Why do patients attend so late? Risk factors for late presentation to an MSF supported Visceral Leishmaniasis (VL) treatment programme in Bihar, India.

Sakib Burza1, Prabhat K Sinha2, Raman Mahajan1, María Angeles Lima3, Gaurab

Mitra1, Neena Verma2, Manica Balsegaram4, Pradeep Das2

1MSF – New Delhi, India 2RMRI Patna, Bihar 3MSF – Barcelona, Spain 3DNDi, Geneva 4Campaign for Access to Essential Medicines, Geneva

Background: VL is an ultimately fatal parasitic disease endemic in Bihar. Between July 2007 and August 2012, MSF implemented a VL treatment project in Bihar, India—an area highly endemic for Leishmania donovani—using intravenous Ambisome 20 mg/kg.This study explore the factors associated with “late presentation” (i.e. >4 weeks of illness prior to treatment) for VL treatment.

MethodThis is an observational retrospective cohort study using routine program data of all VL patients (n=8749) treated by the MSF program from July 2007 to August 2012. A multivariate logistic regression model was also developed to determine risk factors significantly (p<0.05) associated with being a ‘late presenter’ on bivariate analysis

Conclusion:

Among patients presenting to an MSF supported programme in Bihar, being adult, female, of lower caste and receiving treatment at the district hospital level were significantly associated with presenting late for treatment for VL. These results may reflect barriers to care within the community and possibly the need for increased capacity at the PHC level.

Factors not associated with late presentation: Residing within one of the blocks that MSF supports and receiving care in a Mobile treatment camp (p>0.05)

ResultsRisk factors for late presentations (Table 1)•Females (OR 1.2; 95% CI 1.1–1.3; p = 0.001)•Patients from a Scheduled caste (OR 1.2; 95% CI 1.0–1.3; p = 0.03), •Age ≥15 years (OR 1.4; 95% CI 1.3–1.6; p<0.001). Protective factors for late presentations•Receiving treatment in the PHC setting (OR 0.6; 95% CI 0.6–0.7; p<0.001) Mean difference:1 week(95%CI 0.8-1.3 weeks<0.001) from patients directly admitted to district hospital•Previous episode of VL (OR 0.8; 95% CI 0.6–0.9; p = 0.013)

Table 1: Risk factors for late presentations with Visceral leishmaniasis (n=8741)Risk factors Total Number of late

presentersRisk of late presentation (%)

Unadjusted OR (95%CI)

P value Adjusted OR (95%CI)

P value

Sex Female 3747 1641 43.8 1.2(1.1-1.3) 0.001 1.2(1.1-1.3) <0.001Male 4994 2015 40.3 - -

Caste Schedule Caste 2524 1144 45.3 1.2(1.0-1.3) 0.03 1.2(1.0-1.3) 0.02Other Backward class 4805 1921 40.0 0.9(0.8-1.1) 0.26 0.9(0.8-1.1) 0.394Forward 1360 567 41.7 - -

Living in MSF supported blocks

No 4496 1932 43.0 1.1(1.0-1.2) 0.025 1.0(0.9-1.1) 0.906

Yes 4245 1724 40.6 - -Previous Relapse Yes 382 136 35.6 0.8(0.6-0.9) 0.013 0.7(0.5-0.9) 0.001

No 8359 3520 42.1 - -Age ≥15 years 4852 2222 45.8 1.4(1.3-1.6) <0.001 1.5(1.3-1.6) <0.001

<15 years 3889 1434 36.9 - -Treatment location Treatment camp(ambulatory) 164 65 39.6 0.9(0.6-1.2) 0.32 0.8(0.6-1.1) 0.236

Primary health center (ambulatory) 1396 463 33.2 0.6(0.6-0.7) <0.001 0.6(0.57-0.7) <0.001District Hospital (inpatient) 7181 3128 43.6 - -