Effects of distance to treatment centre and case load upon tuberculosis treatment completion

To the Editors: The prompt identification and adequate treatment of tuberculosis (TB) cases are key components of the global control effort [1]. In many high-income countries, TB is relatively uncommon, implying that many clinicians do not have regular and continuing experience of managing TB. To address this, a policy response is a trend towards small numbers of centralised treatment facilities where individuals may receive better and more complete treatment [2, 3]. This centralising trend is the opposite to many low-income countries, where there is a move towards larger numbers of more decentralised TB services to facilitate patient access [4]. The difference is that such countries have sufficient cases to allow clinical staff to maintain their expertise, even in rural areas. If TB services become more centralised, then patients may experience greater difficulty in accessing TB services due to increasing the distance between the home and treatment centre. There is little research on how distance affects TB completion, but rural residence is a known risk factor associated with a delay in the diagnosis and treatment of TB [5] and may therefore affect treatment completion. However, most of this evidence comes from low-income countries. In contrast, in high-income countries, good transport links and reasonable social security systems imply that such barriers may not exist. This epidemiological study examined whether treatment centre case load (annual number of TB patients seen) and healthcare accessibility (proximity of patient residence to TB treatment centre) have an influence upon the completion of TB treatment in England and Wales, UK. The study was based upon a sample of 21,954 patients reported to the national enhanced TB surveillance system (ETS) from 2001 to 2006 in England and Wales.