Outcomes and Challenges in the Programmatic Implementation of Tuberculosis Preventive Therapy among Household Contacts of Pulmonary TB Patients: A Mixed-Methods Study from a Rural District of Karnataka, India
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Study Setting
2.2.1. General Setting
2.2.2. Specific Setting
Organisation of TB Care Services in Kolar District
Diagnosis and Treatment of TB Patients
Contact Tracing Visits and Identification of Household Contacts
Screening of Household Contacts
2.3. Study Population
2.3.1. Quantitative Component
2.3.2. Qualitative Component
2.4. Data Variables and Data Collection
2.4.1. Quantitative Component
2.4.2. Qualitative Component
2.5. Data Entry and Analysis
2.5.1. Quantitative Component
2.5.2. Qualitative Component
3. Results
3.1. Contact Tracing Visits
3.1.1. Enablers in Conducting Contact Tracing Visits
Enabler 1: Effective Counselling of the Index Patients and Assuring Confidentiality
“We also assure them that we will not inform other people. Even if they (neighbours) ask, we will tell them that the person has a cough—they think that we have come to give free medicines. But we don’t tell anybody that he has TB. The household contacts have to be informed because they have to be protected”.HCW 3
“So we call them up before going and make sure all of them stay—but some people ask why? We have to make them understand. But the COVID scenario has helped us of late. People have some awareness—they understand what is contact tracing and what to expect. Without COVID, it would have been tough—definitely been tough”.HCW4
Enabler 2: Private Sector Engagement
“They accept it better when their doctor (private sector) tells them. We meet different private practitioners in the town once fortnightly. We tell them to refer patient contacts for IGRA also. Sometimes they do, but this requires more campaigning and awareness generation”.HCW1
Enabler 3: Visit of NTEP Staff to Private Sector Tertiary Care Hospitals for Initiating Contact Tracing
“She was admitted to a private hospital for about a month with TB. She was in hospital for about a month. The Government health workers have a counter—some office like that in that hospital. So they came to take her sample for testing. We were taking turns to look after her. So they took our details and asked us to be tested as well”.HHC5
3.1.2. Challenges in Conducting Contact Tracing Visits
Challenge 1: Refusal by the Index Patients due to Stigma
“It would be difficult if they come here. The family will get disturbed. Small kids are there. They will get scared. All the neighbours will ask. anyway I go and take the medicines there. So they need not come here”.Index patient 2
“Some people are cooperative. Some of them do not want so many people to visit their house at a time. They will not be cooperative because they feel that people will stigmatize them. In such case, we ask them to come to the PHC itself and we take history here itself”.HCW 2
Challenge 2: Refusal by the Index Patients Notified from the Private Sector
“We had a case recently that was notified from a private hospital. They took ATT in a private hospital. They refused to allow us to do a house visit or contact tracing. They did not allow our staff to contact them or explain. When they get treatment from us, we meet them repeatedly. But if they refuse to take treatment from us, it will be difficult for us to trace the contacts”.HCW6
“The field staff have no problem in going to their [those notified through private sector] house. But they [patient] may be reluctant. Serious problem sometimes—I had a well-educated patient who had TB and was reluctant to take the tablets. We could not do a contact tracing in that house also, because she did not allow it. Then in such cases, my staff also found it difficult—because in cases where it is someone who has lower educational status and understanding capacity than my staff, then they will find it easy—To communicate and to explain in their own language. When a learned person refuses, they find it so difficult”.HCW4
Challenge 3: Hospitalisation/Death of Index Patient
“Actually we did not pick up any calls for a long time [after her death]. Relatives and others were calling. She was young and healthy. suddenly she died. so it was very disturbing. And they kept her [in the hospital] for so many days. We were angry also. So, we did not follow up on anything”.HHC2
“Usually they will not respond. Sometimes address will not be correct, so we may not be able to contact. In some cases, because they have rituals extending up to 15 days [after death], they do not entertain us. Even if we meet them, we might miss out on a few. They are usually agitated by the death of a family member. They are frustrated by the health system also”.HCW1
3.2. Identification of Household Contacts and Evaluation for Active TB
3.2.1. Enablers for Identification of a “Household Contact” and Screening
3.2.2. Challenges in Identification of a “Household Contact” and Screening
- Any person who lived in the same house as the index patient after the symptom onset;
- Any person who lived in the same house as the index patient after the detection of TB;
- Definition (i) or (ii) and whoever is in regular contact with the patient at home (e.g., relatives, neighbours, common friends) but ‘regularity’ is not specified;
- Definition (i) or (ii) and whoever is in regular contact with the patient at home or workplace but the duration of contact is not specified;
- Definition (iii) and any visitor (time and duration is not specified);
- Definition (i) or (ii) and any person named by the family;
- Contacts considered ‘close’ to the index patient within the family by the HCW/index patient/other family members.
“Sometimes there will be visitors. In some cases, there will be a joint family, which has divided. They might be staying in separate houses. Our workers will count them all together. In some cases, they take only the old couple as one family and leave the others out. ASHA usually knows the family composition in her village. The definition varies from house to house. They will usually record whoever is named by the family”.HCW1
- Who is there in the family?
- Who stays in this house?
- Whom does the patient/do you stay with?
- Who looks after the patient/you?
- Who is there with the patient/you?
- Who is in contact with the patient/you?
“My brother’s son was staying with us for about 6 months. He came here to study. Occasionally he would help my husband in his work also. If he gets TB then who will look after him? We don’t have enough money also. So we sent him back to the village as soon as my husband was diagnosed”.HHC4
Challenge 2: Non-Availability of the Contacts at the Time of the House Visit
“Some 8–10 people stay in one room. We tell them (Factory owner/labour agent) not to change rooms till the treatment is over—but there will be a fear factor. In our case, two contacts immediately shifted out to another place. We could contact only one person over the phone. He said he had no symptoms and never came for a check-up. So we told him to observe for at least 6 weeks”.HCW4
“In case of the TB patient, we would have entered details in NIKSHAY. But in the case of HHC, it is a challenge because the data will not be there. We complete the entry with the information that we get in the beginning. Contact tracing in other places might take some time. It might not be done or be missed in data entry”.HCW5
3.3. IGRA Testing among Eligible HHCs
3.3.1. Enablers for Uptake of IGRA Test
Enabler 1: Planning Activities and Informing Household Contacts
“When we plan the visit, we plan everything together, including IGRA. We ask all the family members to come to the PHC or we go to their house after asking if everyone is there. We plan and go”.HCW2
Enabler 2: Identifying and Counselling the Decision-Maker in the Family
“When we go out to the field, most of the patients know us. So when we tell them to get IGRA, they feel that it is important and for their own good. But if we tell them all the details in the beginning itself—that after testing, if it is positive, you will have to take medicines for 6 months, then there will be resistance. They will not agree to get tested then. In some houses, we have made 3–5 visits just to convince one person”.HCW2
Enabler 3: Sample Collection and Transportation
3.3.2. Challenges for Uptake of IGRA Test
Challenge 1: Resistance of HHCs for Testing
“No, we had no symptoms na. so we did not go. The children have school. their father gets off on Sunday. anyway, no one has any problem. we will go if there is any problem. I will discuss it with their father and let you know”.HHC4
Challenge 3: Testing Perceived as Unnecessary
“Testing should be done as soon as possible. When TB is detected, the HHC are usually scared. So they know that it would spread to them also. They would also want to test. So when we meet them at that time, we immediately get the samples also. In 2 days. maximum in a week”.HCW 5
Challenge 4: Non-Availability of IGRA Test Facilities or Lab Technicians in the Health Facility When the HHC Visited
“We went 3–4 times for that. but they kept telling us to come later. The person who takes blood was not there it seems. Actually, we go to get tablets for him monthly right. so we thought we could get it done along with that”.HHC8
“The Govt. hospital is about 10 km from here. We have to work in the fields also. We can’t go and get tested. If they want, they can come and do the test. We can’t go there”.HHC6
“Right now, NTEP does not have separate staff to do IGRA testing. There is a heavy workload. In some districts, they have given these responsibilities to private hospitals and NGOs. They will go and collect the sample, test and then send the report to us. That is an easy way.”HCW1
Challenge 5: Language Barrier
“It is easier to convince if we know the language. In these cases, I have to tell one person, they will understand something and translate it to them. They say something and then we don’t understand. Some of them don’t know Hindi also. Those barriers are there. Once they start taking medicines from us, we manage somehow”.HCW7
Challenge 6: Lack of Awareness among the General Public
“We do it individually for the ones who do not agree to IGRA. Others, we don’t burden them with too much information. It takes almost half an hour to convince them. If they don’t agree, then it will extend to the next day. We also take the help of the medical officer if required”.HCW
“Counseling and awareness generation. It is very difficult to convince people to undertake treatment if awareness is not there. We can’t put that effort every time—it is not possible to put the same amount of effort into every patient every time. When we started, we did it in a mission mode, with a focus only on that. We did not do anything else. But if we do only that and nothing else, then we will not be able to do anything else”.HCW1
3.4. Initiation and Completion of TPT
“Among children, they accept, because when one person is positive for TB, there is a fear factor in the family–regardless of whether it is pulmonary or extrapulmonary. They are more worried about children than old people–because they are their future”.HCW4
“Counseling is important. We base it on their experience and work. We also give examples-when your kids go for job selection in the police or military 10 years down the lane, they have to have good lungs. They will check their endurance and chest circumference. So if you protect the child now, they will have a better future. Otherwise-Upiritittulu bagalekunte inkim chesidi (If lungs are not good, then what good is it?)”.HCW 2
3.5. Reporting and Monitoring of Testing, TPT Initiation and Completion
“We don’t report IGRA negative and other household contact details in Nikshay. Actually, that also has to be entered. We have a facility for that also in Nikshay. Numbers, whether they are positive or negative–numbers are entered. However, the names and other details are not entered. That system must be initiated”.HCW 9
“Contact tracing details are entered in their (field level HCW) books. This should be done in Nikshay at the PHC level itself. We will be able to monitor what is the coverage and cross-check also. Then it will work. This will help in monitoring also”.HCW2
“The important thing is that we have to treat TB infection patients with the same seriousness that we treat TB disease. We have to follow up with them just like that. Then only it will be a success. If we just think that they will come on their own and leave it to them to take the medicines, then they will not do it. We do not have any means to monitor them also. The card is there. For 3 HP something like 99DOTS can be used for follow-up”.HCW1
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
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Characteristics of Index PTB Patients | Total | Not Visited for Contact Tracing | Crude RR (95% CI) 2 | p-Value | |
---|---|---|---|---|---|
Total | n | n | (%) 1 | ||
301 | 54 | (17.9) | - | - | |
Age (in years) | |||||
≤ 14 | 2 | 0 | (0) | - | |
15–29 | 54 | 5 | (9.3) | Ref | |
30–44 | 77 | 15 | (19.5) | 2.1 (0.8–5.4) | 0.125 |
45–59 | 93 | 18 | (19.4) | 2.1 (0.8–5.3) | 0.121 |
≥60 | 75 | 16 | (21.3) | 2.3 (0.9–5.9) | 0.082 |
Gender | |||||
Male | 219 | 38 | (17.4) | Ref | |
Female | 80 | 14 | (17.5) | 1.0 (0.6–1.8) | 0.976 |
Others | 2 | 2 | (100) | - | |
Type of Diagnosis | |||||
Bacteriologically confirmed | 265 | 47 | (17.7) | Ref | |
Clinically diagnosed | 36 | 7 | (19.4) | 1.1 (0.5–2.2) | 0.801 |
Type of Patient Based on Previous History of TB Treatment | |||||
New | 268 | 51 | (19.0) | 2.1 (0.7–6.3) | 0.191 |
Retreatment | 33 | 3 | (9.1) | Ref | |
Tuberculosis Unit (TU No.) | |||||
1 | 80 | 13 | (16.3) | 2.1 (0.8–6.4) | 0.149 |
2 | 64 | 9 | (14.1) | 1.9 (0.6–5.8) | 0.262 |
3 | 103 | 28 | (27.2) | 3.7 (1.4–9.9) * | 0.010 |
4 | 54 | 4 | (7.4) | Ref | |
Health Facility Sector | |||||
Public | 289 | 50 | (17.3) | Ref | |
Private | 12 | 4 | (33.3) | 1.9 (0.8–4.5) | 0.125 |
Characteristics | Total | HHCs Omitted from Symptom Screening | Crude RR (95% CI) 2 | p-Value | |
---|---|---|---|---|---|
Total | n | n | (%) 1 | ||
838 | 73 | (8.7) | - | - | |
Characteristics of TB Index patients | |||||
Age (in years) | |||||
≤14 | 5 | 0 | (0) | - | |
15–29 | 179 | 16 | (8.9) | Ref | |
30–44 | 207 | 15 | (7.3) | 0.8 (0.4–1.6) | 0.543 |
45–59 | 237 | 23 | (9.7) | 1.1 (0.6–2.0) | 0.791 |
≥60 | 210 | 19 | (9.1) | 1.1 (0.5–1.9) | 0.970 |
Gender | |||||
Male | 582 | 37 | (6.4) | Ref | |
Female | 256 | 36 | (14.1) | 2.2 (1.4–3.4) * | <0.001 |
Type of Diagnosis | |||||
Bacteriologically confirmed | 746 | 65 | (8.7) | Ref | |
Clinically diagnosed | 92 | 8 | (8.7) | 1.0 (0.5–2.0) | 0.996 |
Type of Case (Based on Previous Treatment History) | |||||
New | 738 | 63 | (8.5) | Ref | |
Retreatment | 100 | 10 | (10.0) | 1.2 (0.6–2.2) | 0.625 |
Tuberculosis Unit | |||||
1 | 233 | 19 | (8.1) | 1.2 (0.6–2.4) | 0.614 |
2 | 176 | 12 | (6.8) | Ref | |
3 | 236 | 21 | (8.9) | 1.3 (0.7–2.6) | 0.444 |
4 | 193 | 21 | (10.9) | 1.6 (0.8–3.1) | 0.177 |
Health Facility Sector | |||||
Public | 807 | 68 | (8.4) | Ref | |
Private | 31 | 5 | (16.1) | 1.9 (0.8–4.4) | 0.127 |
Characteristics of HHC | |||||
Age (in years) | |||||
≤ 5 | 79 | 9 | (11.4) | 1.4 (0.7–2.6) | 0.370 |
More than 5 | 759 | 64 | (8.4) | Ref | |
Gender | |||||
Male | 375 | 42 | (11.2) | 1.7 (1.1–2.6) | 0.023 |
Female | 463 | 31 | (6.7) | Ref | |
Relationship With the Index Patient | |||||
Spouse/Partner | 175 | 6 | (3.4) | Ref | |
Child 3 | 259 | 21 | (8.1) | 2.3 (1.0–5.7) | 0.057 |
Parent | 104 | 5 | (4.8) | 1.4 (0.4–4.4) | 0.568 |
Sibling | 52 | 2 | (3.9) | 1.1 (0.2–5.4) | 0.886 |
Others 4 | 248 | 39 | (15.7) | 4.6 (2.0–10.6) | <0.001 |
Characteristics | Total | IGRA Test Not Performed | Crude RR (95% CI) 2 | p-Value | |
---|---|---|---|---|---|
Total | n | n | (%) 1 | ||
692 | 400 | (57.8) | |||
Characteristics of TB Index Patients | |||||
Age (in years) | |||||
≤14 | 5 | 0 | (0) | - | |
15–29 | 142 | 78 | (54.9) | 1.2 (0.9–1.4) | 0.166 |
30–44 | 176 | 83 | (47.2) | Ref | |
45–59 | 197 | 120 | (60.9) | 1.3 (1.1–1.6) | <0.001 |
≥60 | 172 | 119 | (69.2) | 1.5 (1.2–1.8) | <0.001 |
Gender | |||||
Male | 496 | 276 | (55.7) | Ref | |
Female | 196 | 124 | (63.3) | 1.1 (1.0–1.3) | 0.058 |
Type of Diagnosis | |||||
Bacteriologically confirmed | 616 | 352 | (57.1) | Ref | |
Clinically diagnosed | 76 | 48 | (63.2) | 1.1 (0.9–1.3) | 0.289 |
Type of Case | |||||
New | 614 | 372 | (60.6) | 1.7 (1.2–2.3) | 0.001 |
Retreatment | 78 | 28 | (35.9) | Ref | |
Tuberculosis Unit | |||||
1 | 193 | 118 | (61.1) | 1.2 (1.0–1.4) | 0.080 |
2 | 148 | 86 | (58.1) | 1.1 (0.9–1.4) | 0.257 |
3 | 196 | 116 | (59.2) | 1.1 (0.9–1.4) | 0.162 |
4 | 155 | 80 | (51.6) | Ref | |
Health Facility Sector | |||||
Public | 667 | 384 | (57.6) | Ref | |
Private | 25 | 16 | (64.0) | 1.1 (0.8–1.5) | 0.491 |
Characteristics of HHC | |||||
Gender | |||||
Male | 297 | 169 | (56.9) | Ref | |
Female | 395 | 231 | (58.5) | 1.0 (0.9–1.2) | 0.678 |
Relationship with the Index Patient | |||||
Child 3 | 197 | 106 | (53.8) | Ref | |
Spouse/Partner | 166 | 94 | (56.6) | 1.1 (0.9–1.3) | 0.590 |
Parent | 99 | 56 | (56.6) | 1.1 (0.8–1.3) | 0.650 |
Sibling | 50 | 28 | (56.0) | 1.0 (0.8–1.4) | 0.778 |
Others 4 | 180 | 116 | (64.4) | 1.2 (1.0–1.4) | 0.036 |
Symptom Screening Status | |||||
Asymptomatic | 678 | 392 | (57.8) | 1.0 (0.6–1.6) | 0.960 |
Chest symptomatic 5 | 14 | 8 | (57.1) | Ref |
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Samudyatha, U.C.; Soundappan, K.; Ramaswamy, G.; Mehta, K.; Kumar, C.; Jagadeesh, M.; Prasanna Kamath, B.T.; Singla, N.; Thekkur, P. Outcomes and Challenges in the Programmatic Implementation of Tuberculosis Preventive Therapy among Household Contacts of Pulmonary TB Patients: A Mixed-Methods Study from a Rural District of Karnataka, India. Trop. Med. Infect. Dis. 2023, 8, 512. https://doi.org/10.3390/tropicalmed8120512
Samudyatha UC, Soundappan K, Ramaswamy G, Mehta K, Kumar C, Jagadeesh M, Prasanna Kamath BT, Singla N, Thekkur P. Outcomes and Challenges in the Programmatic Implementation of Tuberculosis Preventive Therapy among Household Contacts of Pulmonary TB Patients: A Mixed-Methods Study from a Rural District of Karnataka, India. Tropical Medicine and Infectious Disease. 2023; 8(12):512. https://doi.org/10.3390/tropicalmed8120512
Chicago/Turabian StyleSamudyatha, U. C., Kathirvel Soundappan, Gomathi Ramaswamy, Kedar Mehta, Chandan Kumar, M. Jagadeesh, B. T. Prasanna Kamath, Neeta Singla, and Pruthu Thekkur. 2023. "Outcomes and Challenges in the Programmatic Implementation of Tuberculosis Preventive Therapy among Household Contacts of Pulmonary TB Patients: A Mixed-Methods Study from a Rural District of Karnataka, India" Tropical Medicine and Infectious Disease 8, no. 12: 512. https://doi.org/10.3390/tropicalmed8120512