patient records/files. A trained social worker retrieved the information and entered the details in a pre-designed questionnaire under the supervision of the principal investigator. The data were randomly checked by the investigators with the information on the medical records to check the quality of the data.

All the diagnosed patients who left our hospital before completing the treatment were telephonically interviewed using a pre-designed questionnaire. If the patient had passed away, the near relatives were interviewed. Those who could not be contacted were attempted to establish a contact by calling thrice weekly. If they were not able to be contacted after three attempts or if the phone number given was in correct, then the study participant fell in the category of a non-contactable candidate.

The data were entered in MS excel. Simple proportions were calculated.

The study was presented before the Institutional Ethics Committee and approval was obtained. The participants were contacted and informed verbal consent was obtained prior to enrolment in the study.

Operational definitions

Standard case and treatment outcome definitions were used which were adapted from the Manual on the Treatment guidelines for Medical Officers by the Revised National TB Control Programme.

Cured

A pulmonary TB patient with bacteriologically confirmed TB at the beginning of treatment who was smear or culture negative in the last month of treatment and on at least one previous occasion.

Treatment completed

A TB patient who completed treatment without evidence of failure but with no record to show that sputum smear or culture results in the last month of treatment and on at least one previous occasion were negative, either because tests were not done or because results are unavailable.

Died

A TB patient who died for any reason before starting or during the course of treatment.

Treatment interruption

A patient who has interrupted treatment for more than 3 days irrespective of the initiation of the treatment.


  Results Top


A total of 131 patients were diagnosed with TB from the health facility during the study period. Out of the 131 patients, only 70% (n = 92) could be traced or established a contact. The remaining 30% (n = 39) could not be traced [Figure 1].
Figure 1: Flow chart of results

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More than half of the participants were males (63%). The patients with TB were further categorised as pulmonary and extrapulmonary cases. There were 79 (60%) pulmonary TB cases and 52 (40%) extrapulmonary TB cases [Table 1]. Among the 79 patients with pulmonary TB, 48 (60%) were sputum positive and 31 (40%) were sputum negative. The most common presentation of extrapulmonary TB was TB lymph node (n = 28), followed by disseminated TB and TB spine [Table 2].
Table 1: Profile of tuberculosis patients

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Table 2: Classification of extrapulmonary tuberculosis (n=52)

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Only 40 patients (43%) took treatment from the government facility, whereas the majority took treatment from a private facility. Among the patients who were contacted, treatment interruption was observed in 6 (7%) patients. More than one-fourth of the traced patients (n = 62) completed their treatment. Death occurred to 8 (9%) traced patients [Table 3].
Table 3: Outcomes of patients who were traceable (n=92)

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  Discussion Top


A total of 131 patients were diagnosed with TB from the health facility during the study period. Of the 131 patients, only 70% (n = 92) could be traced or established a contact. The remaining 30% (n = 39) could not be traced [Table 1]. As a new teaching and training health institute, the national program was not established in the institution prior to this study. This high proportion of non-traceable patients initiated the beginning of the collaboration with the National TB Programme.

Amongst the 131 patients diagnosed with TB, 40 patients (30.53%) took treatment from government centers or government-accredited centers to pursue with DOTS. A maximum (69%) number of patients took treatment from the private facility. India's NTEP has been committed to providing free, high-quality TB care to patients even in the private sector. More TB patients are treated in the private sector than in the public sector.[1] The choice to treat the patient in the private is a choice taken either by the doctor or could be a request from the patient.

Treatment interruption (7%) was observed in this cohort which is unacceptable for a disease which is going for elimination. The utilisation of a structured referral mechanism is not available in the private sector. The heterogeneous nature of the private sector makes it almost impossible to do so. Hence, the linkage with RNTCP where a structured referral mechanism is available should be utilised for better outcomes. An interventional study done in a tertiary care hospital in Punjab, Pakistan, has shown that the utilisation of a referral register, close monitoring of the referral by telephone and communication with responsible TB coordinators bring about a considerable improvement in the TB patient referral mechanism.[12],[13] This facility is available with the National TB Elimination Programme (NTEP). This calls further for the need of the private institutions to enter into the network with NTEP.[14]

Most of the private hospitals including the present center do not have satellite centers or extension clinics all around the state. The patients of the private sector are mostly from far-flung areas. These patients have to continue the treatment from their home towns where the primary hospital does not have any extension centers. This calls for consulting another doctor who may or may not continue the treatment practiced by the treating physician and there would be paucity in follow-up. This leads to poor treatment outcomes for illness requiring long-term treatment. TB requires long-term treatment and follow-up. The government sector has extension centers all over the country and follows uniform practices. Hence, patients seeking care from the government sector have better treatment outcomes. The needs for new models of partnership between private and public sectors need to be explored.[12],[13] Another study by Khandekar et al. done in a tertiary care center in New Delhi has shown that the 75% of TB patients referred to a government peripheral health institution nearest to their place of residence could be traced.[14]

Treatment interruption (7%) was observed in this cohort which is unacceptable for a disease which is going for elimination. The utilization of a structured referral mechanism is not available in the private sector. The heterogeneous nature of the private sector makes it almost impossible to do so. So the linkage with RNTCP where structured referral mechanism is available should be utilized for better outcomes. An interventional study done in a tertiary care hospital in Punjab, Pakistan has shown that the utilization of a referral register, close monitoring of the referral by telephone and communication with responsible TB coordinators bring about a considerable improvement in the TB patient referral mechanism.[15] This facility is available with the National Tuberculosis Elimination Program (NTEP). This calls further for the need of the private institutions to enter into the network with NTEP.[16]

In the present study, only one-fourth of the traced patients (n = 62) completed their treatment. In a similar study, Khan et al. noted that nearly one-third of bacteriologically confirmed TB cases diagnosed at private facilities in Lahore were never started on treatment, and the outcome was unfavourable for approximately one-fifth of those receiving therapy.[15] Other studies also have highlighted the weak patient referral systems, inadequate patient tracking and support systems, insufficient use of information and communication technologies to reduce leakages from the cascade of care in the private sector and inability to cross-link and identify patients who move between private and public sectors.[17],[18] The main limitation of treatment in the private sector is the absence of a structured follow-up program which has been the main strength of the public sector.

The patient care cascade and patient pathway analysis done by Chin and Christy have reiterated that every patient who is started on treatment is accounted for and assigned a treatment outcome which is better done by integration with the national programme. The review also states that those treated outside the national programme generally have poorer treatment outcomes.[19]

More than half of the participants were males (63.36%). Globally, men are significantly more at risk of contracting and dying from TB than women. In 2017, close to 6 million adult men contracted TB and around 840,000 died from it. The present hospital-based study also joins with the global statistics. Most of the studies from the underdeveloped and developing world shows a male preponderance.[19],[20],[21]

Majority of the patients were in the age group of 40–70 years of age (52%). Majority of TB patients were from the lower socioeconomic strata of the society. From ancient times, TB is known as a disease of the poor and it drives them into more poverty. The present study also points out the need for financial and nutritional assistance for the Tb patients. Since TB is mostly affecting the working class, it lays a huge economic burden on the family.[22],[23]

In our present study, extrapulmonary TB cases constituted 40% of the cases. This finding is in liaison with the reported data of the RNTCP annual report 2017 where 40% of the TB cases in medical schools belonged to the extrapulmonary category. The clinical scenario in a tertiary care private health facility may not be a true reflection of the TB in the state. The difficulty of diagnosing and managing extrapulmonary TB cases at the periphery may be a good reason for the increase in the extrapulmonary caseload. Studies across southern India done in tertiary care centers have shown that there is a higher proportion of extrapulmonary TB cases.[10],[11],[17] A tertiary care center would play a vital role in arriving at a diagnosis in cases of extrapulmonary TB. As in this study, all the extrapulmonary cases of TB were diagnosed on the basis of either histopathology, microbiology or radiological evidence.

This study was conducted prior to introducing integration with NTEP at our center. The results of this study join with other studies from around the globe that the TB is a menace that can be controlled through inter-sectorial coordination, reiterating the principles of Primary Health Care.


  Conclusion Top


This study reiterates the need for private–public coordination in the treatment of TB. It is the responsibility of the healthcare professionals in the private sector to collaborate with the National TB Programme to make the TB treatment success and TB elimination a reality.

Acknowledgement

The investigators would like to thank the District TB Office, Pathanamthitta, Kerala, and Believers Church Medical College Hospital for the support and services for this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Satyanarayana S, Nair SA, Chadha SS, Shivashankar R, Sharma G, Yadav S, et al. From where are tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts. PLoS One 2011;6:e24160.  Back to cited text no. 2
    
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Shewade HD, Gupta V, Satyanarayana S, Kharate A, Murali L, Deshpande M, et al. Are we missing ‘previously treated’ smear-positive pulmonary tuberculosis under programme settings in India? A cross-sectional study. F1000Res 2019;8:338.  Back to cited text no. 3
    
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Khan BJ, Kumar AMV, Stewart A, Khan NM, Selvaraj K, Fatima R, et al. Alarming rates of attrition among tuberculosis patients in public-private facilities in Lahore, Pakistan. Public Health Action 2017;7:127-33.  Back to cited text no. 15
    
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