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Control of tuberculosis is costly, but necessary

By Prof. Blandina Theophile Mmbaga (right – participating the TWENDE Knowledge Transfer workshop) and Ms. Norah Owaraga.

“It is very expensive to be poor.” This observation by Mwalimu Julius Nyerere (RIP) is perhaps even more poignant today in the context of the tuberculosis (TB) scourge within East Africa – at regional, country and individual household levels. Poverty indeed sustains TB 

Control of TB requires proper diagnosis and treatment among other public health interventions. The gold standard for diagnosis of TB for many years, since the 18th century, and which is still the most accessible in TB high incidence countries, is the Sputum Smear Microscopy. However its sensitivity is below 80 percent. 

There are other tests such as TB Culture, but these too come with challenges of low detection limits, are prone to contamination and have huge turn-around-time (six to eight weeks depending on the type of culture medium used). 

Molecular tests, such as those that have been approved by the World Health Organisation (WHO), for example the Xpert MTB/RIF, are highly sensitive and give more specific results. They have a short turn-around-time; are less prone to contamination; can detect both Mycobacterium TB from clinical specimen and can predict their susceptibility to anti-TB drugs.

Nevertheless, there are challenges in implementation of molecular testing too. A major challenge originates from the patients. Molecular testing requires a sputum specimen. Some patients, sadly, are not able to produce quality sputum specimens in terms of quantity and quality. This is particularly the case among people that are living with HIV or are afflicted with AIDS.

Arguably, however, the greater challenges that come with molecular testing include the insufficient in-country availability of personnel within East African countries that have the requisite qualifications to perform the tests and to properly interpret the test results. 

Molecular tests require skilled personnel - those possessing that which is beyond ordinary technical education; and such skilled personnel are mostly rare within East Africa. There is often insufficient capacity within countries of East Africa of the requisite expertise for maintenance and servicing of the diagnostic machines, as well.

In addition, molecular testing tools require specialised infrastructure – laboratories that are well equipped and that have uninterrupted power supply, cold storage facilities and the like. Add to this the fact that for most countries in East Africa the necessary equipment and materials have to be imported, likely from the global-west, thus increasing costs, irrespective of them being subsidized by the Foundation for Innovative New Diagnostics (FIND).

Once the cost of buying the equipment and materials is overcome, the cost of transporting the equipment and materials is another challenge to overcome. Most of the reagents required to run the tests are procured from overseas. When they are imported into a Country they are further confronted with the bureaucracies of customs and medical clearance, and the like.

Due to the nature of molecular tests which demand specialised infrastructure and equipment the tests are invariably costly and consequently are not readily available at primary health care facilities where they are need the most. In most cases, the testing facilities are thus located at higher level and more central locations – such as regional or national referral health care facilities that service much wider geographies.

  • How might the three East African countries of Tanzania, Kenya and Uganda and the individual households of their respective citizens manage the cost of TB control in their respective countries? 
  • How might they ameliorate some or all the challenges that are currently associated with molecular diagnostics in order to make them more available and accessible? 
  • How might they innovate in order to ensure sufficient financial budgetary allocations of their domestic resources are allocated to TB control? 
  • How might they better manage and utilise resources from external funding sources – including direct budget support and or project support – to reach wider, while at the same time ensuring sustainability post donor support? 

These are a few among many such questions that need to be asked and answered in order for East Africa to make significant headway in its fight against TB. The European & Developing Countries Clinical Trials Partnership (EDCTP)  funded project: Tuberculosis: Working to Empower Nations’ Diagnostic Efforts (TWENDE) aspires to do exactly that.

This is a summary of the presentation that Prof. Mmbaga made during the TWENDE Launch Conference on 1st July 2016 at the Nelson Mandela Institute of Science and Technology in Arusha in Tanzania. Prof. Mmbaga is the site Principal Investigator for TWENDE for Northern Tanzania, while Ms. Owaraga, who translated and summarised Prof. Mmbaga’s presentation is the Lead Social Scientist for TWENDE. Read more about the TWENDE Lead Researchers here