Uganda: Why TB Goes Undiagnosed –

Early diagnosis is crucial for the effective management of any disease. In Africa, this is not always possible which affects the ability of countries to bring diseases under control.
Wilber Sabiiti, a Senior Research Fellow in Medicine, University of St Andrews, UK, and colleagues conducted research into the barriers to diagnosis for tubercolosis (TB) in Kenya, Tanzania and Uganda. They also wanted to identify what opportunities there were to maximise the use of diagnostics in healthcare settings.
According to the researchers, the COVID-19 pandemic has led to an unprecedented uptake and utilisation of molecular diagnostics worldwide with over 500 million tests conducted in a period of 9 months by October 2020.
They say health systems have been shaken but most importantly the pandemic has raised public consciousness of the value of diagnostics and interdisciplinary approaches in the control of diseases.
In contrast, tuberculosis (TB) has been a pandemic for time immemorial and a global public health emergency for over 20 years. But the rate of TB testing does not match incidence of TB disease and, consequently, an estimated 3 million cases go undetected every year.
A quarter (1.7 billion) of the world population has TB infection and in 2018, 10 million developed active disease resulting in 1.5 million deaths. Of the 10 million notified cases, 55% were bacteriologically confirmed and a small proportion of these were tested using rapid molecular tests.
The World Health Organisation (WHO) approved routine use of TB molecular tests more than 10 years ago, starting with the Line Probe Assay (LPA) in 2008 and Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) in 2010.
The Xpert MTB/RIF detects both TB and resistance to rifampicin in two hours and is the widely used molecular test for TB. But by 2016, only 16 million Xpert MTB/RIF tests had been performed, translating into 3.2 million tests per year.
The researchers found that, in Kenya, Tanzania and Uganda, the uptake of diagnostics had an urban rural divide. It was highest – over 90% – at large referral hospitals in major municipalities and cities, what they call “tertiary level health care facilities”. Meanwhile, lower level health care facilities, where most people live, were less served by diagnostic tests.
The study was completed prior to emergence of COVID-19. But a similar trend of over concentration of diagnostics in major cities has been repeated in COVID-19 responses in all the three countries.
For instance, in Kenya 26 out of 47 COVID-19 PCR (polymerase chain reaction) testing laboratories are in Nairobi, while in Uganda 17 out of 22 are in Kampala. Until recently Tanzania had one national testing laboratory in Dar es Salaam. Five more laboratories have been approved for PCR testing.
This raises the question of the extent to which COVID-19 testing has been accessed by the rural communities of the three countries.
From their research, we concluded that each country needed to pursue solutions to unlock barriers to increase access to diagnostics.
The scientists says because there is sharp contrast in the rate of uptake of COVID-19 molecular tests compared with TB, a leaf could be borrowed from either disease on how to accelerate and maximise translation of health research innovations into policy and practice.
Countries must be encouraged to distribute essential healthcare provision – like diagnosis – to where people most need them and where they can be accessed more easily.
In addition, solutions must include increased domestic financing to improve healthcare at primary healthcare level; mass education to increase awareness of the available diagnostic and treatment tools and investing in community empowerment solutions.
The obstacles
Kenya, Tanzania and Uganda were ideal for the study because they have relatively similar administrative and health system structures. They are also high TB burden countries.
The health systems in the study countries vary, and grow in size and services in relation to the population they’re serving. They range from level one (the smallest) through to level five (the largest). For instance, at the village level there are small dispensaries or health centres (level 1) whereas at the city level there are large hospitals (level 5).
To assess the barriers to diagnosis the researchers looked at the implementation of WHO approved molecular diagnostics for TB – Xpert MTB/RIF and Line Probe Assay tests.
They spoke to a range of stakeholders. These included healthcare practitioners, patients, survivors, carers, community leaders, policy makers and implementers. They further inspected the participating healthcare centres to ascertain the existence of facilities referred to by practitioners in the interview.
Health officers representing 190 districts/counties participated in the survey across Kenya, Tanzania and Uganda. The survey findings were corroborated by 145 healthcare facility (HCF) audits and 11 policy-maker engagement workshops.
In Uganda, regions were based on areas represented by a regional hospital while districts were taken as they are currently structured as administration units. In Tanzania, regions and districts are clearly demarcated administrative units and so were covered as such. For Kenya, regional units were counties while the subcounties were equivalent to districts in Uganda and Tanzania.
Participants were healthcare administrators such as regional/county and district health (medical) officers, HCF managers and healthcare professionals of participating HCFs. Apart from managers and practitioners, patients, TB survivors, community health volunteers, opinions leaders among the HCF users, local council leaders and national policy-makers in ministry of Health and parliament were engaged.
In all the countries, government was the main TB clinical service provider, owning over 80% of the HCFs. Level 5 hospitals (national, consultant level, regional referral) were 42, level 4 (regional hospitals) 34, level 3 (district hospitals) 57, level 2 (health centre IV) 6 and level 1 (dispensary, health centre 1-3) 6. The majority, 86 of the TB laboratories were able to deliver biosafety level II (BSL II) followed by BSL I, 23 and BSL III, 6 and 4 general laboratories.
At the time of the survey, smear microscopy was the most available diagnostic tool use in 185 out 190 districts/counties surveyed, followed by clinical diagnosis used in 128 of 190. The Xpert MTB RIF lagged and was used in 125 of 190. The TB culture and LPA were the least used in just 13 of 190.
At country level, Xpert MTB/RIF test coverage was 74% and 39% districts in Uganda and Tanzania respectively and 42% subcounties in Kenya.
The main barriers we found were: Under financing by government, lack of awareness, shortage of water and electricity, inadequate human resource, and procurement difficulties.
Under financing by government was the main factor underlying low uptake or absence of molecular diagnostics at healthcare facilities. Lack of money means healthcare centres cannot buy laboratory equipment and supplies, pay for utilities, hire and retain qualified staff.
The second biggest factor was a lack of awareness. For instance, 33% of healthcare administrators and 49% of practitioners were unaware of Line Probe Assay as TB diagnostic. Only 33% of the 111 health care facilities we examined used the Xpert MTB/RIF test to its full capacity of performing 8 or more tests per day.
A shortage of water and electricity was a major obstacle because water is used to dissolve substances (a solvent) and is a cleaning agent. Without water most laboratory operations are compromised. Without electricity, the testing machines cannot operate.
Inadequate human resource led to work overload and patient samples going untested because there weren’t enough people to run the tests. One healthcare facility reported going six months without giving the Xpert MTB/RIF test because the person in charge was “off sick”.
Procurement difficulties resulted in the failure to acquire supplies in time. This was a cause of laboratory reagent stock outs and hence under-utilisation of molecular testing facilities.
Next steps
To increase the uptake of diagnostics, we identified a number of important steps governments should take.
First, governments need to create a decentralised hub system supported by an efficient referral system.
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The laboratory capacity of level three and four healthcare facilities (at the district level) need to be increased. These would serve as hubs receiving referral specimens from level 1 and 2 healthcare facilities.
Uganda has tried to do this with TB diagnostics, and there’s been some success, but it needs to be made more efficient. There needs to be more awareness and strengthen specimen referral system at level 1 and 2 healthcare facilities.
The hub system would allow the consolidation of skilled human resource. It would also mean that the supply of essential utilities – like water and electricity – are better harnessed.
Alongside the creation of hub systems, governments must invest in digital information systems. This would ensure that test results are fed back to clinics and patients in real-time.
Governments also need to run public awareness programmes aimed at healthcare administrators, practitioners and service users. The awareness programmes should explain the health system structure, the available services and how to access them.
They also need to streamline procurement systems. We recommend that unnecessary bureaucracy be removed, and that partnerships are created between the public and private sector to ensure the swift acquisition of laboratory supplies.
Rooting out corruption in the procurement system would also go a long way in ensuring healthcare facilities acquire all their diagnostic supplies on time.
Encouraging and supporting the local manufacture of diagnostic and treatment tools would also significantly ease the procurement difficulties.
The elephant in the room is financing. As researchers we support the idea of a national health fund that specifically addresses healthcare needs. A percentage of the country tax revenue would be dedicated to health. We believe that this would enable countries to meet the Abuja agreement target of allocating 15% of their national annual budget to healthcare. It would also increase the resilience of health system to manage effectively in periods of health emergency like COVID-19.
Read the original article on Independent (Kampala).
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