A pilot community programme to improve TB detection in northern Tanzania has shown good results and could be replicated nationwide as the country seeks to improve its TB treatment and prevention systems.
Tanzania has been battling TB for years, a struggle intensified by the parallel HIV epidemic; approximately 47 percent of new adult cases in the country are HIV-positive. Without proper treatment, about nine in 10 people living with HIV who become ill with active TB will die within two to three months, according to UNAIDS.
The programme, which ran from April to September 2011, systemized the way suspected TB cases were reported and handled. It encouraged healthcare professionals to work closely with community leaders to raise awareness of symptoms at every opportunity, such as at village meetings. It also used posters and slogans to make sure high-risk groups were aware of symptoms. This produced more patient referrals to health centres for diagnosis, treatment and follow-up care.
Another crucial part of the TB pilot project was the creation of a "cough register" in each area, recording who was referred to a healthcare professional for further testing, by whom and the results of that referral.
Management Science for Health collaborated with the NGO, PATH, and the National Tuberculosis and Leprosy Programme, with financial support from the US Agency for International Development, at 12 health facilities in northern Tanzania's Arusha and Meru district councils. A crucial tenet of the programme was emphasising that TB and HIV treatment must be done "hand in hand".
"In both districts the standard operating procedure intervention has improved TB case notification in children and women," said Zahra Mkome, director, TB/HIV projects at PATH in Tanzania. "[It] improved team work, commitment, motivation of healthcare workers, awareness and involvement of communities in TB control activities."
An evaluation comparing six months of TB case notification before and after the project showed a 54 percent increase in detection of TB in all forms in Meru, while in Arusha it increased by 117 percent.
The standard operating procedure “rules” were used to provide clear and simple instructions to the health workers on how to improve TB case detection at different units and sections within health facilities, both outpatient and inpatient departments. Each area was provided with a plan and goals to implement their strategy, plus additional equipment to aid diagnosis such as paediatric score charts. Each area appointed a task force for TB treatment and these groups were encouraged to hold regular feedback meetings.
Little data exists on the scale of the TB epidemic in Tanzania, and experts believe the records created by this system could prove a crucial tool in combating its spread and establishing where it is already most prevalent.
One doctor based in a rural practice was particularly encouraged by the increased reporting of paediatric cases. He said some children suffering severe respiratory distress had been saved, "who in normal circumstances would have died". A number of the clinicians involved attributed an increase in notification of cases in the under-16 age group specifically to the wider use of paediatric diagnostic score charts.
However, several challenges were flagged during the pilot: healthcare workers at Arusha's Selian Hospital said there was an urgent need to strengthen laboratory services to help confirm diagnoses; a lack of microscopes in labs and delays in issuing results were also highlighted.
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Challenges to scale-up
Rolling out the rules on a national scale could also prove challenging as the majority of Tanzanians live in very rural areas and a poor road network means access to healthcare is limited.
Mobile diagnosis and training centres that offer new methods of testing - for example, with the use of fluorescence microscopes - could make diagnosis much faster and more accurate.
"Patients in Tanzania often have to travel very long distances as most live in rural areas, which costs them money to travel every day and some are essentially too week to go on their own as a very large number are already suffering from the weakness that comes with HIV," said Alex Schulzer of the Novartis Foundation for Sustainable Development, which runs patient-centred TB programmes with the government.
A shortage of medical professionals could also hinder the expansion of the programme; Schulzer recommended the use of lower cadre health workers and the community itself to fill gaps. The Novartis programme gives patients the choice to either take the daily treatment at a health facility under the supervision of a medical professional, or at home, supported by a family or community member. In the case of home-based treatment, the patient and treatment supporter are required to visit the health facility once a week during the two-month intensive phase to refill prescriptions and see a medical professional.
Schulzer said the programme had created a system that gave patients "the freedom not to have to walk miles to the clinic every day.
"We also needed to relieve some of the healthcare providers who cannot cope with such large patient numbers on a daily basis," he added.