Evaluation of the postal service for referral of specimen of drug resistance tuberculosis in Amhara region, Ethiopia; mixed method

BACKGROUND

In Ethiopia, specimens of presumptive drug resistant tuberculosis cases are transported by courier system from district sample collection centers to reference laboratories. It is essential to track the effectiveness of the referral system and identify challenges in order to take timely and appropriate actions. We assessed turnaround time and quality of specimens, and explored challenges of the specimen referral system in Amhara region, Ethiopia, 2017.

METHODS

With mixed methods, we retrospectively examined 385 randomly selected presumptive drug resistance TB specimens, and interviewed 53 purposively selected key informants from laboratories and post offices. We calculated median TAT and proportion of acceptable quality. We analyzed qualitative data thematically.

RESULTS

Of the 385 specimens, 94.5% (364/385) had acceptable quality at arrival in the reference laboratories. All the 364 specimens had result. Three - fourth (76.1%) of results were dispatched to the referring health facilities within the recommended turnaround time. Ineffective communication and lack of feedback among institutions were mentioned as challenges.

CONCLUSION

The postal service was effective in keeping quality and majority of test results were timely delivered. Yet, there were operational challenges. Therefore, effective communication, using dedicated vehicle for specimen shipment and awareness creation on specimen collection and handling are recommended.

Modeling the patient and health system impacts of alternative xpert® MTB/RIF algorithms for the diagnosis of pulmonary tuberculosis in Addis Ababa, Ethiopia

Background

To reduce global tuberculosis (TB) burden, the active disease must be diagnosed quickly and accurately and patients should be treated and cured. In Ethiopia, TB diagnosis mainly relies on spot-morning-spot (SMS) sputum sample smear analysis using Ziehl-Neelsen staining techniques (ZN). Since 2014 targeted use of xpert has been implemented. New diagnostic techniques have higher sensitivity and are likely to detect more cases if routinely implemented. The objective of our study was to project the effects of alternative diagnostic algorithms on the patient, health system, and costs, and identify cost-effective algorithms that increase TB case detection in Addis Ababa, Ethiopia.

Methods

An observational quantitative modeling framework was applied using the Virtual Implementation approach. The model was designed to represent the operational and epidemiological context of Addis Ababa, the capital city of Ethiopia. We compared eight diagnostic algorithm with ZN microscopy, light emitting diode (LED) fluorescence microscopy and Xpert MTB/RIF. Interventions with an annualized cost per averted disability adjusted life year (DALY) of less than the Gross Domestic Product (GDP) per capita are considered cost-effective interventions.

Results

With a cost lower than the average per-capita GDP (US$690 for Ethiopia) for each averted disability adjusted life year (DALY), three of the modeled algorithms are cost-effective. Implementing them would have important patient, health system, and population-level effects in the context of Addis Ababa

❖ The full roll-out of Xpert MTB/RIF as the primary test for all presumptive TB cases would avert 91170 DALYs (95% credible interval [CrI] 54888 – 127448) with an additional health system cost of US$ 11.6 million over the next 10 years. The incremental cost-effectiveness ratio (ICER) is $370 per DALY averted.

❖ Same day LED fluorescence microscopy for all presumptive TB cases combined with Xpert MTB/RIF targeted to HIV-positive and High multidrug resistant (MDR) risk groups would avert 73600 DALYs( 95% CrI 48373 - 99214) with an additional cost of US$5.1 million over the next 10 years. The ICER is $169per DALY averted.

❖ Same-day LED fluorescence microscopy for all presumptive TB cases (and no Xpert MTB/RIF) would avert 43580 DALYs with a reduction cost of US$ 0.2 million over the next 10years. The ICER is $13 per DALY averted.

Conclusions

The full roll-out of Xpert MTB/RIF is predicted to be the best option to substantially reduce the TB burden in Addis Ababa and is considered cost effective. However, the investment cost to implement this is far beyond the budget of the national TB control program. Targeted use of Xpert MTB/RIF for HIV positive and high MDR risk groups with same-day LED fluorescence microscopy for all other presumptive TB cases is an affordable alternative.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2417-6) contains supplementary material, which is available to authorized users.

Assessment of national tuberculosis and HIV collaborative program implementation status in health care settings of Ethiopia

BACKGROUND

Ethiopia has adopted the World Health Organization recommendation for TB and HIV collaborative activities since 2004. These collaborative activities have been scaled up in a phased manner and covered large number of health facilities across the nation. However, there is scarcity of information on implementation of these collaborative activities in Ethiopia.

OBJECTIVE

To assess the status of implementation of TB and HIV collaborative activities in health facility settings of Ethiopia.

METHODS

A cross sectional study mainly quantitative supplemented by qualitative methods was undertaken from May 10 to July 10, 2014 in 132 selected health facilities. Statistical analysis was performed using SPSS version 20.

RESULT

About 81% of the respondents in the selected health facilities reported the screening of People Living with HIV in care for TB at every follow up visit, whereas, only 28.7% of those health facilities reported the screening of PLWHIV for TB at enrolment to HIV chronic care. About half of the public health facilities assessed were not implementing Isoniazid Preventive Therapy and only 18.2% of eligible clients were getting this Preventive Therapy. Among the co-infected patients, 32% were not linked to chronic care services and 45.3% were not getting ART during TB treatment. On the other hand, about two thirds of the co-infected patients are getting the Cotrimoxazole Prophylaxis Therapy.

CONCLUSION

Most of anti-TB and HIV collaborative activities were not implemented as expected in the health facilities. Thus it needs integration from the ministry to the health facilities level in order to improve the collaborative activities.

The Ethiopian initiative to build sustainable capacity for operational research: overview and lessons learned

SETTING

Programme-based operational research is instrumental for the enhancement of tuberculosis (TB) control. In 2012, the Ethiopian Federal Ministry of Health launched an initiative for capacity building in operational research (OR).

OBJECTIVE

To develop sustainable capacity for OR in Ethiopia in a multiyear initiative.

DESIGN

The initiative was developed in collaboration with regional, national and international experts. Teams representing regions in Ethiopia conducted OR addressing national and regional priorities. To make use of local expertise and increase sustainability, a domestic mentor training programme was included. Existing capacity was enhanced through a competitive grant scheme providing TB researchers with financial and technical support. The Ethiopian Tuberculosis Research Advisory Committee was also supported in its functions. Regional ethics review bodies were strengthened or established where they did not exist.

RESULTS

Fifty-two people were trained and conducted 13 OR projects, of which six have been published to date. In addition, eight protocols were supported through grants. Ethics review bodies were strengthened in all regions.

CONCLUSION

The initiative trained participants from all regions and succeeded in the completion of all stages of the OR process. The success of the programme can be attributed to the team approach, 'learning while doing', integrated mentorship programme and strong national ownership.

Assessment of Directly Observed Therapy (DOT) following tuberculosis regimen change in Addis Ababa, Ethiopia: a qualitative study

Background

Tuberculosis remains a major public health problem in Ethiopia. In 2010 the TB treatment regimen was shortened from 8 to 6-months treatment. With this new regimen, the full course of treatment should be taken under Directly Observed Therapy (DOT) unlike the 8-month regimen where TB patients were only observed during the intensive phase, this has not been tried before and may be difficult to implement. Therefore this study aimed to investigate the experiences from both TB patients and health care providers’ perspective of implementing DOT for the full course of TB treatment.

Methods

Qualitative study consisted of 11 in-depth interviews and 4 Focus Group Discussions (FDGs) were conducted between March and April, 2014. Overall, 18 TB patients and 16 HCPs were involved from three selected public health facilities (2 Health Centers and 1 Hospital) in Addis Ababa, Ethiopia. Qualitative data analysis software (Open Code Version 3.5) was employed to identify the key issues from these interviews through coding, categorization and grouping into emergent themes.

Results

Participants reported that making a daily visit to health facilities for DOT was difficult due to the distance of the facilities from their residences, lack of or high transportation cost and had undesired implications on their work and social lives. TB patients had to overcome many challenges to comply with TB treatment on a daily basis. HCPs also indicated the difficulties of implementing facility based daily DOT mainly due the implication it had on their TB patients and stated DOT had not always been implemented for the full course as recommended. HCPs also shared deep concern regarding the risk of acquiring multiple drug resistant TB.

Conclusion

This study indicated there are several challenges associated with facility based daily DOT as a method of TB treatment supervision in public health facilities in Addis Ababa. This may be indicative of the situation in other health facilities in Addis Ababa as well as elsewhere in the country. Hence the TB control program has to explore how best to improve TB treatment delivery options to ensure adequate treatment. A more patient-centered approach could be strengthened by further decentralizing the DOT to the community level in order to ensure adherence of patients to their TB treatment.

Ambulatory care for multidrug-resistant tuberculosis: lessons learned in Addis Ababa, Ethiopia

SETTING

Ethiopia is one of the high multidrug-resistant tuberculosis (MDR-TB) burden countries. Efforts by the National TB Programme to control MDR-TB include expanding ambulatory care.

OBJECTIVE

To investigate the opportunities and challenges faced by treatment follow-up health centres (TFCs) when managing MDR-TB patients, with greater focus on recording, TB infection control (IC) and supervision practices.

METHODS

A facility-based cross-sectional study was conducted by reviewing the records of all MDR-TB cases in all 25 TFCs in Addis Ababa, Ethiopia. The TB focal point, pharmacy and laboratory heads were also interviewed.

RESULT

A total of 221 MDR-TB patients were registered; 157 (71%) patients had been referred from one of the two treatment initiating centres. While some TFCs oversaw up to 41 patients, others had just one patient. The majority of the TFCs (n = 21, 84%) followed standardised TB IC procedures. Poor documentation of patient information was observed at all sites; for example, human immunodeficiency virus and current treatment status was not indicated for respectively 86 (38%) and 41 (18%) patients.

CONCLUSION

The study revealed that infection prevention practices were largely adhered to. Documentation of patient-related information was a major challenge, and regular supervision of the TFCs should be emphasised. Record keeping is critical.

A qualitative assessment of challenges to tuberculosis management and prevention in Northern Ethiopia

OBJECTIVE

To elicit Ethiopian health care providers' understanding of challenges to effectively preventing, diagnosing and treating tuberculosis (TB).

DESIGN

Qualitative data were collected via in-depth interviews and focus group discussions with 73 providers, including physicians, nurses, pharmacists and laboratory technicians, in five hospitals in the Northern Ethiopian regions of Amhara and Tigray. There was no intervention.

RESULTS

Focus groups and interviews shared a number of prominent common themes. Respondents identified numerous challenges associated with active case identification, infection control practices, diagnostics, including the absence of TB culture and drug susceptibility testing capacity, and the lack of infrastructure for diagnosing and treating multidrug-resistant TB. Pharmacists noted a need for improved procurement practices and pediatric dosages for TB medications. Providers shared concerns regarding isoniazid preventive therapy, health workforce challenges and the risk of contracting TB in the workplace.

CONCLUSIONS

Health care providers in the Northern Ethiopian regions of Tigray and Amhara identified many challenges to effectively preventing, diagnosing and treating TB. These challenges are complicated by severe resource constraints and challenges in attracting and retaining providers in government hospitals in centers outside Addis Ababa.