Disparities in access to diagnosis and care in Blantyre, Malawi, identified through enhanced tuberculosis surveillance and spatial analysis
Disparities in access to diagnosis and care in Blantyre, Malawi, identified through enhanced tuberculosis surveillance and spatial analysis
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DOI：
10.1186/s12916-019-1260-6
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发表时间：
2019-01-29
期刊：
影响因子：
9.3
通讯作者：
Corbett, Elizabeth L.
中科院分区：
文献类型：
--
作者：
MacPherson, Peter;Khundi, McEwen;Corbett, Elizabeth L.
背景：相当一部分结核病（TB）病例未被诊断。通过分析结核病登记的人口统计学、微生物和地理空间监测数据，我们旨在确定不公平获得诊断和护理的可修改预测因素。方法：政府社区卫生工作者（CHW）在2015年12月至2015年12月期间对315个集水区的所有家庭进行了计数。从2015年1月起，政府结核病官员在布兰太尔的所有公共和私人结核病治疗登记中心（共18个诊所）定期实施加强结核病监测。这包括从登记的结核病患者中收集人口统计学和临床特征，用于结核病显微镜检查和培养的单一痰液样本，以及使用电子卫星地图应用程序对居住地进行地理定位。我们估计了集水区的结核病例年报告率（CNRs），按微生物状态分层。为了确定CHW集水区结核病病例报告率的人口和地区水平预测因素，我们构建了贝叶斯空间自相关回归模型与泊松响应分布。Worldpop数据被用来估计poverty.Results：总共，315 CHW集水区包括753，489人（范围162至13，066人/集水区）。在2015年至2017年期间，有6077例结核病病例（61%为男性; 99%经艾滋病毒检测; 67%艾滋病毒阳性; 55%经文化确认）被地理定位，其中3723例（61%）居住在CHW集水区。在调整后的模型中，距离最近的结核病登记诊所更远与结核病CNR呈负相关，距离每增加3.2倍（95% CI 2.24-5.21），CNR减半。贫困随着与诊所距离的增加而增加，与结核病CNR呈负相关，（95%CI 17-34%），相当于结核病病例报告率减半。结论：通过加强对布兰太尔结核病病例的监测，我们显示了一种与“反向护理法”相一致的生态关系，即较贫穷的社区和离结核病诊所最远的社区相对CNR较低。如果确诊为低病例检出率，则需要采取有利于穷人的战略，促进公平获得结核病诊断和治疗。
Background: A sizeable fraction of tuberculosis (TB) cases go undiagnosed. By analysing data from enhanced demographic, microbiological and geospatial surveillance of TB registrations, we aimed to identify modifiable predictors of inequitable access to diagnosis and care.Methods: Governmental community health workers (CHW) enumerated all households in 315 catchment areas during October-December 2015. From January 2015, government TB Officers routinely implemented enhanced TB surveillance at all public and private TB treatment registration centres within Blantyre (18 clinics in total). This included collection from registering TB patients of demographic and clinical characteristics, a single sputum sample for TB microscopy and culture, and geolocation of place of residence using an electronic satellite map application. We estimated catchment area annual TB case notification rates (CNRs), stratified by microbiological status. To identify population and area-level factors predictive of CHW catchment area TB case notification rates, we constructed Bayesian spatially autocorrelated regression models with Poisson response distributions. Worldpop data were used to estimate poverty.Results: In total, the 315 CHW catchment areas comprised 753,489 people (range 162 to 13,066 people/catchment area). Between 2015 and 2017, 6077 TB cases (61% male; 99% HIV tested; 67% HIV positive; 55% culture confirmed) were geolocated, with 3723 (61%) resident within a CHW catchment area. In adjusted models, greater distance to the nearest TB registration clinic was negatively correlated with TB CNRs, which halved for every 3.2-fold (95% CI 2.24-5.21) increase in distance. Poverty, which increased with distance from clinics, was negatively correlated with TB CNRs; a 23% increase (95% CI 17-34%) in the mean percentage of the population living on less than US$ 2 per day corresponded to a halving of the TB case notification rates.Conclusions: Using enhanced surveillance of TB cases in Blantyre, we show an ecological relationship consistent with an 'inverse care law' whereby poorer neighbourhoods and those furthest from TB clinics have lower relative CNRs. If confirmed as low case detection, then pro-poor strategies to facilitate equitable access to TB diagnosis and treatment are required.