Faster diagnosis key to fighting TB in Sri Lanka: TB review mission reveals

Prasad* is a 19-year-old student studying engineering at a local university. Prasad had been sick with a persistent cough for more than two weeks.

“I noticed something was seriously wrong when I started coughing out blood-stained sputum. I had a severe pain in my chest bone so I visited an OPD in January,” says Prasad. “After a check-up, the doctors initially told me that I did not have any serious medical illness.”

However, 6 months later Prasad’s cough had worsened and he spent one entire night coughing out blood-stained phlegm. He visited the chest-clinic the next day and following two sputum (phlegm) tests, he was diagnosed with tuberculosis (TB). Prasad immediately began his antibiotic treatment regime which would last 6 months.

“A large number of people visit OPDs of hospitals daily with symptoms like a persistent cough and fever. However, constraints on time and resources to screen for tuberculosis means that not all cases are immediately diagnosed,” explains Dr Janakan Navaratnasingam, WHO National Professional Officer for Communicable Diseases. “In 2016, only 8 866 cases were reported compared to the estimated incidence of 13 500 cases. As individuals with symptoms suggestive of TB delay seeking medical care, they infect much more people and treatment becomes increasingly difficult.”

WHO recently supported the mid-term review of Sri Lanka’s National Programme for TB Control and Chest Diseases (NPTCCD) to evaluate the current status of TB control in the country and make recommendations for further improvements to the National TB Strategic Plan.

Dr Paul Nunn at Welisara clinic

Dr Paul Nunn, world-renowned TB expert, was supported by two national consultants, Dr Sunil Senanayake (former WHO Regional Advisor for Health Information) and Dr Deepthi Perera (former Provincial Director of Health Services, Western Province) in the TB review mission facilitated by WHO. The team visited the district chest clinics in Gampaha, Colombo and Batticaloa from 17 to 28 July 2017 to assess the performance of the TB programme, including drug-resistant TB. They also visited treatment facilities in the locality including Directly Observed Treatment Short-course (DOTS) centres, and met with health workers, patients, community leaders, academia, and key stakeholders involved in the national TB response.

The team made several recommendations on addressing the current challenges posed by TB. Specific interventions to improve case detection, strengthen monitoring and evaluation systems and enhance coordination between stakeholders were proposed to the Ministry of Health.

Remaining challenges posed by TB

Sri Lanka maintains a low prevalence of TB compared to the majority of other countries in the WHO South-East Asia Region; however, there are many remaining challenges which require specific programmatic interventions. Low case detection is a significant cause for concern as there is a gap of approximately 4000 plus cases between the estimated and the reported cases.

In addition, since 2012 treatment success has remained below the 85% target advocated by WHO. About 1200 people die each year from TB in the country. Such a high fatality rate may reflect the advanced stage of the disease at the time of diagnosis and possibly the presence of co-morbidities, such as HIV and diabetes.

TB review mission: results and recommendations

The review mission reiterated the need for scaling up interventions for case detection and the importance of upgrading diagnostic facilities at OPD centres to address this. One key recommendation was to have sputum smear microscopy (checking sputum for TB bacilli using microscopes) and digital X-ray services at OPDs to facilitate early detection and timely treatment on confirmed cases.

Chest X-rays help with diagnosing TB

Poor monitoring and evaluation were identified as other issues needing urgent attention. There are significant disparities in case reporting at the clinical level. Introducing a laboratory information system and a web-based patient record system for TB patients is recommended for timely reporting and actions taken.

Finally, poor coordination between districts and the central level impedes disease surveillance. The team strongly recommended havingone policy, one plan and one surveillance system for a comprehensive and seamless response. The review mission proposed demonstration projects in 2 -3 districts to implement the recommendations and monitor for impact. The learning would then be extended to the rest of the country. WHO will continue to provide technical support to ‘bend the curve’ to end TB by 2030.

Strengthening services will significantly accelerate case detection, improve treatment outcomes and bring down the TB burden in Sri Lanka. Improving the national TB programme will help people like Prasad to get the treatment they need much faster.

*Names changed to protect privacy.