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Lessening the Tuberculosis Burden in Tanzania

 

Dr. Erica Sanga (MPH) has authored this context analysis on behalf of National Institute for Medical Research (NIMR) – Mbeya Medical Research Centre. She is the community Outreach Coordinator for NIMR Mbeya - Medical Research Centre. She is a public health specialist and her research interests are in Public health and HIV care. She will supporting NIMR- Mbeya Medical Research Centre as the lead qualitative investigator for the Tuberculosis: Working to Empower the Nations’ Diagnostic Effort (TWENDE) study.

Deducing from 2014 country health profiles published by the World Health Organisation (WHO), in July 2013, the United Republic of Tanzania (Tanzania) became one of the first five African countries to complete a national tuberculosis (TB) prevalence survey. The Minister of Health and Social Welfare, Hon. Dr. Hussein Mwinyi, highlighted progress made in TB control in the country, noting  the use of directly observed treatment shorts (DOTS) course for TB, the introduction of fixed dose combination (FDC) and patient centred TB treatment (PCT). The Minister is quoted ) as having said: 

“The prevalence of TB in the country is 295 per 100,000. This shows that TB is still a major burden in the country. Furthermore, results have shown that TB is more prevalent in males than in females and that the prevalence of HIV infection among TB suspects is 4.8 percent and among TB patients is 6.5 percent. This calls for renewed efforts by all to strengthen the current health delivery system and program interventions for tuberculosis in Tanzania.”

WHO in its global TB report for 2015, however, has reviewed the Tanzanian prevalence to 528 per 100,000. Tanzania, therefore, remains among the 22 highest TB burden countries in the world. TB cases notification declined in the past decade to around 61,800 notifications, but increased in 2014 with 63,151 cases, before dropping to 61,827 in 2015. 

The Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS) of 2011/12 estimates HIV prevalence for Tanzania mainland to be 5.1percent. The National Tuberculosis and Leprosy Programme (NTLP) report of 2014 in fact estimates that TB/HIV co-infection has remained at around 36 percent for the last three years. The NTLP report concludes that:   

”The DOTs strategy was probably effective over the past couple of decades to reduce the TB burden as much as possible, in combination with other factors. However, the reduction has currently reached a plateau. Novel case-finding, screening and diagnostic approaches must be now adopted to make further strides in reducing the disease burden." 

In an endeavour to fight TB in three countries in the East Africa Region, a team of experts from academia and research settings in Tanzania, Uganda, Kenya and the United Kingdom  have joined efforts under the project titled: Tuberculosis: Working to Empower the Nations’ Diagnostic Effort;  abbreviated as TWENDE.  This consortium of seven institutions includes: National Institute for Medical Research (NIMR)-Mbeya Medical Research Centre; Kilimanjaro Clinical Research Institute in Tanzania, Makerere University Kampala (MUK) and CPAR Uganda Ltd from Uganda; Kenya Medical Research Institute (KEMRI), Kenya; University of St. Andrews, Scotland, United Kingdom and the East African Health Research Commission (EAHRC) of the East African Community. 

The TWENDE consortium has been awarded grant funding by the European Union through the European & Developing Countries Clinical Trials Partnership (EDCTP) to conduct research on TB in Tanzania, Kenya and Uganda. TWENDE will:

• Evaluate the extent of the implementation of two WHO approved molecular diagnostics and explore how to implement the rapid MYcobacterial Treatment Response Assay (MYTRA) developed by the University of St Andrews.

• Assess the benefits of these methods to health care staff and to the health care system and gauge the attitude of administrators to the funding of these tests.

• Seek both local and international avenues to unravel the impediments to a wider uptake of effective TB diagnostics

• Engage policy makers to accelerate the uptake of research innovations 

• Build capacity by offering expert advice on policy formulation as well as equipping and training knowledge transfer officers and regional user groups (clinicians and laboratory technologists), in order to sustain the translation of research output to the public domain. 

The impact of this study is expected to be far-reaching, with findings applicable not only to TB but to the entire health care system in the country.  In the southern part of Tanzania TWENDE will research in five regions. According to the Tanzania Bureau of Statistics (TBOS)  the the southern part of Tanzania has a total area of 492,690 square kilometres and it consists of 12 Regions as follows: Dodoma, Mbeya, Sumbawanga, Katavi, Iringa, Morogoro, Njombe, Songea, Mtwara, Lindi, Pwani and Dar-es-Salaam.  

TBOS estimates that Southern Tanzania has a population of 19,197,596 people. The inter linkages between components of population such as age, structural composition, density, distribution and its characteristics must be considered in the context of sustainable development and human wellbeing. The complex relationship between economic transformation and demographic transition need multisectorial efforts in successfully reducing disease burdens. 

Dr. Nyanda Elias Ntinginya and Dr. Leonard Maboko, both of the National Institute for Medical Research – Mbeya Medical Research Centre, will coordinate the implementation of this project in Southern Tanzania. Data will be collected in five selected regions namely: Mbeya, Rukwa, Dar es Salaam, Mtwara and Dodoma.  These regions have 32 districts in total. The TWENDE study, however, will be conducted in 15 districts (rural and urban) of the 32 districts of Southern Tanzania due to logistical and funding issues. The districts in this part are having relatively similar TB diagnostic infrastructure and data gathered are expected to be representative for urban and rural settings.  Under the leadership of Dr. Nyanda and Dr. Maboko, a team of researchers at the NIMR-Mbeya Medical Research Centre will collect data under the TWENDE project as follows: 

Quantitative data shall be collected through a survey of District TB coordinators and Lab coordinators in all districts in Southern Tanzania. And in-depth field audits of 17 health care facilities shall be conducted as follows: Seven in Mbeya Region, four in Rukwa Region , three in Mtwara Region and three in  Dar es salaam Region.  

In order to generate qualitative data in Southern Tanzania the NIMR-Mbeya Medical Research Centre team shall conduct 15 in-depth interviews with lab managers, lab technicians, local community leaders and former TB patients.  In addition, four FGD will be conducted, one in each research region - Mbeya, Dar es salaam, Rukwa and Dodoma; each FGD shall comprise an estimated 12 persons, making 48 respondents participate in FGDs. The participants in FGDs shall include:  District Health officers, TB coordinators, Laboratory technician and DOTS nurses in the 12 selected health facilities in the 15 districts. 

TWENDE is expected to contribute to what is known and unknown about TB diagnostics uptake in the country for implementation and policymaking, thus lessening the burden of TB in Tanzania. Policy makers will be engaged through invitation in various fora prepared at different levels of the project implementation by the TWENDE team in Tanzania including the Southern part.  The impact of this study is expected to be far-reaching, with findings applicable not only to TB but to the entire health care system in the country.