Overall, from September 2016 to February 2019, the CHWs in Bengaluru and Hyderabad had referred 31617 TB symptomatic individuals for TB diagnoses (approximately 1% of the total slum population). Of those referred, 23976 (76%) persons had completed TB testing and were provided with results (see Table 1). The proportion of referred individuals undergoing testing increased over time from 57% in the first cohort to 86% in the last. This increase to over 80% of those referred being tested and receiving results was seen in both cities, across gender and all age groups. The annualized case detection rate through CHW referrals in Bengaluru increased from 5.5 to 52.0 per 100000 during the period, while in Hyderabad it was 35.4 initially and increased up to 118.9 per 100000 persons.
Table 1
Coverage indicators reflecting the cascade of TB care including number of persons referred by CHW, undergone test, tested positive, started treatment, followed-up according to various referral cohorts
Six monthly referral cohorts
|
Number referred
|
Number tested
|
Number tested positive
|
Number started treatment
|
Registered for follow-up by CHW
|
% undergone test
|
% tested positive
|
% started treatment
|
% Registered for follow-up
|
Total
|
|
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
2952
|
1691
|
298
|
296
|
203
|
57.3
|
17.6
|
99.3
|
68.6
|
Mar - Aug, 2017
|
4176
|
2525
|
516
|
515
|
362
|
60.5
|
20.4
|
99.8
|
70.3
|
Sep, 2017 -Feb, 2018
|
8270
|
6077
|
1,082
|
1,079
|
800
|
73.5
|
17.8
|
99.7
|
74.1
|
Mar -Aug, 2018
|
7904
|
6521
|
1,022
|
1,010
|
696
|
82.5
|
15.7
|
98.8
|
68.9
|
Sep, 2018 - Feb 2019
|
8315
|
7162
|
923
|
912
|
699
|
86.1
|
12.9
|
98.8
|
76.6
|
Bengaluru
|
|
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
1179
|
588
|
41
|
40
|
31
|
49.9
|
7.0
|
97.6
|
77.5
|
Mar - Aug, 2017
|
1946
|
1118
|
105
|
104
|
85
|
57.5
|
9.4
|
99.0
|
81.7
|
Sep, 2017 -Feb, 2018
|
3436
|
2632
|
220
|
217
|
185
|
76.6
|
8.4
|
98.6
|
85.3
|
Mar -Aug, 2018
|
3593
|
3159
|
303
|
294
|
226
|
87.9
|
9.6
|
97.0
|
76.9
|
Sep, 2018 - Feb 2019
|
4978
|
3979
|
393
|
382
|
315
|
79.9
|
9.9
|
97.2
|
82.5
|
Hyderabad
|
|
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
1,773
|
1103
|
257
|
256
|
172
|
62.2
|
23.3
|
99.6
|
67.2
|
Mar - Aug, 2017
|
2,230
|
1407
|
411
|
411
|
277
|
63.1
|
29.2
|
100.0
|
67.4
|
Sep, 2017 -Feb, 2018
|
4,834
|
3445
|
862
|
862
|
615
|
71.3
|
25.0
|
100.0
|
71.3
|
Mar -Aug, 2018
|
4,311
|
3362
|
719
|
716
|
470
|
78.0
|
21.4
|
99.6
|
65.6
|
Sep, 2018 - Feb 2019
|
3337
|
3183
|
530
|
530
|
384
|
95.4
|
16.7
|
100.0
|
72.5
|
Male
|
|
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
1549
|
893
|
170
|
169
|
114
|
57.7
|
19.0
|
99.4
|
67.5
|
Mar - Aug, 2017
|
2,142
|
1305
|
290
|
289
|
213
|
60.9
|
22.2
|
99.7
|
73.7
|
Sep, 2017 -Feb, 2018
|
4,159
|
3067
|
574
|
573
|
429
|
73.7
|
18.7
|
99.8
|
74.9
|
Mar -Aug, 2018
|
4,073
|
3361
|
534
|
524
|
360
|
82.5
|
15.9
|
98.1
|
68.7
|
Sep, 2018 - Feb 2019
|
4286
|
3674
|
513
|
504
|
387
|
85.7
|
14.0
|
98.2
|
76.8
|
Female
|
|
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
1403
|
798
|
128
|
127
|
89
|
56.9
|
16.0
|
99.2
|
70.1
|
Mar - Aug, 2017
|
2,034
|
1220
|
226
|
226
|
149
|
60.0
|
18.5
|
100.0
|
65.9
|
Sep, 2017 -Feb, 2018
|
4,111
|
3010
|
508
|
506
|
371
|
73.2
|
16.9
|
99.6
|
73.3
|
Mar -Aug, 2018
|
3,831
|
3160
|
488
|
486
|
336
|
82.5
|
15.4
|
99.6
|
69.1
|
Sep, 2018 - Feb 2019
|
3766
|
3488
|
410
|
408
|
312
|
92.6
|
11.8
|
99.5
|
76.5
|
Age < 15 years
|
|
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
185
|
90
|
11
|
11
|
7
|
48.6
|
12.2
|
100.0
|
63.6
|
Mar - Aug, 2017
|
334
|
174
|
24
|
24
|
19
|
52.1
|
13.8
|
100.0
|
79.2
|
Sep, 2017 -Feb, 2018
|
833
|
539
|
55
|
55
|
43
|
64.7
|
10.2
|
100.0
|
78.2
|
Mar -Aug, 2018
|
636
|
452
|
68
|
68
|
36
|
71.1
|
15.0
|
100.0
|
52.9
|
Sep, 2018 - Feb 2019
|
489
|
394
|
32
|
32
|
23
|
80.6
|
8.1
|
100.0
|
71.9
|
Age 15–49 years
|
|
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
1,164
|
656
|
224
|
222
|
154
|
56.4
|
34.1
|
99.1
|
69.4
|
Mar - Aug, 2017
|
2,367
|
1388
|
391
|
390
|
263
|
58.6
|
28.2
|
99.7
|
67.4
|
Sep, 2017 -Feb, 2018
|
4,346
|
2972
|
795
|
793
|
580
|
68.4
|
26.7
|
99.7
|
73.1
|
Mar -Aug, 2018
|
5,410
|
4435
|
765
|
758
|
529
|
82.0
|
17.2
|
99.1
|
69.8
|
Sep, 2018 - Feb 2019
|
5576
|
4749
|
707
|
700
|
537
|
85.2
|
14.9
|
99.0
|
76.7
|
Age 50 + years
|
|
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
576
|
361
|
63
|
63
|
42
|
62.7
|
17.5
|
100.0
|
66.7
|
Mar - Aug, 2017
|
888
|
500
|
101
|
101
|
80
|
56.3
|
20.2
|
100.0
|
79.2
|
Sep, 2017 -Feb, 2018
|
1,800
|
1309
|
232
|
231
|
177
|
72.7
|
17.7
|
99.6
|
76.6
|
Mar -Aug, 2018
|
2,083
|
1691
|
189
|
184
|
131
|
81.2
|
11.2
|
97.4
|
71.2
|
Sep, 2018 - Feb 2019
|
2299
|
1959
|
184
|
180
|
139
|
85.2
|
9.4
|
97.8
|
77.2
|
Total
|
31617
|
23976
|
3841
|
3812
|
2760
|
75.8
|
16.0
|
99.2
|
72.4
|
Overall, 16% of those tested were diagnosed to have TB and the TB detection among those tested reduced from 17.6 to 12.9%. The proportion of people who tested TB positive was consistently higher in Hyderabad than in Bengaluru, among males than among females and among those aged 15-49.
Overall, 99% of individuals diagnosed with TB were started on ATT with minor fluctuations in levels between Bengaluru and Hyderabad. Overall, 72% of them consented to be registered and documented for the follow-up visits using the PCS card, with proportions ranging from between 69% and 77%. The proportion of TB patients who consented to be registered for PCS is comparatively lower in Hyderabad as compared to Bengaluru for all the referral cohorts examined. Also, in few of the cohorts slightly lesser proportion of TB patients aged below 15 years were registered for follow-up visits as compared to TB patients in other age groups.
Table 2 provides the mean and total number of follow-up visits during the intensive and the continued treatment phases. Though, fluctuations were observed in the mean number of follow-up visits with Bengaluru indicating a reduction and Hyderabad showing an increase across various referral cohorts, the standard deviation reduced across groups indicating that the intensity of follow up became more or less uniform over time. We also noticed the same kind of results for the visits in the intensive and continuation phases as well.
Table 2
Mean number of total follow-up visits, mean number of visits during intensive phase and during continuation phase for TB patients referred by CHW according to different referral cohorts
Referral cohorts
|
Total follow-up visits
|
Follow-up visits at Continuation phase
|
Follow-up visits at Intensive Phase
|
Number of cases
|
Mean
|
SD
|
Mean
|
SD
|
Mean
|
SD
|
|
Total
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
6.2
|
4.2
|
3.8
|
2.8
|
2.4
|
2.0
|
203
|
Mar - Aug, 2017
|
7.4
|
5.0
|
4.5
|
3.2
|
2.9
|
2.4
|
362
|
Sep, 2017 -Feb, 2018
|
7.5
|
4.2
|
4.4
|
2.7
|
3.0
|
2.1
|
800
|
Mar -Aug, 2018
|
6.9
|
2.9
|
3.8
|
2.3
|
3.1
|
1.3
|
696
|
Sep, 2018 - Feb 2019
|
8.4
|
3.6
|
5.0
|
3.1
|
3.4
|
1.2
|
699
|
Bengaluru
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
11.0
|
6.8
|
5.8
|
4.7
|
5.2
|
2.9
|
31
|
Mar - Aug, 2017
|
12.5
|
7.0
|
6.8
|
4.8
|
5.6
|
2.9
|
85
|
Sep, 2017 -Feb, 2018
|
11.4
|
6.1
|
6.0
|
4.2
|
5.4
|
2.7
|
185
|
Mar -Aug, 2018
|
7.5
|
3.1
|
4.0
|
2.5
|
3.5
|
1.4
|
226
|
Sep, 2018 - Feb 2019
|
7.3
|
3.3
|
4.2
|
2.7
|
3.1
|
1.2
|
315
|
Hyderabad
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
5.3
|
2.7
|
3.4
|
2.1
|
1.9
|
1.3
|
172
|
Mar - Aug, 2017
|
5.8
|
2.7
|
3.7
|
2.0
|
2.1
|
1.3
|
277
|
Sep, 2017 -Feb, 2018
|
6.3
|
2.3
|
3.9
|
1.9
|
2.3
|
1.1
|
615
|
Mar -Aug, 2018
|
6.7
|
2.7
|
3.8
|
2.2
|
2.9
|
1.2
|
470
|
Sep, 2018 - Feb 2019
|
9.3
|
3.6
|
5.7
|
3.2
|
3.6
|
1.2
|
384
|
Male
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
6.2
|
4.7
|
3.7
|
3.0
|
2.5
|
2.3
|
114
|
Mar - Aug, 2017
|
8.0
|
5.4
|
4.8
|
3.4
|
3.1
|
2.5
|
213
|
Sep, 2017 -Feb, 2018
|
7.9
|
4.5
|
4.6
|
3.0
|
3.2
|
2.2
|
429
|
Mar -Aug, 2018
|
7.1
|
2.9
|
3.9
|
2.4
|
3.2
|
1.3
|
360
|
Sep, 2018 - Feb 2019
|
8.4
|
3.8
|
5.1
|
3.3
|
3.3
|
1.2
|
387
|
Female
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
6.1
|
3.4
|
3.9
|
2.5
|
2.2
|
1.6
|
89
|
Mar - Aug, 2017
|
6.5
|
4.4
|
3.9
|
2.7
|
2.6
|
2.2
|
149
|
Sep, 2017 -Feb, 2018
|
7.0
|
3.7
|
4.1
|
2.4
|
2.8
|
1.9
|
371
|
Mar -Aug, 2018
|
6.8
|
2.8
|
3.8
|
2.2
|
3.0
|
1.3
|
335
|
Sep, 2018 - Feb 2019
|
8.4
|
3.4
|
4.9
|
2.8
|
3.5
|
1.2
|
312
|
Age < 15 years
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
7.4
|
3.2
|
5.3
|
3.1
|
2.1
|
1.6
|
7
|
Mar - Aug, 2017
|
6.1
|
4.0
|
3.9
|
2.6
|
2.2
|
1.8
|
19
|
Sep, 2017 -Feb, 2018
|
6.6
|
3.8
|
4.0
|
2.5
|
2.6
|
1.8
|
43
|
Mar -Aug, 2018
|
7.1
|
2.7
|
3.8
|
1.9
|
3.3
|
1.2
|
36
|
Sep, 2018 - Feb 2019
|
7.7
|
2.7
|
4.6
|
2.1
|
3.1
|
1.3
|
23
|
Age 15–49 years
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
6.3
|
4.3
|
3.9
|
2.8
|
2.4
|
2.1
|
154
|
Mar - Aug, 2017
|
6.9
|
4.5
|
4.2
|
2.8
|
2.7
|
2.2
|
263
|
Sep, 2017 -Feb, 2018
|
7.4
|
4.2
|
4.4
|
2.8
|
3.0
|
2.1
|
580
|
Mar -Aug, 2018
|
7.0
|
2.8
|
3.9
|
2.3
|
3.1
|
1.3
|
529
|
Sep, 2018 - Feb 2019
|
8.4
|
3.7
|
5.0
|
3.1
|
3.4
|
1.2
|
537
|
Age 50 + years
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017
|
5.4
|
3.7
|
3.2
|
2.5
|
2.2
|
1.9
|
42
|
Mar - Aug, 2017
|
9.1
|
6.4
|
5.4
|
4.2
|
3.7
|
2.8
|
80
|
Sep, 2017 -Feb, 2018
|
7.8
|
4.3
|
4.5
|
2.7
|
3.2
|
2.2
|
177
|
Mar -Aug, 2018
|
6.6
|
3.0
|
3.6
|
2.5
|
3.0
|
1.2
|
131
|
Sep, 2018 - Feb 2019
|
8.4
|
3.7
|
5.1
|
3.1
|
3.3
|
1.2
|
139
|
Total
|
7.5
|
3.9
|
4.4
|
2.8
|
3.1
|
1.8
|
2760
|
Table 3 provides the percentage of TB patients having successful treatment outcomes according to the various referral cohorts. Overall, we noticed that the percentage of patients who experienced successful treatment outcomes improved over time from 87.1 to 91.3%, with small fluctuations in between. The increase in successful treatment outcomes was highest in Bengaluru and among those aged >50 years of age. The successful treatment outcomes were consistently higher (>90%) among females than among males for all the cohorts examined.
Table 3
Successful treatment according to various referral cohorts of patients who are referred and followed-up by the CHW
Referral cohorts
|
% with successful outcomes
|
Number of cases
|
Total
|
|
|
Sep 2016 - Feb, 2017
|
87.1
|
193
|
Mar - Aug, 2017
|
90.3
|
339
|
Sep, 2017 -Feb, 2018
|
89.0
|
735
|
Mar -Aug, 2018
|
90.1
|
636
|
Sep, 2018 - Feb 2019
|
91.3
|
677
|
Bengaluru
|
|
|
Sep 2016 - Feb, 2017
|
64.5
|
31
|
Mar - Aug, 2017
|
74.7
|
79
|
Sep, 2017 -Feb, 2018
|
70.2
|
161
|
Mar -Aug, 2018
|
79.4
|
214
|
Sep, 2018 - Feb 2019
|
85.8
|
309
|
Hyderabad
|
|
|
Sep 2016 - Feb, 2017
|
91.4
|
162
|
Mar - Aug, 2017
|
95.0
|
260
|
Sep, 2017 -Feb, 2018
|
94.3
|
574
|
Mar -Aug, 2018
|
95.5
|
422
|
Sep, 2018 - Feb 2019
|
95.9
|
368
|
Male
|
|
|
Sep 2016 - Feb, 2017
|
81.5
|
85
|
Mar - Aug, 2017
|
87.6
|
138
|
Sep, 2017 -Feb, 2018
|
85.5
|
343
|
Mar -Aug, 2018
|
85.5
|
305
|
Sep, 2018 - Feb 2019
|
87.4
|
303
|
Female
|
|
|
Sep 2016 - Feb, 2017
|
94.1
|
108
|
Mar - Aug, 2017
|
94.2
|
201
|
Sep, 2017 -Feb, 2018
|
93.0
|
392
|
Mar -Aug, 2018
|
95.1
|
331
|
Sep, 2018 - Feb 2019
|
96.0
|
374
|
Age < 15 years
|
|
|
Sep 2016 - Feb, 2017
|
100.0
|
6
|
Mar - Aug, 2017
|
100.0
|
19
|
Sep, 2017 -Feb, 2018
|
94.7
|
38
|
Mar -Aug, 2018
|
94.1
|
34
|
Sep, 2018 - Feb 2019
|
100.0
|
22
|
Age 15–49 years
|
|
|
Sep 2016 - Feb, 2017
|
91.2
|
147
|
Mar - Aug, 2017
|
91.1
|
247
|
Sep, 2017 -Feb, 2018
|
89.2
|
539
|
Mar -Aug, 2018
|
91.5
|
483
|
Sep, 2018 - Feb 2019
|
91.5
|
520
|
Age 50 + years
|
|
|
Sep 2016 - Feb, 2017
|
70.0
|
40
|
Mar - Aug, 2017
|
84.9
|
73
|
Sep, 2017 -Feb, 2018
|
86.7
|
158
|
Mar -Aug, 2018
|
83.2
|
119
|
Sep, 2018 - Feb 2019
|
88.9
|
135
|
Total
|
89.9
|
2580
|
Note: Successful outcome includes cured and treatment completed TB patients. Only patient whose outcome is known are included.
|
The successful treatment outcomes according to the characteristics of the TB patients and according to the characteristics of follow-up visits for the total cohorts of patients during the reference periods is given in the Table 4. The overall successful treatment outcome was higher in Hyderabad at 95% as compared to Bengaluru at 79%. The successful treatment outcome was found to be relatively higher among females, patients who are aged below 15 years, patients who are single, patients who have extra pulmonary TB, patients who were not previously treated for TB, patients whose initial weight was equal to or above a median reference standard (females (38 kg) and males (43kg)) [24], patients who did not miss any doses, and patients who received individual counselling on TB awareness, adherence and nutrition or family level counselling. We noticed a higher proportion of successful treatment outcomes among patients who were visited by CHWs, two or more times in the intensive phase of the treatment. For the follow-up visits during the continuation phase and the total visits, we noticed that as the number of visits increased the successful treatment outcomes also increased.
We noticed that a number of patient as well as follow-up visit characteristics were associated with the successful treatment outcome. Hence, we applied multiple logistic regression models in order to identify any significant improvement in the successful treatment outcome across the referral cohorts when the other potential factors are controlled for. We conducted three separate models while considering the follow-up visits during intensive phase, continuation phase as well as the total visits made to know how controlling for these differs for the successful treatment outcomes across the referral cohorts.
Table 4
Successful treatment outcome and the unadjusted odds ratio according to various characteristics of the patient who are referred and followed-up by the CHW
Characteristics
|
% of successful outcomes
|
Unadjusted OR
|
p-value
|
Number of cases
|
Name of district
|
|
|
|
|
Bangalore
|
79.0
|
|
|
794
|
Hyderabad
|
94.7
|
4.79
|
< 0.001
|
1786
|
Age
|
|
|
|
|
< 15 years
|
96.6
|
|
|
119
|
15–49 years
|
90.8
|
0.34
|
0.038
|
1936
|
50 + years
|
85.0
|
0.20
|
0.002
|
525
|
Gender
|
|
|
|
|
Female
|
94.5
|
|
|
1174
|
Male
|
86.0
|
0.35
|
< 0.001
|
1406
|
Marital status
|
|
|
|
|
Currently married
|
88.2
|
|
|
1605
|
Marriage dissolved
|
87.1
|
0.90
|
0.673
|
170
|
Single (Never married)
|
93.9
|
2.07
|
< 0.001
|
805
|
HIV Status
|
|
|
|
|
Negative
|
88.6
|
|
|
1919
|
Positive
|
72.0
|
0.33
|
0.014
|
25
|
Unknown
|
94.3
|
2.14
|
< 0.001
|
636
|
Type of TB
|
|
|
|
|
Extra Pulmonary TB
|
94.9
|
|
|
451
|
Pulmonary TB
|
88.8
|
0.43
|
< 0.001
|
2129
|
History of previous TB treatment
|
|
|
|
|
No
|
90.6
|
|
|
2331
|
Yes
|
82.7
|
0.49
|
< 0.001
|
249
|
Initial weighta
|
|
|
|
|
Below median value
|
86.8
|
|
|
310
|
Median value or above
|
91.3
|
1.60
|
0.027
|
758
|
Unknown
|
89.8
|
1.34
|
0.117
|
1511
|
Patient's Relationship with care supporter
|
|
|
|
|
No care supporter
|
92.6
|
|
|
512
|
Parent
|
90.5
|
0.77
|
0.205
|
728
|
Siblings/Son/Daughter
|
85.0
|
0.45
|
< 0.001
|
386
|
Spouse
|
88.8
|
0.64
|
0.029
|
678
|
Others
|
92.8
|
1.03
|
0.928
|
276
|
Number of visits during CP
|
|
|
|
|
< 2
|
57.5
|
|
|
348
|
2–3
|
91.0
|
7.51
|
< 0.001
|
446
|
4+
|
95.9
|
17.36
|
< 0.001
|
1786
|
Number of visits during IP
|
|
|
|
|
< 2
|
82.3
|
|
|
417
|
2–3
|
92.2
|
2.55
|
< 0.001
|
1191
|
4+
|
90.3
|
2.02
|
< 0.001
|
972
|
Total number of follow-up visits
|
|
|
|
|
< 4
|
63.7
|
|
|
311
|
4–7
|
91.7
|
6.29
|
< 0.001
|
1022
|
8+
|
94.9
|
10.73
|
< 0.001
|
1247
|
Missed any doses
|
|
|
|
|
No
|
91.2
|
|
|
2264
|
Yes
|
80.7
|
0.41
|
< 0.001
|
316
|
Provided TB awareness counselling
|
|
|
|
|
No
|
88.6
|
|
|
2089
|
Yes
|
95.5
|
2.75
|
< 0.001
|
491
|
Provided adherence counselling
|
|
|
|
|
No
|
87.7
|
|
|
1888
|
Yes
|
96.0
|
3.34
|
< 0.001
|
692
|
Provided nutritional counselling/support
|
|
|
|
|
No
|
88.3
|
|
|
1960
|
Yes
|
94.8
|
2.43
|
< 0.001
|
620
|
Provided family level counselling
|
|
|
|
|
No
|
89.5
|
|
|
2357
|
Yes
|
94.2
|
1.90
|
0.029
|
223
|
Total
|
89.9
|
|
|
2580
|
Note: successful outcome include cured and treatment completed TB patients
|
a Considered median value of 43 Kgs for males and of 38 Kgs for females above 15 years. For children, we have considered as median or above, if the weight is known.
|
The first model included the number of visits in the intensive phase as well as all other significant factors as per the backward stepwise multiple logistic regression model. This model indicated that the successful treatment outcomes over the different referral cohorts were not significant and thus were not included in the model (Table 5). In other words, we did not notice any independent effect of the referral cohorts on the successful treatment outcomes in the model that considered the follow-up visits in the intensive phase as a control variable. The same model also suggested that successful treatment outcomes were significantly higher in Hyderabad than Bengaluru, patients who were never married, who received more than 2 follow-up visits during the IP visits, whose initial weight is more than the median weight according to sex, who received adherence counselling and who received nutritional counselling and/or nutritional support during the follow-up visits. However, male patients, patients who have pulmonary TB, who are previously treated for TB and who missed any dose are significantly less likely to experience a successful treatment outcome. Though the initial weight and nutritional counselling and/or nutritional support were identified to be a significant factor in the first model. However, in the second and third model its effect was not significant hence excluded in the models that included the follow-up visits during the continuation phase and the total follow-up visits, respectively.
Table 5
Results of multivariate logistic regression model for successful outcome among TB patient referred and followed-up by CHW
Characteristics
|
Model 1
|
Model 2
|
Model 3
|
AOR
|
95% CI
|
p-value
|
AOR
|
95% CI
|
p-value
|
AOR
|
95% CI
|
p-value
|
Referral cohort
|
|
|
|
|
|
|
|
|
|
Sep 2016 - Feb, 2017a
|
|
|
|
|
|
|
|
|
|
Mar - Aug, 2017
|
|
|
|
1.11
|
[0.56–2.20]
|
0.760
|
1.16
|
[0.61–2.23]
|
0.653
|
Sep, 2017 -Feb, 2018
|
|
|
|
0.74
|
[0.40–1.35]
|
0.326
|
0.81
|
[0.45–1.44]
|
0.468
|
Mar -Aug, 2018
|
|
|
|
1.35
|
[0.72–2.54]
|
0.346
|
1.25
|
[0.68–2.28]
|
0.477
|
Sep, 2018 - Feb 2019
|
|
|
|
2.48
|
[1.28–4.81]
|
0.007
|
2.21
|
[1.15–4.27]
|
0.018
|
Name of district
|
|
|
|
|
|
|
|
|
|
Bangalorea
|
|
|
|
|
|
|
|
|
|
Hyderabad
|
5.45
|
[3.75–7.92]
|
< 0.001
|
5.15
|
[3.43–7.75]
|
< 0.001
|
6.39
|
[4.17–9.78]
|
< 0.001
|
Gender
|
|
|
|
|
|
|
|
|
|
Femalea
|
|
|
|
|
|
|
|
|
|
Male
|
0.48
|
[0.35–0.67]
|
< 0.001
|
0.44
|
[0.30–0.62]
|
< 0.001
|
0.43
|
[0.30–0.60]
|
< 0.001
|
Marital status
|
|
|
|
|
|
|
|
|
|
Currently marrieda
|
|
|
|
|
|
|
|
|
|
Marriage dissolved
|
0.88
|
[0.51–1.51]
|
0.639
|
|
|
|
0.89
|
[0.49–1.61]
|
0.693
|
Single
|
1.68
|
[1.14–2.48]
|
0.008
|
|
|
|
1.59
|
[1.05–2.40]
|
0.029
|
HIV Status
|
|
|
|
|
|
|
|
|
|
Negativea
|
|
|
|
|
|
|
|
|
|
Positive
|
|
|
|
0.28
|
[0.09–0.85]
|
0.025
|
0.30
|
[0.10–0.88]
|
0.029
|
Unknown
|
|
|
|
1.42
|
[0.89–2.28]
|
0.141
|
1.21
|
[0.77–1.91]
|
0.418
|
Type of TB
|
|
|
|
|
|
|
|
|
|
Extra Pulmonary TBa
|
|
|
|
|
|
|
|
|
|
Pulmonary TB
|
0.65
|
[0.41–1.05]
|
0.076
|
0.50
|
[0.30–0.85]
|
0.01
|
0.58
|
[0.35–0.96]
|
0.034
|
History of previous TB treatment
|
|
|
|
|
|
|
|
|
|
Noa
|
|
|
|
|
|
|
|
|
|
Yes
|
0.63
|
[0.42–0.97]
|
0.035
|
0.56
|
[0.35–0.9]
|
0.016
|
0.58
|
[0.36–0.91]
|
0.019
|
Patients' Relationship with care supporter
|
|
|
|
|
|
|
|
|
|
No care supportera
|
|
|
|
|
|
|
|
|
|
Parent
|
1.23
|
[0.76–2.01]
|
0.398
|
2.23
|
[1.31–3.82]
|
0.003
|
1.48
|
[0.88–2.50]
|
0.139
|
Siblings/Son/Daughter
|
0.79
|
[0.48–1.29]
|
0.347
|
1.10
|
[0.63–1.93]
|
0.729
|
0.94
|
[0.55–1.61]
|
0.828
|
Spouse
|
1.45
|
[0.89–2.34]
|
0.133
|
1.60
|
[0.95–2.68]
|
0.076
|
1.49
|
[0.89–2.48]
|
0.126
|
Others
|
1.36
|
[0.76–2.45]
|
0.297
|
1.97
|
[1.03–3.75]
|
0.041
|
1.74
|
[0.93–3.26]
|
0.082
|
Number of visits during CP
|
|
|
|
|
|
|
|
|
|
< 2a
|
|
|
|
|
|
|
|
|
|
2–3
|
|
|
|
7.56
|
[4.86–11.74]
|
< 0.001
|
|
|
|
4+
|
|
|
|
28.89
|
[19.54–42.72]
|
< 0.001
|
|
|
|
Number of visits during IP
|
|
|
|
|
|
|
|
|
|
< 2a
|
|
|
|
|
|
|
|
|
|
2–3
|
2.66
|
[1.84–3.84]
|
< 0.001
|
|
|
|
|
|
|
4+
|
3.85
|
[2.61–5.69]
|
< 0.001
|
|
|
|
|
|
|
Total number of follow-up visits
|
|
|
|
|
|
|
|
|
|
< 4a
|
|
|
|
|
|
|
|
|
|
4–7
|
|
|
|
|
|
|
6.48
|
[4.44–9.45]
|
< 0.001
|
8+
|
|
|
|
|
|
|
22.71
|
[14.71–35.06]
|
< 0.001
|
Missed any doses
|
|
|
|
|
|
|
|
|
|
Noa
|
|
|
|
|
|
|
|
|
|
Yes
|
0.34
|
[0.23–0.49]
|
< 0.001
|
0.23
|
[0.15–0.35]
|
< 0.001
|
0.25
|
[0.16–0.37]
|
< 0.001
|
Provided adherence counselling
|
|
|
|
|
|
|
|
|
|
Noa
|
|
|
|
|
|
|
|
|
|
Yes
|
2.06
|
[1.28–3.31]
|
0.003
|
|
|
|
1.62
|
[0.99–2.65]
|
0.057
|
Provided nutritional counselling/support
|
|
|
|
|
|
|
|
|
|
Noa
|
|
|
|
|
|
|
|
|
|
Yes
|
1.88
|
[1.19–2.98]
|
0.007
|
|
|
|
|
|
|
Initial weight
|
|
|
|
|
|
|
|
|
|
Below median valuea
|
|
|
|
|
|
|
|
|
|
Median value or above
|
1.63
|
[1.03–2.59]
|
0.038
|
|
|
|
|
|
|
Unknown
|
1.06
|
[0.67–1.67]
|
0.814
|
|
|
|
|
|
|
Model 1 is based on the stepwise backward deletion multivariate logistic regression with 0.10 p-value as a group as a whole and included the number of follow-up visits during the intensive phase and other characteristics of the patient
|
Model 2 is based on the stepwise backward deletion multivariate logistic regression with 0.10 p-value as a group as a whole and included the number of follow-up visits during the continuation phase and other characteristics of the patient
|
Model 3 is based on the stepwise backward deletion multivariate logistic regression with 0.10 p-value as a group as whole and included the number of follow-up visits and other characteristics of the patient
aReference category
|
In the second model, we found significantly higher successful treatment outcome for patients whose care supporter is parent, and other relatives; such as uncle/aunt, in-laws, grand-parents or friends as compared to patients who are under self-care. The result also suggests that the likelihood of successful treatment outcome is significantly higher as the number of follow-up visits during the continuation phase are increased to 2 or more visits. Also, we noticed that HIV positive TB patients were found to have significantly lower successful treatment outcomes.
According to the third model, the chance of successful treatment increases as the total number of follow-up visits is 4 or more as compared to patients who received less than 4 follow-up visits totally. The results from the second and third model indicated that the cohorts of patients who were referred during September 2018 and February 2019 were found to have significantly higher likelihood of completing the treatment successfully as compared to the patients who were referred during September 2016 and February 2017.
The common variables that we identified to have significantly influenced the successful treatment outcome in all the three models were sex of the patient, place (city) of patient, type of TB, status of previous TB treatment and the experience of missed doses. The findings from the analysis also indicate that the CHW approach to improve the TB care cascade may not yield immediate results and may require minimum of two years of implementation to get significant positive results.