Eligible but not tested: Missed Opportunities for TB Diagnosis Using GeneXpert MTB/RIF Assay in Health Centre IIIs, IVs and Hospitals in Tororo and Busia Districts in Uganda

Abstract

Background: Missed opportunities for TB diagnosis are associated with TB-related morbidity, mortality and continued transmission due to delayed or no treatment. GeneXpert is superior to the more common TB diagnostic tests in Uganda. However, at TASO Tororo, which had physical access to GeneXpert testing, only 33.3% of Xpert-eligible adult clients, and none of the eligible children (0%) got tested by GeneXpert during the quarter October to December 2014. In 2015, the National TB prevalence survey revealed that about 41,000 cases of TB go undiagnosed annually. Even to this day, the challenge of underutilization of GeneXpert technology still exists in Uganda.

Objective: To determine the level of missed opportunities for TB diagnosis using GeneXpert assay for eligible persons and associated factors in higher level health facilities in Tororo and Busia districts.

Methods: A cross-sectional study with a mixed methods concurrent convergent approach was conducted for the period October-December 2014. Seventeen (17) TB diagnostic and treatment units in Tororo and Busia districts were studied. St. Anthony’s Hospital- Tororo was the testing hub. Three hundred and forty-two (342) patient records were reviewed using a health facility data abstraction form and entered into Microsoft Excel 2013 to study the level of missed opportunities for GeneXpert testing and associated patient factors (age, sex, eligibility by patient type and sample provision). A structured questionnaire was administered to 115 health workers and data entered into Epi-Info 3.5.1 to assess their knowledge, attitudes and practices. Two (2) voice-recorded structured key informant interviews of the laboratory in-charge at the hub and the hub rider were conducted, transcribed and coded for qualitative thematic analysis to determine health system (charging patients, working on weekends and holidays, hub functionality) and technical factors like machine calibration and power stabilization. Quantitative data was analyzed in Stata 14 at univariate, bivariate and multivariate levels. Frequencies, proportions, levels of significance and measures of association between different factors and the outcome of missed opportunities for GeneXpert testing were determined. Chi-squared test was used for bivariate analysis at a significance level of p=0.05 and 95% confidence interval. Modified Poisson and Multiple logistic regression were used for multivariate analysis. Logical model building was used to adjust for confounders.

Results: Of the 342 eligible patients, 181 missed opportunities for GeneXpert testing (52.9%) were observed. After adjusting for confounders, statistical significance was shown with health workers having attended Continuing Medical Education (CME) [Adjusted OR=10.60, (95% CI 2.99 – 37.54), p≤0.001], knowing the frequency of sample pick-up by the hub rider [Adjusted OR=7.95, (95% CI 1.73 – 36.64), p=0.008] and acquiring knowledge from peers about GeneXpert testing [Adjusted OR=0.11, (95% CI 0.02 – 0.53), p=0.006]. Availability of HIV testing kits and HIV testing were important for GeneXpert utilization for TB diagnosis. Health worker attitudes to GeneXpert testing were positive with 92.9% of laboratory staff (n=28) and 74.8% (n=115) of all staff [Adjusted OR=1.27 95% CI 0.29 – 5.46, p=0.750] comfortable handling TB samples.

Conclusion and Recommendation: We conclude that in-house CMEs involving all cadres, notification of health workers about the frequency of sample pick up by the hub rider, access to GeneXpert testing even on weekends and holidays and availability of logistics were important factors associated with utilization of GeneXpert testing in Tororo and Busia. More research needs to be conducted in the area of GeneXpert utilization in Uganda and globally.