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 Table of Contents  
Year : 2015  |  Volume : 2  |  Issue : 4  |  Page : 137-141

Notified or missed cases? An assessment of successful linkage for referred tuberculosis patients in South India

Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Web Publication24-Dec-2015

Correspondence Address:
Ramesh Chand Chauhan
Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry - 605 014
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2225-6482.172652

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Background and Objectives: Although tuberculosis (TB) is a notifi able disease in India, most of the cases of TB are either not recorded or reported. Among diagnosed cases, for improving reporting, proper feedback on referral outcome needs to be ensured to all health care providers who refer cases to the public health system. Materials and Methods: All the received feedbacks for TB patients referred for treatment from July 2013 to December 2013 were analyzed. Feedback reports including referral date, the age and sex of patients, type of disease, and date of treatment initiation were examined. Results: Of the total 1,259 referred TB patients during the study period, feedback was received for 54% of them. Only 42.3% (n = 532) of the referred patients were successfully linked at the treatment facility. Seven (0.6%) referred patients died before the initiation of treatment while 3.7% migrated, 2.4% gave the wrong address, 1.0% started private treatment, and 0.6% were nontraceable; in 3.2% cases only was the TB number given. Feedback was signifi cantly associated with sex, age group, type of treatment, disease type, and place of residence. Conclusion: The feedback received for referred patients was poor and for improving the care of TB patients, there is a need to strengthen the feedback mechanism in Revised National Tuberculosis Control Programme (RNTCP) for referred patients.

Keywords: Feedback outcomes, India, Revised National Tuberculosis Control Programme (RNTCP)

How to cite this article:
Chauhan RC, Purty AJ, Singh Z. Notified or missed cases? An assessment of successful linkage for referred tuberculosis patients in South India. Community Acquir Infect 2015;2:137-41

How to cite this URL:
Chauhan RC, Purty AJ, Singh Z. Notified or missed cases? An assessment of successful linkage for referred tuberculosis patients in South India. Community Acquir Infect [serial online] 2015 [cited 2023 Jun 7];2:137-41. Available from: http://www.caijournal.com/text.asp?2015/2/4/137/172652

  Introduction Top

India ranks first among the high tuberculosis (TB) burden countries. In 2012, out of the estimated global annual incidence of 8.6 million TB cases, 2.3 million were estimated to have occurred in India.[1] With 26% of the total TB incidence cases, India has one of the largest and well-run national TB control programs in the world. Although, India's TB control program is on track as far as reduction in disease burden is concerned,[2] it is essential to have complete information of all TB cases to ensure proper case management, reduce TB transmission and address the problems of emergence of spread of drug-resistant TB.

The Government of India declared TB as a notifiable disease in 2012 but nearly one-third of the three million missed cases worldwide are from India.[3],[4] One of the major policy decisions taken by the Revised National Tuberculosis Control Programme (RNTCP) was to change the focus of the new sputum positive (NSP) case detection objective of at least 70% to the concept of universal access to good quality care for TB patients.[5] To reach the unreached, Stop TB Partnership has also focused on diagnosis, treatment, and cure for all.[6] To achieve universal access to TB treatment, special attention needs to be paid to the referral and feedback mechanism already in place. Although referral and feedback for TB patients is an agenda item in every state level RNTCP quarterly review and boarder state meeting, more importance is usually given to the case detection.

For improving reporting, proper feedback to all health care providers who refer cases to the public health system should be ensured.[7] The referring unit should receive the feedback on patients referred to other tuberculosis units (TUs) in the same district within 14 days and for patients referred outside the district/state within 1 month.[8]

In India, national and regional task forces has been set up to involve all public and private medical college hospitals, with related financial aid for operating hospital-based TB clinics, which contribute up to 15% of national case reporting from these facilities.[9] From medical colleges, apart from diagnosis and treatment, a large number of cases are referred for treatment to other reporting units/peripheral health institutions (PHIs) and their feedback is received. Feedback of the TB patients referred from medical colleges to PHIs for treatment initiation ranges 62-73%.[10] The overall aim of feedback is to confirm that the referred case has reached and started on appropriate treatment at the receiving unit. Apart from routine feedback, the type of feedback including successful linkage for referred TB patients is important.

This study was conducted to assess whether the TB patients referred from the medical colleges of Puducherry, India actually present themselves, are registered, and initiate treatment at the health facilities to which they are referred. An attempt to describe the approaches that can be used to strengthen existing TB patient referral mechanisms from medical colleges under RNTCP in India was also made.

  Materials and Methods Top

Study design

This is a descriptive study conducted through a retrospective record review related to the referral of TB patient for initiation of treatment.

Study setting and population

With a population of 1.2 million and four small unconnected districts, the union territory of Puducherry is has nine medical colleges.[11] All TB patients diagnosed at the medical college hospitals are registered and started on directly observed treatment, short-course (DOTS) or directly referred to PHIs.

All TB patients referred from the medical colleges of the study area from July 2013 to December 2013 were included in the study. A list of all the TB cases referred (n = 1259) from the medical colleges of Puducherry, India was collected and their referral feedback outcomes were assessed. Other patient particular data including referral date, age and sex of patient, type of disease, and date of treatment initiation were collected from the referral forms.

After reviewing the data stored in the Excel spreadsheet, feedback was considered as received if the referred patients were approached by the TB health visitor/treatment supervisor and any information regarding the follow-up of referred patients such as the allocation of TB number and/or starting of treatment and others was available from PHIs. A successful linkage to PHIs for a given patient was considered if it was assured that the referred patient was started on treatment. Primary access rate (PAR), the proportion of all TB cases who were diagnosed and referred from the medical colleges and were subsequently confirmed to have started treatment at the referred health facility, was used as a measure of successful linkage.

Ethics approval

The study was approved by the RNTCP State Task Force, Puducherry, India. Individual patient consent was deemed unnecessary as the study was for evaluation of the implementation of national program and data from the record were used. No personal identifier was recorded in the electronic databases.

Referral mechanism for tuberculosis patients diagnosed at medical colleges of Puducherry

The patients diagnosed with TB at medical colleges are formally referred (by filling a referral for treatment form) to a PHI closest to their residence for continuation of anti-TB treatment. After verification of address at the receiving unit, appropriate treatment is started. The medical college hospitals fill the TB referral forms in duplicate; the hospital keeps one of the copies and gives another copy to the referring patient. All referrals and feedbacks are documented on a “referral for treatment” register maintained at medical college hospitals. The hospital also sends a list of all the referred patients including details in the referral form to the district TB center (DTC) of their respective district. This list is further sent to the DTC of the receiving unit by e-mail. At the receiving unit, an electronic database in an Excel spreadsheet is maintained. DTCs through a senior treatment supervisor (STS) are expected to follow the status of the referred patients by their visits to the PHC units and at monthly intradistrict meetings held at the DTC office.

Data collection and analysis

Data from the referral registers and feedback forms were used to gather information related to this study. These data were entered into a prestructured format in Microsoft Excel. The data were analyzed using Statistical Package for the Social Sciences (SPSS) software version 17 (SPSS Inc.). For categorical and continuous variables, proportions and means were calculated respectively. Chi-square test was appropriately applied to find the determinants of feedback and successful referral. P value <0.05 was considered as significant.

  Results Top

As per the feedback for referrals shown in [Table 1], a total of 1259 patients were referred. Among them, majority were male (74.3%). The mean age of referred patients was 43.3 years ± 16.3 years (range 1-90 years). Most (40.9%) of the patients were in the age-group of 40-59 years. Children (<15 years) and elderly comprise 2.5% and 18.7% of referred patients respectively. Apart from the majority (72.3%) of new cases, 13% were previously treated patients. Approximately one-third (32.8%) of TB patients were extra-pulmonary cases.
Table 1: Association of feedback with various TB patient characteristics, referring institutes, and time of referral

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Among 1259 referred patients, feedback was received for 680 (54%) patients and only 532 (42.3%) were successfully linked at the PHIs. Further, the date of starting of treatment was mentioned for 506 (40.2%) referred patients and for 26 (2.1%) patients, feedback received was “treatment started” without any mention of the date of starting treatment. For remaining 148 (11.3%) patients, following feedback were obtained; 7 (0.6%) referred patients died before initiation of treatment, 47 (3.7%) migrated, 30 (2.4%) had given wrong address, 13 (1.0%) obtained treatment from private practitioners, 8 (0.6%) were non-traceable, 40 (3.2%) were given only TB number and no information regarding the starting of treatment was given. One patient refused treatment, one referred to inappropriate PHI and one patient was further referred to higher centre from PHI [Figure 1].
Figure 1: Flow diagram of TB patients diagnosed at the medical colleges of Puducherry from July 2013 to December 2013

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As compared to male TB patients, feedback was received for more females. Also, compared to elderly, better feedback was obtained for adults and children and this difference was statistically significant (P< 0.05). The feedback was significantly lower among category II patients, previously treated patients and among patients who were referred during 4th quarter (P< 0.05). There was a statistically significant difference in the feedback received with respect to the gender, age groups of patients, type of treatment received, disease type and areas referred to Puducherry or outside (P< 0.05).

For 476 (37.8%) patients, the date of referral and date of starting treatment was clearly mentioned. Among them, only 302 (63.4%) were started on treatment within one week; 103 (21.6%) and 71 (14.9%) were started on treatment during second week and beyond two weeks of referral respectively. The mean interval between referral and starting the treatment was 7.4 days ± 8.5 days (Range 0-69 days).

  Discussion Top

To achieve and maintain the objective of treatment success rate of >85%, the confirmation of all referral patients to be started on treatment is important. Few studies have assessed the successful linkage for continuing anti-TB treatment after referral from medical colleges in India, where a large proportion of all TB patients are diagnosed and referred.[12] In the present study, only 13 (0.9%) patients were started on treatment at the DOTS center of the medical colleges and majority (87.6%) of the TB patients diagnosed were referred to start and continue treatment at the PHIs. Among those thirteen patients, who were started on treatment at the DOTS centre of medical colleges, seven patients were offered non-DOTS or non-RNTCP drug regimens. The reasons for this non-compliance with national RNTCP treatment guidelines have not been specified.

In the present study, formal feedbacks from peripheral facilities were received for 54% of the referred patients only. The study carried by Kondapaka et al.[12] in Hyderabad, India shows (74%) successful feedback whereas a study by Al-Hammady et al.[13] in Yemen revealed (88.8%) successful feedback which is higher than the feedbacks received in the present study. The lower feedback in the present study could be due to the fact that a large number of TB patients diagnosed at the medical colleges of Puducherry are referred to other states having different administrative jurisdiction. Also, the feedback from PHIs situated in other states was particularly lower in the present study.

The present study found that nearly half of the referred TB patients (46%) were without any feedback and were likely to be lost by RNTCP. Further, those patients who were registered at PHIs, were delayed started on treatment. Many of these patients without any feedback are actually lost by the TB control programme, indicating deficiencies in referral for treatment and feedback mechanism and such patients may become defaulters or MDR cases. This further highlights the need for better links and discussions with PHIs as well as ensuring active feedback mechanism. Direct communication by mobile phones between referring facility and the facility to which the patients are referred, can be considered as a way to improve this linkage.[14] Also, for improving the feedback, there is need to improve the coordination with other border districts and the role of RNTCP State and Zonal Task Forces could be of vital importance in this regard.

In the present study, 532 (42.3%) referred TB patients were started on treatment. Further, as per the RNTCP guidelines, treatment should be started within one week of diagnosis; but among those who were started on treatment at PHIs, only 337 (63.4%) were started on treatment within one week of referral. Overall, the average duration between referral and starting the treatment was 7.4 days which is higher than other study.[14]

There is need to strengthen the feedback mechanism in RNTCP and to investigate the reasons for initial default. Keeping the high initial default rate and poor feedback, it is suggested that patients who do not collect their sputum smear results be traced and that RNTCP staff fill in and neatly file referral sheets whenever a referral is made. Many patients who had given wrong address and/or were referred to inappropriate PHI were usually lost and there is no mechanism to reach these patients. A directory having addresses of all the PHIs, where patients were usually referred can be helpful for the referring physician. As per the referral guidelines of RNTCP, referral form should be filled in triplet; which should be followed strictly. This study included a large number of TB patients and information was gathered on an individual basis including some of the patient characteristics. Also, as we used routine programme data, the findings are likely to reflect the operational reality on the ground and further appropriate steps can be taken to improve the feedback mechanism. The findings of this study can be generalized to referral and feedback of TB patients, particularly to those medical colleges where a large proportion of TB patients are reporting from nearby districts. We followed the STROBE guidelines for reporting observational studies.[15]


The authors would like to thank Dr. S. Govindrajan, STO, Puducherry, India for the valuable support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Global Tuberculosis Report 2013. World Health Organization, Geneva: 2013. (WHO/HTM/TB/2013.11). Available from: http://www.who.int/tb/publications/global_report/en/index.html. [Last accessed on 2014 Apr 10].  Back to cited text no. 1
TB Annual Report 2014. Ministry of Health and Family Welfare, New Delhi. Available from: http://www.tbcindia.nic.in. [Last accessed on 2014 Apr 12].  Back to cited text no. 2
Guidance for TB Notification in India, 2012. Ministry of Health and Family Welfare. Available from: http://tbcindia.nic.in/pdfs/Guidance%20tool%20for%20TB%20notification%20in%20India%20-%20FINAL.pdf. [Last accessed on 2014 Apr 16].  Back to cited text no. 3
Annual Report 2014. Tuberculosis Control in the South-East Asia Region. Available from: http://www.searo.who.int/entity/tb/annual_tb_report_2014.pdf. [Last accessed on 2014 Apr 12].  Back to cited text no. 4
Universal Access to TB Care, India. Available from: http://www.tbcindia.nic.in/pdfs/Universal_accessto_TB_Care.pdf. [Last accessed on 2014 Apr 12].  Back to cited text no. 5
Stop TB Partnership. World TB Day 2014. Available from: http://www.stoptb.org/events/world_tb_day/. [Last accessed on 2014 Apr 18].  Back to cited text no. 6
Standards for TB Care in India. World Health Organization; 2014. Available from: http://www.searo.who.int/india. [Last accessed on 2014 Apr 12].  Back to cited text no. 7
Technical and Operational Guidelines for Tuberculosis Control. RNTCP. Available from: http://www.tbcindia.nic.in/documents.html. [Last accessed on 2014 Apr 12].  Back to cited text no. 8
Sharma SK. Report of the National Task Force 2010. Presented at the National Task Force Meeting for Involvement of Medical Colleges in the RNTCP, Hyderabad, 18-20th January 2011. Available from: http://tbcindia.nic.in/documents.html. [Last accessed on 2014 Apr 12].  Back to cited text no. 9
Sharma SK, Mohan A, Chauhan LS, Narain JP, Kumar P, Behera D, et al.; Task Force for Involvement of Medical Colleges in Revised National Tuberculosis Control Programme. Contribution of medical colleges to tuberculosis control in India under the Revised National Tuberculosis Control Programme (RNTCP): Lessons learnt & challenges ahead. Indian J Med Res 2013;137:283-94.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
List of Colleges Teaching MBBS. MCI. Available from: http://www.mciindia.org/InformationDesk/ForStudents/ListofCollegesTeachingMBBS.aspx. [Last accessed on 2014 Apr 22].  Back to cited text no. 11
Kondapaka KK, Prasad SV, Satyanarayana S, Kandi S, Zachariah R, Harries AD, et al. Are tuberculosis patients in a tertiary care hospital in Hyderabad, India being managed according to national guidelines? PLoS One 2012;7:e30281.  Back to cited text no. 12
Al-Hammady A, Ohkado A, Masui T, Al-Absi A. A survey on the referral of tuberculosis patients at the National Tuberculosis Institute, Yemen. Int J Tuberc Lung Dis 2007;11:928-30.  Back to cited text no. 13
Harlow T. TB net tracking network provides continuity of care for mobile TB patients. Am J Public Health 1999;89:1581-2.  Back to cited text no. 14
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. J Clin Epidemiol 2008;61:344-9.  Back to cited text no. 15


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