The Importance of Implementation Strategy in Scaling Up Xpert MTB/RIF for Diagnosis of Tuberculosis in the Indian Health-Care System: A Transmission Model

Salje, H and Andrews, J R and Deo, S and Satyanarayana, S and Sun, A Y and Pai, M and Dowdy, D W (2014) The Importance of Implementation Strategy in Scaling Up Xpert MTB/RIF for Diagnosis of Tuberculosis in the Indian Health-Care System: A Transmission Model. PLoS Medicine, 11 (7). pp. 1-14. ISSN 1549-1277

[img]
Preview

| Preview

Abstract

Background:India has announced a goal of universal access to quality tuberculosis (TB) diagnosis and treatment. A number of novel diagnostics could help meet this important goal. The rollout of one such diagnostic, Xpert MTB/RIF (Xpert) is being considered, but if Xpert is used mainly for people with HIV or high risk of multidrug-resistant TB (MDR-TB) in the public sector, population-level impact may be limited.Methods and Findings:We developed a model of TB transmission, care-seeking behavior, and diagnostic/treatment practices in India and explored the impact of six different rollout strategies. Providing Xpert to 40 of public-sector patients with HIV or prior TB treatment (similar to current national strategy) reduced TB incidence by 0.2 (95 uncertainty range UR: -1.4%, 1.7%) and MDR-TB incidence by 2.4% (95% UR: -5.2%, 9.1%) relative to existing practice but required 2,500 additional MDR-TB treatments and 60 four-module GeneXpert systems at maximum capacity. Further including 20% of unselected symptomatic individuals in the public sector required 700 systems and reduced incidence by 2.1% (95% UR: 0.5%, 3.9%); a similar approach involving qualified private providers (providers who have received at least some training in allopathic or non-allopathic medicine) reduced incidence by 6.0% (95% UR: 3.9%, 7.9%) with similar resource outlay, but only if high treatment success was assured. Engaging 20% of all private-sector providers (qualified and informal providers with no formal medical training) had the greatest impact (14.1% reduction, 95% UR: 10.6%, 16.9%), but required >2,200 systems and reliable treatment referral. Improving referrals from informal providers for smear-based diagnosis in the public sector (without Xpert rollout) had substantially greater impact (6.3% reduction) than Xpert scale-up within the public sector. These findings are subject to substantial uncertainty regarding private-sector treatment patterns, patient care-seeking behavior, symptoms, and infectiousness over time; these uncertainties should be addressed by future research.Conclusions:The impact of new diagnostics for TB control in India depends on implementation within the complex, fragmented health-care system. Transformative strategies will require private/informal-sector engagement, adequate referral systems, improved treatment quality, and substantial resources.Please see later in the article for the Editors' Summary. © 2014 Salje et al.

Affiliation: Indian School of Business
ISB Creators:
ISB CreatorsORCiD
Deo, SUNSPECIFIED
Item Type: Article
Uncontrolled Keywords: diagnostic test; disease transmission; follow up; health care personnel; health care system; health impact assessment; help seeking behavior; human; incidence; infection control; mortality; multidrug resistant tuberculosis; nonhuman; prevalence; risk assessment; sensitivity analysis; sputum cytodiagnosis; treatment failure; treatment outcome; treatment planning; tuberculosis; Xpert MTB RIF Test
Subjects: Health care and delivery
Depositing User: Ilammaran A
Date Deposited: 12 Nov 2014 15:48
Last Modified: 17 Jun 2015 07:45
URI: http://eprints.exchange.isb.edu/id/eprint/230
Publisher URL: http://dx.doi.org/10.1371/journal.pmed.1001674
Publisher OA policy: http://www.sherpa.ac.uk/romeo/issn/1549-1277/
Related URLs:

Actions (login required)

View Item View Item
Statistics for DESI ePrint 230 Statistics for this ePrint Item