Investigating Barriers to Tuberculosis Evaluation in Uganda Using Geographic Information Systems

Jennifer M. Ross Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut

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Adithya Cattamanchi Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut

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Cecily R. Miller Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut

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Andrew J. Tatem Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut

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Achilles Katamba Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut

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Priscilla Haguma Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut

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Margaret A. Handley Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut

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J. Lucian Davis Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut

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Reducing geographic barriers to tuberculosis (TB) care is a priority in high-burden countries where patients frequently initiate, but do not complete, the multi-day TB evaluation process. Using routine cross-sectional study from six primary-health clinics in rural Uganda from 2009 to 2012, we explored whether geographic barriers affect completion of TB evaluation among adults with unexplained chronic cough. We measured distance from home parish to health center and calculated individual travel time using a geographic information systems technique incorporating roads, land cover, and slope, and measured its association with completion of TB evaluation. In 264,511 patient encounters, 4,640 adults (1.8%) had sputum smear microscopy ordered; 2,783 (60%) completed TB evaluation. Median travel time was 68 minutes for patients with TB examination ordered compared with 60 minutes without (P < 0.010). Travel time differed between those who did and did not complete TB evaluation at only one of six clinics, whereas distance to care did not differ at any of them. Neither distance nor travel time predicted completion of TB evaluation in rural Uganda, although limited detail in road and village maps restricted full implementation of these mapping techniques. Better data are needed on geographic barriers to access clinics offering TB services to improve TB diagnosis.

Author Notes

* Address correspondence to Jennifer M. Ross, Division of Infectious Diseases, University of Washington, 1959 NE Pacific Street, Box 356423, Seattle, WA 98195-6423. E-mail: jross3@uw.edu

Funding supports: Jennifer M. Ross acknowledges funding support from NIH/NIAID (T32AI007140). Andrew J. Tate acknowledges funding support from the RAPIDD program of the Science and Technology Directorate, Department of Homeland Security, and the Fogarty International Center, National Institutes of Health, and is also supported by grants from NIH/NIAID (U19AI089674) and the Bill and Melinda Gates Foundation (#49446 and #1032350). J. Lucian Davis acknowledges support from NIH/NIAID (K23AI080147). Adithya Cattamanchi acknowledges support from NIH/NHLBI (K23HL094141).

Authors' addresses: Jennifer M. Ross, Division of Infectious Diseases, University of Washington, Seattle, WA, E-mail: jross3@uw.edu. Adithya Cattamanchi and Cecily R. Miller, Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, E-mails: acattamanchi@medsfgh.ucsf.edu and cecily.miller@ucsf. J. Lucian Davis, Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, CT, E-mail: lucian.davis@yale.edu. Andrew J. Tatem, Department of Geography and Environment, University of Southampton, Southampton, United Kingdom, E-mail: andy.tatem@gmail.com. Achilles Katamba, College of Health Sciences, Makerere University, Kampala, Uganda, E-mail: akatamba@yahoo.com. Priscilla Haguma, MU-UCSF Research Collaboration, Kampala, Uganda, E-mail: phaguma@idrc-uganda.org. Margaret A. Handley, Department of Epidemiology and Biostatistics, UCSF School of Medicine, San Francisco, CA, E-mail: handleym@medsfgh.ucsf.edu.

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