Tuberculosis Diagnostics; Time For Change

Ms Elizabeth Msoka (MSc) has authored this context analysis on behalf of the Kilimanjaro Clinical research Institute (KCRI). She is a postgraduate nurse trained in health system and policy research and currently runs social science studies at KCRI. She is a research nurse working at KCRI, Kilimanjaro Christian Medical Centre at the Department of Clinical Trial. She has training in the field of Health system and policy research and Research Management. She has been involved in several clinical and community based research which address public health problems in Tanzania including; Human Immunodeficiency Virus (HIV), malaria and Tuberculosis.  

The World Health Organisation (WHO) estimates that Tanzania is the 15th country among 22 countries with highest tuberculosis (TB) burden in the world. Incidence of TB in Tanzania in 2014 was estimated to be 327 per 100,000 populations (World Bank, 2014). The number of TB patients in the country has been increasing rapidly from 11,000 people in 1984 to 62,000 in 2006; then up to 63,892 in 2012 reaching 65,000 in 2013 (WHO, 2013).

TB is one of the biggest health challenges facing the country as the disease kills an estimated 12,000 people annually (WHO, 2012).  Almost half (47%) of all newly diagnosed people with TB in Tanzania are also co-infected with HIV. The TB and TB/HIV co-infection pose a substantial burden on the health system in Tanzania and remains a significant cause of morbidity and mortality. 

The National TB and Leprosy survey (NTLP) revealed that the elderly and people in the villages are more vulnerable to the disease as they can hardly access health services (NTLP, 2013). The TB burden varies by region with regions, Arusha, Dar es Salaam, Kilimanjaro, Mara, Manyara, Mbeya, Morogoro, Mwanza, Coast, Shinyanga, Tabora and Tanga accounting for 70 percent of all TB patients diagnosed in the country (Tanzania health statistics, 2015). 

Case finding in Tanzania is still passive, and TB control is integrated into the general health system, depending on the patients themselves to present to health services when they suspect TB (NTLP, 2013).  Tanzania was reported among countries with the longest total delay in the diagnosis of TB (WHO, 2006-2009). Delay occurs when a patient fails to recognise symptoms due to lack of knowledge or when they do not have the confidence that the health service will provide adequate services (NTLP, 2013). 

Health seeking behaviour and the perceived knowledge on causes of TB among community members is very critical and may reduce or increase the transmission of the disease. Certain local practices and beliefs and failure to recognize symptoms early may delay diagnosis hence increasing the spread of the disease in the community.

Like HIV/AIDS, TB is often associated with stigmatization and thus may create resistance among patients to seek proper diagnosis and treatment (NTLP, 2013). Early and proper diagnosis of TB is crucial for treatment success and disease outcome for patients. 

With a public health budget of about US $ 6 per capita per year, the TB epidemic puts significant stress on the meagre budget and thus affects the health system performance.  The emerging drug resistance is becoming a challenge for treatment success. The drug options for resistant TB are more expensive, difficult treatment regime, and the outcome is more likely to be fatal if not well adhered.  

The WHO approved diagnostic tools for early detection of TB; Xpert MTB/Rif and Line Probe assays, which have been implemented in different Government and designated hospitals in Tanzania. The tools are expected to be fully functional and increase TB case identification for suspected TB patients in most areas where these diagnostic tools exist. 

The Tuberculosis: Working to Empower Nations’ Diagnostic Efforts (TWENDE) consortium funded by the European & Development Countries Clinical Trial Partnership (EDCTP) will investigate the extent of implementation of these diagnostic tools and explore opportunities to unlock the barriers that hinder wide implementation and accessibility to good diagnostic service. 

KCRI will work to implement TWENDE objectives in the Northern half of Tanzania composed of 13 regions accounting for 56.8 percent of the Tanzania population (TBOS 2012).  Out of the 13 regions, TWENDE purposively selected eight regions in which the study will be conducted namely: 

  • Kilimanjaro
  • Arusha
  • Manyara
  • Singida
  • Mwanza
  • Shinyanga
  • Kagera
  • Kigoma. 

Locating the study in the eight regions will cover 34.5 percent of the Tanzanian population and approximately 61 percent of the population in northern half of Tanzania. 

The researchers of KCRI, the KCRI -TWENDE team, led by Prof. Blandina Mmbaga and Dr. Alphonce Liyoyo, in the second half of 2016 will conduct a survey of all district health officers in the northern half of Tanzania to get the overview of the general state of TB diagnostics and treatment in this part of Tanzania. 

The survey will be followed by audits of the selected health care facilities (HCF) that are located in selected regions covering 26 hospitals to assess the implementation of the Xpert MTB/RIF and Line Probe assays and establish the rate and factors thereof for uptake of molecular diagnosis for TB; Xpert MTB/Rif and Line Probe assays. 

The HCFs will be selected to include at least one Consultant, one referral, one designated and two District hospitals in each region and TB national hospital. Therefore, a total of 15 District/designated hospitals, eight regional hospitals, two consultants’ referral hospitals and one National TB hospital will be covered.  Furthermore, the survey will target 8 Regional TB & Leprosy Coordinators (RTLCs) one from each selected region and about 16 district coordinators (DTLCs). 

Themes emanating from the HCF audits will be followed up with one-to-one interviews and focus group discussion to understand the issues underlying the themes and map out ways for appropriate intervention by the government.

Qualitative data collection including one-to-one interviews and focus group discussion will commence in the last quarter 2016 ending in the first quarter 2017. Elizabeth Msoka with support from KCRI team will lead this phase of study.  

Forty-two in-depth interviews and a minimum of 16 focus group discussions (FGDs) will be conducted.  Two FGDs will be done in each of the 8 visited regions, which will have a total of 6-8 participants per sessions to make a total of 96-128 participants. 

Participants for FGDs will be members from the community around the healthcare centres audited by the study team mainly; Medical doctors, District and regional TB and leprosy coordinators, laboratory technicians, TB community advisory board members and TB nurse coordinators. 

The in-depth interviews will be conducted among 48 respondents six in each region, these will includes: District Medical Officer, Village Chairpersons, Regional Medical Officer, HCF administrators, GenEXpert Unit in-charges, laboratory managers/supervisors, out-patient nurses in charge, TB and Leprosy regional coordinators, TB patients and TB patient care givers. 

In the last phase of the study, workshops will be arranged in which researchers will discuss the study findings with policy makers and implementers with the aim of drawing actionable strategies for accelerating uptake diagnostic innovations into policy and practice Importantly, TWENDE’s aspiration is to contribute towards creating TB awareness and increasing accessibility to TB diagnostics and treatment for TB patients and community at a large. 

Reference

Ministry of Health: (NTLP, 2013) Annual report of the National Tuberculosis and Leprosy Control Programme in Tanzania. National TB and Leprosy Programme 

Tanzania Health Statistics, (2015) 

National Bureau of Statistics (NBS) (Tanzania) and ICF Macro (2011) Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: National Bureau of Statistics and ICF Macro.

World Health Organization, (2010) The Global Plan to Stop TB, 2011Bstra. Geneva,   (WHO/HTM/STB/2010.2). Available at here  

WHO, (2006): Diagnostic and treatment delay in tuberculosis. Geneva, World Health Organisation.

World Health Organization.(2009) Global tuberculosis control: epidemiology, strategy, financing. Geneva, Switzerland: WHO/HTM/TB/2009.411.

WHO,( 2013) Tuberculosis  in Tanzania

World Bank, (2014)