People with tuberculosis falling through the cracks

Subbaraman et al. present a cascade of care for tuberculosis (TB) in India’s public sector for the year 2013. Drawing from the World Health Organization (WHO) Global TB Reports, the Revised National TB Control Programme (RNTCP) of the Government of India annual reports as well as three systematic reviews conducted by the authors, this study provides estimates of the number of patients with TB in India who reach each step along the pathway from care-seeking to cure. Although prior research has characterized barriers to specific stages of care[1] or components of the cascade in subnational samples,[2] this study is considered to be the first to describe a national-level TB care cascade.[3]

The authors conceptualize the pathway of public sector TB care to include six separate steps and the corresponding gaps: (i) total prevalent active TB cases; (ii) evaluation for TB in public sector facilities; (iii) successful diagnosis with TB; (iv) treatment registration through RNTCP; (v) treatment completion or cure; and (vi) 1-year recurrence-free survival. Starting with the WHO figure of 2.7 million individuals with active TB in India in 2013, it was estimated that only 39% of patients with TB successfully reached the final cascade step. Overall, the largest gap in the cascade was access to care with 28% of all prevalent TB cases not reaching public sector TB diagnostic facilities. The attrition between each of the remaining steps in the care cascade was similar, ranging from 13% to 16%.

As individuals with different forms of TB may face disparate barriers to care, separate public sector care cascades were also constructed for different categories of TB: new smear-positive, new smear-negative, retreatment smear-positive, retreatment smear-negative, extrapulmonary and multidrug-resistant (MDR)-TB. Notably, the gaps in public sector care were different for different categories of TB. For example, new and retreatment smear-positive patients had high levels of pre-treatment loss to follow-up (i.e. diagnosed with TB but not initiating treatment; 15% attrition), poor treatment outcomes (i.e. treatment loss to follow-up, treatment failure or death; 12% new, 29% retreatment) and recurrence or death within 1 year of treatment completion (16% new, 27% retreatment). In contrast, reaching public sector diagnostic facilities but not being successfully diagnosed was the largest gap for extrapulmonary (20% attrition), MDR (59%) and both categories of smear-negative TB (38% new, 29% retreatment). MDR-TB patients also experienced high levels of poor treatment outcomes (54%).

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People with tuberculosis falling through the cracks