Where are patients missed in the tuberculosis diagnostic cascade? A prospective cohort study in Ghana
Where are patients missed in the tuberculosis diagnostic cascade? A prospective cohort study in Ghana
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DOI：
10.1371/journal.pone.0230604
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发表时间：
2020-03-19
期刊：
影响因子：
3.7
通讯作者：
Grant, Alison D.
中科院分区：
文献类型：
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作者：
Der, Joyce B.;Grint, Daniel;Grant, Alison D.
背景加纳的全国患病率调查显示，结核病 (TB) 患病率高于预期，这表明许多结核病患者没有得到识别和治疗。本研究旨在在开始治疗之前确定结核病诊断级联中的差距。方法在加纳东南部的城市和农村卫生机构中进行了一项前瞻性队列研究。对通常被确定需要进行结核病检测的连续患者进行两个月的随访，以查明是否提交了痰液和/或是否开始了治疗。在使用逻辑回归研究危险因素之前，评估了医疗机构位置对提交痰液的因果影响。结果总共招募了 428 人（平均年龄 48 岁，67.3% 女性），其中 285 人（66.6%）来自城市，143 人（33.4%）来自农村机构。在410人（96%）的随访中，290人（70.7%）提交了痰液，其中27人（14.1%）的结果呈阳性并开始治疗。在访问城市设施的人中，245/267（91.8%）的人提出了痰，而访问农村设施的人为 45/143（31.5%）。在城市设施招募的参与者更有可能提交痰样本（优势比 (OR) 24.24，95% CI 13.84-42.51）。调整混杂因素后，前往城市设施与提交痰液之间仍然存在很强的关联（调整后的 OR (aOR) 9.52，95% CI 3.87-23.40）。到实验室的旅行距离 > 10 公里是不提交痰液的最强预测因素（aOR 0.12，95%CI 0.05-0.33）。结论 大多数在农村卫生机构就诊的结核病疑似患者没有提交痰液进行检测，主要是因为到实验室的旅行距离较长。弥合诊断级联中的这一差距可能会改善病例检测。
BackgroundGhana's national prevalence survey showed higher than expected tuberculosis (TB) prevalence, indicating that many people with TB are not identified and treated. This study aimed to identify gaps in the TB diagnostic cascade prior to starting treatment.MethodsA prospective cohort study was conducted in urban and rural health facilities in south-east Ghana. Consecutive patients routinely identified as needing a TB test were followed up for two months to find out if sputum was submitted and/or treatment started. The causal effect of health facility location on submitting sputum was assessed before risk factors were investigated using logistic regression.ResultsA total of 428 persons (mean age 48 years, 67.3% female) were recruited, 285 (66.6%) from urban and 143 (33.4%) from rural facilities. Of 410 (96%) individuals followed up, 290 (70.7%) submitted sputum, among which 27 (14.1%) had a positive result and started treatment. Among those who visited an urban facility, 245/267(91.8%) submitted sputum, compared to 45/143 (31.5%) who visited a rural facility. Participants recruited at the urban facility were far more likely to submit a sputum sample (odds ratio (OR) 24.24, 95%CI 13.84-42.51). After adjustment for confounding, there was still a strong association between attending the urban facility and submitting sputum (adjusted OR (aOR) 9.52, 95%CI 3.87-23.40). Travel distance of > 10 km to the laboratory was the strongest predictor of not submitting sputum (aOR 0.12, 95%CI 0.05-0.33).ConclusionThe majority of presumptive TB patients attending a rural health facility did not submit sputum for testing, mainly due to the long travel distance to the laboratory. Bridging this gap in the diagnostic cascade may improve case detection.