Gridlock from diagnosis to treatment of multidrug-resistant tuberculosis in Tanzania: low accessibility of molecular diagnostic services and lack of healthcare worker empowerment in 28 districts of 5 high burden TB regions with mixed methods evaluation

• Published in: BMC public health 2019-04, Vol.19 (1), p.395-395, Article 395
• Main Authors: Mpagama, Stellah G, Mbelele, Peter M, Chongolo, Anna M, Lekule, Isaack A, Lyimo, Johnson J, Kibiki, Gibson S, Heysell, Scott K
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; Adult; AIDS; AIDS (Disease); Antitubercular Agents - therapeutic use; Care and treatment; Clinical outcomes; Clinics; Delay; Diagnosis; Diagnostic systems; Districts; Drug resistance; Drugs; Empowerment; Female; Health aspects; Health care; Health care industry; Health care policy; Health care workers; Health Personnel - psychology; Health services; Health Services Accessibility - statistics & numerical data; HIV; HIV infections; HIV tests; Human immunodeficiency virus; Human immunodeficiency virus (HIV); Humans; Immunodeficiency; Implementation barriers; Laboratories; Leprosy; Male; Medical care utilization; Medical diagnosis; Medical personnel; Medical tests; Medical treatment; Microbial drug resistance; Microbial Sensitivity Tests - statistics & numerical data; Middle Aged; Mixed methods research; Molecular diagnostics, Health Systems; Multidrug resistance; Multidrug resistant organisms; Multidrug resistant tuberculosis (MDR-TB); Mycobacterium tuberculosis; Pathology, Molecular - statistics & numerical data; Patients; Population; Power, Psychological; Public health; Regions; Risk groups; Studies; Tanzania; Time-to-Treatment - statistics & numerical data; Tuberculosis; Tuberculosis, Multidrug-Resistant - diagnosis; Tuberculosis, Multidrug-Resistant - drug therapy; Workers
• ISSN: 1471-2458; 1471-2458
• DOI: 10.1186/s12889-019-6720-6

Multidrug-resistant tuberculosis (MDR-TB) outcomes are adversely impacted by delay in diagnosis and treatment. Mixed qualitative and quantitative approaches were utilized to identify healthcare system related barriers to implementation of molecular diagnostics for MDR-TB. Randomly sampled districts from the 5 highest TB burden regions were enrolled during the 4th quarter of 2016. District TB & Leprosy Coordinators (DTLCs), and District AIDS Coordinators (DACs) were interviewed, along with staff from all laboratories within the selected districts where molecular diagnostics tests for MDR-TB were performed. Furthermore, the 2015 registers were audited for all drug-susceptible but retreatment TB cases and TB collaborative practices in HIV clinics, as these patients were in principal targeted for drug susceptibility testing by rapid molecular diagnostics. Twenty-eight TB districts from the 5 regions had 399 patients reviewed for retreatment with a drug-susceptible regimen. Only 160 (40%) had specimens collected for drug-susceptibility testing, and of those specimens only 120 (75%) had results communicated back to the clinic. MDR-TB was diagnosed in 16 (13.3%) of the 120 specimens but only 12 total patients were ultimately referred for treatment. Furthermore, among the HIV/AIDS clinics served in 2015, the median number of clients with TB diagnosis was 92 cases [IQR 32-157] yet only 2 people living with HIV were diagnosed with MDR-TB throughout the surveyed districts. Furthermore, the districts generated 53 front-line healthcare workers for interviews. DTLCs with intermediate or no knowledge on the clinical application of XpertMTB/RIF were 3 (11%), and 10 (39%), and DACs with intermediate or no knowledge were 0 (0%) and 2 (8%) respectively (p = 0.02). Additionally, 11 (100%) of the laboratories surveyed had only the 4-module XpertMTB/RIF equipment. The median time that XpertMTB/RIF was not functional in the 12 months prior to the investigation was 2 months (IQR 1-4). Underutilization of molecular diagnostics in high-risk groups was a function of a lack of front-line healthcare workforce empowerment and training, and a lack of equipment access, which likely contributed to the observed delay in MDR-TB diagnosis in Tanzania.