Assessment of delay in diagnosis and treatment of multi-drug resistant tuberculosis: magnitude and associated institutional barriers

Abstract

Background: Multi-drug-resistant tuberculosis (MDR-TB) is a serious public health concern in Tanzania. Currently, however, there is a still large gap in management of MDR-TB with respect to detection, laboratory diagnosis and starting treatment. Nonetheless, there has been a substantial increase in the contribution of molecular testing which has reduced the delay in diagnosis dropping to the current 34 days from 269 days in 2013. Yet, TB related mortality attributable to the delay in diagnosis and treatment remains high at an estimated 6.4% (WHO, 2014). Several studies have explored socio-economic and patient related factors that contribute to delays in diagnosis and treatment of MDR-TB. However, little is known on the role of institutional barriers in explaining delays observed in diagnosis and treatment of MDR-TB, particularly in the Tanzanian context.

Objectives: The main objective of this study was to assess the magnitude of MDR-TB diagnosis and treatment delays and associated institutional barriers to diagnosis and treatment.

Methodology: This was a cross sectional study that used both retrospective and explorative designs. Data was obtained by using quantitative and qualitative approaches. On the quantitative part, the MDR-TB patient data was collected from the registers and files kept at KIDH and at CTRL. The qualitative component of the study involved interviewing pre determined health facility superintendents, heads of TB units, laboratory managers and regional TB and Leprosy Coordinators in three regional referral hospitals in Dar es Salaam. Analysis was manually conducted and ethical issues were observed.

Results: The study revealed a serious problem of delay in establishing diagnosis of MDR-TB as well as in initiating treatment to the already confirmed MDR-TB patients. From this study, it was found that 50% (n=192) had their MDR-TB diagnosis delayed. It took an average duration of 94 days (SD = 74.2 days) for the patient to be sent for DST diagnosis and receiving results. When a sample is sent for Gene Xpert diagnosis, the result is obtained after 11 days (SD = 32 days). Moreover, there was late initiation of treatment for 59 % of confirmed MDR-TB patients. The average duration between MDR-TB laboratory diagnosis by using DST method and starting treatment was about 83 days (SD=122 days). But when diagnosis is done by using Gene Xpert method, treatment was found to start after 40 days (SD=34 days). Institutional barriers such as financial difficulties, shortage of staff, poor clinical and laboratory capacity, poor adherence to guidelines and inadequate managerial and coordination efforts have been found to be associated with these delays.

Conclusion: The magnitude of MDR-TB diagnosis and treatment delay in Tanzania is still high in spite of the increasing number of patients who are tested by using different diagnostic methods. The duration from testing and receiving result and starting treatment has not decreased despite adopting modern techniques like Gene Xpert, Hain or LPA.

Recommendation: There is a need of paying attention to the factors contributing to the delays, including those in the healthcare system. That is, interventions targeting late diagnosis and treatment of MDR-TB should take the identified institutional barriers into account.