Performance of the tuberculosis specimen referral system in the South Western TB zone of Uganda
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Background: Multidrug resistant tuberculosis (MDR-TB) stands at 12.5% in Uganda among the retreatment TB cases. In an effort to accelerate the WHO-recommended MDR-TB diagnosis and surveillance, the Uganda NTLP in 2008 initiated the Tuberculosis Specimen Referral System (TSRS). Under the TSRS, sputum is collected from smear positive retreatment TB cases at the peripheral health facilities and sent via the post office to the National TB Reference Laboratory (NTRL) - the only public TB culture facility in Uganda. The aim of this study was to evaluate the performance of the TSRS during the year 2010. This was a cross sectional study carried out in the South West TB zone of Uganda. Onsite visits were made to the health facilities participating in the TSRS to: i. review laboratory records on proportion of eligible specimens referred, ii. interview health workers on reasons for failure to refer samples, and whether the results were received and/or used for patient care. Out of the 239 eligible smear positive sputum from retreatment TB cases, 135 (57%) were referred to the NTRL. Of the135 samples, 106 (79%) result reports were issued by the NTRL and verified as dispatched to the health facilities but the health facilities received only 71 (52%) of the dispatched reports. Of the 71 reports, 38 (54%) were verified as actually discussed with the patients for care, 23 (32%) were never discussed with the patients and for the remaining 10 (14%) reports found on patient files, the respondents were not certain of their status. The two major factors for failure to refer the samples were insufficient health workers understanding of the TSRS attributed to high staff turnover/transfers, and delayed transport refund reported by 59% of the respondents. Almost half of the eligible sputum samples from the retreatment TB cases in the South Western TB zone were never refered to the NTRL for culture and sensitivity testing. Out of the 135 referred sputum samples, only 38 (28%) results were actually used for patient care, raising questions on the actual utility of the TSRS under the current health care settings. Insufficient understanding of the TSRS by health workers and delayed transport refund hindered the sample referrals. The NTRL should conduct periodic health workers training on the sample referrals. Countries contemplating initiation of similar TB specimen referral systems should consider newer faster systems for refund of the transport costs and improve on documentations.