The effect of Scale up of TB-DOTS Services on Case Detections and Treatment success rates in Central Uganda.

By Denis Kaffoko,(MSC.DE,B.STAT,PCGME)

• Overview • Background • Methods • Results • Conclusion • Recommendation

Outline

Acronyms

• CB DOTS :Community Based Directly Observed Treatment • CDR • DOTS • TSR • MDR Case Detection Rate Directly Observed Treatment Treatment Success Rate Multi Drug Resistance

Background: According to 2012/2013 ASPR , •TB Treatment Success Rate increased from 71.1% in 2011/12 to 79% in 2012/13.

•DOTS coverage increased from 47% in 2011/12 to 55% in 2012/13.

•And in 2008,Uganda had one of the highest new cases with the new case detection rate at 1.12 per 100,000 of population and about 8 percent of new cases were children under 15 years of age, (WHO Global TB Report,2008).

Background cont’d • In the same period, WHO-recommended a treatment strategy for detection and treatment of TB called "Directly Observed Treatment, Short-course" (DOTS) which combines five elements: – Political commitment, – Microscopy services, – Drug supplies, – Surveillance and monitoring systems – Use of highly efficacious regimes with direct observation of treatment.

Background Cont’d • Amref Health Africa’s Mission is to improve the health of people in Africa by partnering with and empowering communities, and strengthening health systems.

• Amref Health Africa in Uganda between 2007 – 2012, supported three district health offices to scale up TB case detection, treatment and control through the TB REACH Project using the DOTS strategy as recommended by WHO.

Background Cont’d Description of the Intervention • TB REACH was a 3 year project which started in2008 and had some of the following activities ; » Supply of essential drugs » Community mobilization and awareness creation about DOTs » Capacity building stakeholders through trainings of various » Strengthening of the referral system » Strengthening of the Microscopy services through equipping Laboratories with essential materials and Medicines

Purpose of Study • The study was to establish the effect of the scale for TB-DOTS strategy on case detection rates and treatment success rate for the central region in Uganda.

Objectives of the study: • To establish the coverage of DOTS and the understanding of the benefits in regards to improving treatment success rates in the community • To establish the effect of CB-DOTS strategy on improving Case Detection Rates and Treat Success Rates in Central Region of Uganda.

Method:

Study area:

The study was conducted in the 3 districts(Kiboga, Wakiso and Luwero) where the TB REACH project had been implemented and Nakaseke district as the control district

Research Design:

• The study used a cross-sectional survey design both at Baseline and End line ,using qualitative and quantitative methods of data collection were used together with retrospective design on the TB clients .

Method cont’d:

Sampling Design:

• Multi stage sampling was used as follows; • Purposive sampling to select districts of the study, Sub Counties, Parishes and Health Facilities • Simple random sampling was used to select Households, Health facilities and Key Informants.

•

Sample size determination:

The study calculated the sample size for the Households using Keish & Leslie, 1996

Sample Unit

Households 1034 Health Units 35

N

TB Patients 211 VHT Community Leaders Health Workers 350 153 139

Sampling Framework n Intervention Districts Control Distrist

160 15 120 12 40 3 32 32 32 48 25 25 25 44 7 7 7 4

Data collection methods

Structured questionnaire

: – Household heads, TB patients and Expert clients •

Key informant interview guide:

– Health units, VHTs , community leaders , teachers ,health workers were selected •

Desk Reviews:

– Health facility records which included NTLP Register • Data Analysis on raw data was done using SPSS and secondary data was done in Excel

%age coverage of CB-DOTs by districts and year between 2008 - 2012 35% 30% 25% 20% 15% 10% 5% 0% Intervention Area Non Intervention Area 2008 5% 2% 2009 18% 3% 2010 19% 2% 2011 22% 0% 2012 29% 0%

The Effect of CB-DOTS strategy on CDR and TSR in Central Uganda CDR TSR 100,00% 90,00% 80,00% 70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% 2008 2012 Kiboga district 2008 2012 Luwero district Intervention Districts 2008 2012 Wakiso district 2008 2012 Nakaseke district Control District

The Proportion of various stakeholder who reported adequacy of support for scale up of CB-DOTS strategy to improve CDR and TSR Household heads TB patients VHTs 80,00% 70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% Wakiso Luwero Intervention Districts

Implementation area

Kiboga Nakaseke Control District

Conclusion:

Overall, the Scale up of TB-DOTS Services Contributed to improving; – The CDR from an average of 58% in 2008 to and average of 62% in 2012 – TSR from an average of 71% in 2008 to an average of 75% in 2012 slightly below the national TSR of 79% in the implementation area of TB reach in Central Uganda.

• The CB DOTS coverage improved from an average of 10% 2008 to an average of 70% in 2012 higher than the national target of 55% in the implementation

Conclusion cont’d • The control district the level of awareness was noticeably low as compared to districts where the project was implemented.

• The poorly performing districts were faced with challenges of severe drug stock outs, low staffing levels and absenteeism, the low capacity of some health units to detect and treat TB.

Recommendations

• Strengthen the drug and other logistics supply to communities and health facilities.

• Facilitate VHTs and community health workers to Monitor and track TB patients • Palliative care needs to be strengthened through the integrated Community-Family Based DOTS initiative suggested.

• There is still need to have an effective outreach programmes in communities that would raise awareness and change peoples’ attitudes towards Tuberculosis which is presently highly stigmatized.

THANK YOU