title: Creating an Effective Routine Surveillance System for Drug-Resistant Tuberculosis Among Previously Treated Patients in Tanzania
Creators: name: Doulla, Basra
Publisher: name: University of Liverpool Repository
Year: 2021

description: Creating an Effective Routine Surveillance System for Drug-Resistant Tuberculosis Among Previously Treated Patients in Tanzania. Introduction: Tuberculosis routine surveillance is an essential tool for scrutinising the effectiveness of TB Programmes and especially for monitoring drug resistance. This study sought to understand the effectiveness of the existing Routine Surveillance System for drug-resistant Tuberculosis amongst previously treated TB patients in Tanzania, identify weaknesses and interventions leading to improvements, and then pilot these interventions. Methods: Both quantitative and qualitative methods were used to gather the current Routine Surveillance System information among previously treated tuberculosis patients. Quantitative data were collected from the routine laboratory databases over a three-year period (2011-2013). Qualitative data were collected using key informant interviews and focus group discussions. Based on the results, an intervention to improve the Routine Surveillance System was designed and a pilot study was implemented in the Mwanza region. The intervention considered the implementation of rapid molecular techniques such as Xpert MTB/RIF and Line Probe Assay at the Central Tuberculosis Reference Laboratory. Revised communication measures and request form completion strategies were also included. A further qualitative study was undertaken for comparison after implementation. Results: The initial quantitative analysis showed that, over the surveyed period, 2,750 specimens were received at the reference laboratory from across the country. This was only 32% of the anticipated numbers, although it reached 61% in 2013. The median and interquartile ranges of turnaround times for microscopy, culture and drug sensitivity testing were: 1(1, 1), 61(43, 71) and 129(72, 170) days respectively. Contamination was evident in both culture and susceptibility testing. The qualitative analysis showed a mixed picture; the system of sending specimens via post was seen to be efficient, though many challenges were noted, in particular: inadequate supplies, poor completion of forms, staff shortages and demotivation. Delays in the transportation of specimens were associated with inadequate funding, training and poor supervision. A revised routine surveillance system for drug-resistant tuberculosis amongst previously treated tuberculosis patients in Tanzania was designed to address many of the identified shortfalls. The revised system, piloted in Mwanza, increased the volume of specimens received from 75 in 2016 to 185 in 2017. The system reduced the time it took for specimens to reach the reference laboratory by 22% (from 9 to 7 days). The median time for results getting back to the requesters was shortened by 36% (from 11 to 7 days). Overall, the number of drug resistant cases increased by 67% (from 12 to 20). In the qualitative analysis undertaken following the pilot, stakeholders identified earlier diagnosis, timely feedback of results, strengthened communication and reliable specimen transportation arrangements as key gains. Conclusion: The routine surveillance system is critical to the effectiveness of the Tuberculosis Programme in Tanzania. The existing routine surveillance policy was poorly executed and lacked new technology, which led to long delays, specimen inertness, discontentment and compromised patient care. A revised routine surveillance system can overcome these weaknesses and increase MDR-TB detection. These lessons are highly relevant to other resource-limited settings, including elsewhere in sub-Saharan Africa.