Such a long journey for DR-TB.

The care-seeking pathway of a 19 year old male with no past history of TB.

Total number of providers seen by the patient- 7

Total minimum distance travelled before receiving of effective treatment- 185km

Care Pathway duration- 103 days

Patient initially had a cough in August 2016 which he thought was a normal infection. After one week of cough he approaches a private facility (P1) in his vicinity who gave him around 1 week of symptomatic treatment which gave him temporary relief. After one month he visits another private doctor (P2) in his vicinity who again gives him one week of symptomatic treatment. Patient again gets temporary relief.

After 20days he experiences haemoptysis and approaches a PPIA informal facility (P3). The facility conducts CXR on the same day and diagnosis the patient with TB based on it.

Refers the patient to Public hospital for treatment initiation. Patient approaches the referred facility (P4) the very next day where he had Blood, LPA test conducted. He was referred to the nearest DOTS centre.

The patient did not go to the referred centre but instead approached a formal PPIA facility (P5) since his relative had taken TB treatment there. He had CXR and Sputum Microscopy conducted the same day based on which the facility confirmed the previous diagnosis and initiated CAT-I treatment. GX was advised on the same day but conducted after 4 days. After the patient collected the report, he was diagnosed with DR-TB and his CAT-I treatment was stopped. He was referred to Public facility. Meanwhile, the same public facility called the patient to receive the LPA report.

After 1week patient approaches the referred facility (P4a) where he was re-diagnosed with DR-TB based on the results of the LPA test report. His Pre Treatment Examination tests were conducted within 10 days and he was referred to DOTS centre for his DR-TB treatment initiation. He approached the referred nearest DOTS centre (P6) the same day and was initiated on CAT-IV treatment regime.

After 37 days of treatment, the (P4b) public facility called the patient back from the DOTS centre since he was eligible for BDQ treatment. From here he was referred to another public facility (P7) for getting admitted in the hospital for the BDQ treatment. He was put on BDQ treatment for 20 days post which he was referred back to nearest DOTS centre (P6a) for continuation of his treatment.

The case exemplifies:

· Poor diagnostic ability of private providers

· Excessive multi location movement in the public sector due to referrals

· Need for a rapid point of care test for diagnosis & timely treatment for DR-TB