|Year : 2022 | Volume
| Issue : 1 | Page : 103-107
Turnaround times of the sputum sample courier system at tuberculosis treatment centers in Lusaka, Zambia, 2021
Samuel Daka1, Yuko Matsuoka1, Masaki Ota2, Susumu Hirao2, Abraham Phiri3
1 Japan Anti-Tuberculosis Association, Lusaka, Zambia
2 Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Lusaka, Zambia
3 Department of Tuberculosis, Ministry of Health, Lusaka District Health Office, Lusaka, Zambia
|Date of Submission||05-Jan-2022|
|Date of Decision||22-Jan-2022|
|Date of Acceptance||25-Feb-2022|
|Date of Web Publication||12-Mar-2022|
C/o. Japan Anti-tuberculosis Association, Zambia Plot No. 2 Njolwe Close, Woodlands, Lusaka, 10101
Source of Support: None, Conflict of Interest: None
Background: Health facilities which do not have capacity to diagnose tuberculosis (TB) depend on other facilities. This involves the courier of specimen such as sputum to diagnostic centers. This study was aimed at determining the turnaround time of sputum examinations for TB patients involving a courier system between the treatment and diagnostic centers. Methods: The study tracked the sputum samples between TB treatment and diagnostic centers. Sputum samples for both diagnosis and follow-up reasons were purposely and serially tracked from the time they were sent to the laboratory to the time results were received at the treatment centers. Results: Of the 65 sputum samples tracked at Chazanga, results were available for 49 (75.4%), 6 (9.2%) were unaccounted for, 4 (6.2%) were rejected by the laboratory, 4 (6.2%) had “error” results, and 2 (3.1%) were declared “missing” because it took more than a month to return the results. The turnaround time ranged from 2 days to 18 days with an average of 5.8 days (95% confidence interval [CI]: 4.5–7.1 days). At Kaunda Square, of the 49 samples tracked, results were available for 44 (89.8%), 2 (4.1%) were unaccounted for, 2 (4.1%) were rejected, and 1 (2.0%) was declared “missing.” The turnaround time ranged from 2 to 25 days with an average of 6.3 days (95% CI: 5.3–7.4 days). Conclusion: The turnaround times of sputum examinations of the two treatment centers were long. The courier system should be closely monitored to determine if it is performing well because the system is still necessary for facilities without laboratories.
Keywords: Bacteriologically confirmed, diagnostic center, presumptive, sputum examination
|How to cite this article:|
Daka S, Matsuoka Y, Ota M, Hirao S, Phiri A. Turnaround times of the sputum sample courier system at tuberculosis treatment centers in Lusaka, Zambia, 2021. Int J Mycobacteriol 2022;11:103-7
|How to cite this URL:|
Daka S, Matsuoka Y, Ota M, Hirao S, Phiri A. Turnaround times of the sputum sample courier system at tuberculosis treatment centers in Lusaka, Zambia, 2021. Int J Mycobacteriol [serial online] 2022 [cited 2022 Aug 15];11:103-7. Available from: https://www.ijmyco.org/text.asp?2022/11/1/103/339518
| Introduction|| |
Tuberculosis (TB) is a disease spread by droplet nuclei when people who are sick with TB expel the bacteria into the air, for example, by coughing. The disease typically affects the lungs (pulmonary TB) but can also affect other sites (extrapulmonary TB), and about a quarter of the world's population is infected with Mycobacterium tuberculosis, the bacterium that causes TB.
Zambia is among the 30 high TB burden countries in the world. TB continues to rank among the major causes of morbidity, and it is one of the top ten causes of mortality. Ending this disease entails finding TB cases through proper diagnosis and putting the patients on correct treatment. This curtails its transmission in the community. However, diagnosing TB has its own challenges, especially for resource-poor countries.
In Zambia in general, and Lusaka in particular, the number of TB laboratories is limited. This means that while government health facilities have the capacity to treat and monitor TB patients, not all are able to diagnose TB. Hence, health facilities without the capacity to diagnose TB depend on other facilities, usually larger hospitals. This involves transportation of specimens such as sputum from TB treatment centers to diagnostic centers through a special courier system, and the referring facilities receive their results through the same system.
The logistics of collecting sputum specimens from treatment centers and transporting them to diagnostic health facilities is challenging. These logistical hurdles are not unique to Zambia alone, as several African and Asian countries have also reported similar challenges.,
Although there is some information available about the laboratory courier system for the Japan International Cooperation Agency (JICA)-sponsored project sites outside the Lusaka district, no information exists for Lusaka itself. In general, TB treatment sites in Lusaka complain about delayed TB treatment initiation due to the long waiting time for sputum results. Delaying TB treatment initiation or losing bacteriologically confirmed TB patients before treatment is initiated contributes to ongoing TB transmission and poor patient outcomes.
The aims of this study were to determine the turnaround time for TB sputum examination results and identify challenges regarding the courier system between the treatment and diagnostic centers.
The study was conducted at two TB treatment sites in Lusaka, Chazanga Clinic (population: 44,128) and Kaunda Square Clinic (population: 61,169). Chazanga Clinic refers sputum samples to Chipata General Hospital, which is about 6 km away. Kaunda Square Clinic refers sputum samples to the Chelstone Zonal Health Center which is about 5 km away.
Both treatment sites use motorbikes to transport sputum samples to the diagnostic centers. At Chazanga, the courier system runs from Monday to Friday and two couriers work on a rotational basis of 1 week each. At Kaunda Square, it runs for about 3 days/week, though the courier does not consistently stick to the schedule.
Diagnosis of TB at the two diagnostic sites is done using Xpert and microscopy. Diagnosis of TB in Zambia is based on finding at least one of two sputum smear samples positive for acid-fast bacilli using Ziehl–Neelsen staining or fluorescence microscopy, or being positive on Xpert® MTB/RIF (Cepheid, Sunnyvale, CA, USA) assay.
There are two types of sputum samples: one comes from the community through TB treatment supporters (TS) and the other comes from presumptive TB patients within the treatment centers. These are ferried to the diagnostic centers through motorbikes. The Chipata Hospital Laboratory receives sputum samples from seven treatment centers, while the Chelstone Zonal Clinic Laboratory receives sputum samples from ten treatment centers. Once samples are processed and examined, the referring facilities receive their results through the same courier system.
We conducted this prospective study from April 2021 to September 2021. Sputum samples for both diagnosis and follow-up reasons were purposely and serially tracked from the time they were sent to the laboratory to the time results were received at the two treatment centers. However, samples that leaked or spilled were excluded from the study. Similarly, samples for which the examination process was not completed and ended up with “error results” were also excluded from the study. Furthermore, samples that had incomplete documentation in the TB laboratory registers were also excluded from the study.
At the Chazanga and Kaunda Square Clinics (TB treatment sites), a register was improvised to capture the dates when sputum samples were sent to the laboratories. The couriers signed for the sputum samples every time they were taken to the laboratories. The improvised register also captured the dates the results were received from the laboratories.
The study was conducted during the dry season, and we visited the treatment and diagnostic centers once per week for 8 weeks. Data were collected using the data collection form, and dates at various points of the courier system were collected. These included the dates sputum samples were taken to the laboratories, received at the laboratories, examined, and dispatched, and finally, the dates results were received at the treatment centers.
The data were then transferred and recorded in Excel (ver. 2010. Microsoft Corp. Seattle, USA) spreadsheets. The means, 95% confidence intervals, and ranges of the turnaround times for sputum examination results were calculated for the two treatment sites using R (The R Foundation for Statistical Computing, Vienna, Austria).
In this study, there was no direct interaction with patients. Instead, sputum samples were tracked within the courier system, collecting important dates at various points of the system using codes to represent the patients. This study was conducted as part of the review and monitoring activities of routine TB case finding in relation to TB control. The investigators sought research permission from the Zambia National Health Research Authority (Ref No: NHRA00002/13/05/2021) and ethical clearance from the Institutional Review Board (Ref. No. 2021-Jan-013). Confidentiality was observed and maintained at all stages of the study, and only investigators had access to the collected data.
Patients consent form
The study involved tracking already submitted sputum samples between treatment and diagnostic centers. Therefore, patient consent was not necessary as the study was conducted under the operational condition in which we needed to improve the performance of the local national TB program as well as the project and we had obtained the permission from the Ministry of Health through the Zambia National Health Authority.
| Results|| |
At both clinics, sputum samples were serially chosen from July 1, 2021, to August 26, 2021. Of the 65 sputum samples that were tracked at Chazanga Clinic, 49 (75.4%) had results available, 6 (9.2%) were unaccounted for, 4 (6.2%) were rejected by the laboratory because they leaked, and 4 (6.2%) had “error” results. For two samples (3%) that were fully processed, the results did not reach the clinic for more than a month from the time they were dispatched; therefore, they were declared missing. Furthermore, while the laboratory processed most of the samples within 48 h of receipt, the study found that there was a delay of up to 14 days in picking up the results from the laboratory by the courier. The turnaround time for the results ranged from 2 days to 18 days, with an average of 5.8 days (95% confidence interval [CI]: 4.5–7.1 days).
At Kaunda Square Clinic, 49 samples were tracked. Of these, results were available for 44 (89.8%), 2 (4.1%) were unaccounted for, and another 2 (4.1%) were rejected by the laboratory because they leaked. The result for one sample (2%) did not reach the clinic for more than a month from the time it was dispatched by the laboratory and it was declared missing. Furthermore, while the laboratory examined most of the samples within 24 h of receipt, the study found that there was a delay of up to 5 days in dispatching (entering results in the register and declaring them ready for collection) the results by the laboratory and also another delay of up to 21 days in picking up the results from the laboratory by the courier. The turnaround time for the results ranged from 2 to 25 days, with an average of 6.3 days (95% CI: 5.3–7.4 days).
The data above are summarized in [Table 1]a and [Table 1]b. [Figure 1]a and [Figure 1]b shows the duration of the major activities within the sputum courier system, while the sputum turnaround time is summarized in [Figure 2]a and [Figure 2]b.
|Figure 1: (a) Schematic diagram showing durations of major activities within the sputum sample courier system at Chazanga Clinic, Lusaka, 2021. (b) Schematic diagram showing duration of major activities within the sputum sample courier system at Kaunda Square Clinic, Lusaka, 2021|
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|Figure 2:(a) Sputum turnaround time at Chazanga Clinic, Lusaka, 2021. (b) Sputum turnaround time at Kaunda Square Clinic, Lusaka, 2021|
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| Discussion|| |
We undertook a study at the Chazanga and Kaunda Square Clinics in order to have a full understanding of the sputum courier systems and determine the turnaround times for the results. At Chazanga Clinic, results were available for three-quarters of the sputum samples. The turnaround time ranged from a few days to more than 2 weeks. At Kaunda Square Clinic, results were available for almost 90% of the samples and the turnaround time ranged from a few days to almost 1 month.
At both facilities, the turnout of the results was affected by sample rejection, errors by the Xpert machines, unaccounted for samples, and missing results. The rejected samples had leaked during transportation and the laboratories discarded them as they were unsafe to handle. The error results recorded at the Chipata Diagnostic Center were due to technical issues with the Xpert machine. Furthermore, the samples that were unaccounted for had been picked from the facilities and signed for before being taken to the diagnostic centers. However, the laboratories had no record of receiving them. It may be that these samples were not actually picked from the clinic despite being signed for or that the laboratory had discarded them without indicating so anywhere.
The missing results for both facilities may have been misplaced by the laboratories, lost within the courier system, or mistakenly picked up by other facilities. The turnaround times for the results at both facilities were generally long. At both Chipata and Chelstone, while the laboratories promptly processed the samples, there were delays in picking up the results by the couriers and this greatly increased the turnaround time. The actual cause for this delay was not known. However, it could be that the couriers were paying more attention to sputum sample transportation than result collection or due to logistical reasons. At the Chelstone Laboratory, long turnaround time was also attributed to delay in dispatching the results by the laboratory, which ranged from within 24 h to almost 1 week. The delay in dispatching results might have been due to work overload in the laboratory or because the laboratory personnel did not pay attention to the importance of dispatching the results quickly.
The long turnaround time, rejected samples, unaccounted for samples, and missing results have various implications. Although there is no agreed good turnaround time, shorter ones, of <7 days, are better. When clients submit sputum samples at the two treatment centers, they are usually told to return for the results within a week. A long turnaround time is associated with delayed initiation of TB treatment. Such delayed initiation of treatment contributes to ongoing TB transmission in the community and pretreatment lost to follow-up., Delayed commencement of treatment may also lead to premature deaths of TB patients., There is a need for the laboratory personnel at Chelstone to dispatch the results as soon as the sputum samples are examined. In addition, the couriers should pay attention not only to sample delivery but also prompt collection and delivery of the results to the treatment centers. The district health office must also ensure that motorbikes are always in good working condition as well as having a continuous supply of fuel in order to avoid any disruption of the service.
Another cause for concern is the rejected sputum samples due to spillage. After rejection, chances of sputum resubmission by clients are slim and this frustrates efforts to control TB. Therefore, chest clinic nurses and TB TS should provide adequate education to clients so that not only are quality samples produced but also to ensure that the container lids are tightly secured. In addition, sputum containers should be properly packed in cooler boxes before being transported to the laboratories.
Like rejected samples, unaccounted for samples pose a challenge to TB control. Each submitted sample needs to be accounted for; hence, before the names of clients are entered in the register at the treatment site, the nurses and TS must confirm that sputum samples have been submitted. Similarly, the courier transporting samples to the laboratory must ensure that each sample signed for is picked up and taken to the laboratory. At the laboratory, the personnel should also account for each sample including the rejected ones.
The finding of already processed results being missing implies that there are gaps within the courier system that need urgent attention. The laboratories must carefully dispatch the results to the referring facilities. This will ensure that results from various facilities are not mixed. Well-labeled dispatch trays will be purchased and provided to the laboratories to assist in this regard. The authors will also hold meetings at the two treatment sites where the courier and laboratory personnel will be invited. The meetings will aim at finding solutions to the challenges identified in the sputum courier system.
Our findings are consistent with a study conducted by the JICA in the Choma and Kalomo districts of Zambia on sputum referral systems. In that study, 7% of the samples referred to the laboratory did not reach it, 10% of the results did not return to the treatment centers, and 24% of the results were received at the treatment centers 2 weeks after referring the samples to the laboratory.
In Malawi, despite engaging with a bus company to provide transport of sputum specimens from peripheral units to a reference laboratory, the system did not perform well. Overall, only 40% of specimens reached the Central Reference Laboratory. In Tanzania, the number of sputum samples from retreatment cases that did not reach the laboratory level was unacceptably high at 91%. This study has strengths. This is the first assessment of the turnaround time of the laboratory courier system in Lusaka.
| Conclusion|| |
The study has generally shown that the turnaround times for sputum results at the two treatment centers are long. Long turnaround time is associated with delayed TB treatment and losing of patients before they start treatment. The sputum courier systems at the two sites are also marred by other challenges that include missing samples and results. These are among many other factors that impede efforts to control TB. Since not all health facilities have the capacity to diagnose TB, sputum courier systems are still necessary. However, they need to be closely monitored if they are to perform well.
Limitation of the study
The study has some limitations. First, the sputum samples were tracked over a short period of time; hence, the findings may not represent what occurs all the time. Second, the findings may not be generalizable to other sites in Lusaka or elsewhere as the courier systems operate under varying conditions. Third, the presence of researchers at these sites during the study period may have influenced the sputum courier system, either positively or negatively.
This study was approved by the Institutional Review Board under number (Ref. No. 2021-Jan-013).
Financial support and sponsorship
This study was financially supported by the Research Institute of TB/Japan Anti-Tuberculosis Association.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]