An online method for diagnosis of difficult TB cases for developing countries

Optimal use of limited human, technical and financial resources is a major concern for tuberculosis (TB) control in developing nations. Further impediments include a lack of trained physicians, and logistical difficulties in arranging face-to-face (f-2-f) TB Diagnostic Committee (TBDC) consultations. Use of e-Health for virtual TBDCs (Internet and "iPath"), to address such issues is being studied in the Philippines and Pakistan. In Pakistan, radiological diagnosis of 88 sputum smear negative but suspected TB patients has been compared with the 'gold standards' (TB culture, and 2-month clinical follow up). Of 88 diagnostic decisions made by primary physicians at the spoke site and electronic TBDC (e-TBDC) at hub site, there was agreement in 71 cases and disagreement on 17 cases. The turn-around time (TAT; patient registration at spoke site for f-2-f diagnosis to receiving the electronic diagnosis), averaged 34.6 hours; ranging 9 minutes to 289.2 hours. Average TAT at the rural site (59.15 hours) was more than the urban site (15.9 hours). Comparison of e-TBDC and f-2-f diagnosis with the gold standards showed only slight differences. Using culture as the gold standard, e-TBDC decisions showed greater accuracy (sensitivity - 32.4%) as compared to f-2-f (27.6%); using 2-month clinical follow-up as the gold standard, f-2-f diagnosis showed slightly better improvement in patient symptoms and weight as compared to e-TBDC. In Philippines "iPath" was trialed and demonstrated that e-TBDCs have potential. Such groups could review cases, diagnose, and write comments remotely, reducing the diagnosis and treatment delay compared to usual care.