Descriptive Data Analysis of Tuberculosis Surveillance Data, Sene East District, Ghana, 2020

Rapheal Gyan Asamoah¹, Delia Akosua Bandoh^2,&, Samuel Dapaa², Joseph Asamoah Frimpong², Ernest Kenu²

 

¹Ghana Health Service, Sene East District Health Directorate, Kajaji, Ghana, ²Ghana Field Epidemiology and Laboratory Training programme, University of Ghana School of Public Health, Legon, Accra

 

 

^&Corresponding author
Delia Akosua Bandoh, Ghana Field Epidemiology and Laboratory Training programme, University of Ghana School of Public Health, Legon, Accra. deliabandoh@gmail.com

 

 

 

 

Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis [1]. The bacteria usually affect the lungs but can affect other parts of the body such as the kidney and brain, although about 90% of tuberculosis cases affect the lungs [1]. The bacterium is spread from person to person via droplets when a person with pulmonary tuberculosis coughs, sneezes or spits [2]. Signs and symptoms of tuberculosis include chronic cough, weight loss, night sweats, loss of appetite and chest pains [3].

 

TB remains a serious health threat, especially for people living with Human Immunodeficiency Virus (HIV) as they are more likely to come down with TB compared to others without HIV. Without treatment, TB and HIV can work to shorten lifespan with each speeding the other´s progress [4].

 

Tuberculosis is the leading cause of death from a single infectious agent, killing over 1.4 million people globally in 2018 [3]. Globally, 10 million people were diagnosed of TB, with an estimated 1.5 million deaths in 2018. In the African region, 2.5 million people were diagnosed with TB, with over 450,000 deaths in 2018 [5]. In Ghana, there were over 44,000 new TB cases with over 15,000 deaths in 2018 [5]. Of these, a total of 568 cases with 40 deaths occurred in the Bono East Region the same year [6]. In the Sene East district, 11 cases were recorded in 2018.

 

World Health Organization End TB Strategy seeks to end the global TB epidemic through patient care, policy and research. With patient care at the center of TB service delivery, early case detection and successful treatment outcomes would be achieved [7]. Ghana adopted and implemented the Integrated Disease Surveillance and Response (IDSR) strategy in 2002 to help conduct effective surveillance activities and integrate multiple surveillance systems so that personnel and resources can be used efficiently [8].

 

The surveillance system for tuberculosis in place in the Sene East forms part of the Integrated Disease Surveillance and Response system and the goal of this surveillance system is to detect people with infectious lung disease early and to improve chances of clinical improvement and reduce transmission of TB and also to improve the percentage of TB cases confirmed by microscopy. TB surveillance contributes to achieving integrated, patient-centered care and prevention which is the first pillar of the End TB strategy.

 

As part of surveillance activities, routine health care data on TB in the Sene East district is collected with TB screening tools, laboratory and treatment registers and is entered into the District Health Information Management Systems II (DHIMS2) by the District TB coordinator. Periodic analysis of this TB surveillance data collected routinely provides information on the district´s progress being made towards ending the TB epidemic.

 

The study assessed the Sene East district´s TB surveillance data from January 2015 to December 2019 to estimate TB case notification rate, describe the trends of confirmed TB cases and treatment outcome, and evaluate treatment outcomes of TB-HIV coinfection cases.

 

 

Study design

 

We conducted a descriptive analysis of TB surveillance data reported in the Sene East district from January 2015 to December 2019. The study was conducted from April 2020 to June 2020 where we reviewed TB registers and Laboratory registers using a checklist.

 

Study Area

 

We conducted the study in the Sene East district in the Bono East region. The district is located in the eastern corridor of the region and covers a land area of 4,392.4sq.km and a projected population of 75,973. The district shares boundaries East with Krachi West District of the Oti Region, to the West, Sene West District, to the North, Pru District and the Sekyere East District of Ashanti Region to the South [9]. There are 179 communities of which 38 are island communities interconnected by poor and untarred road networks. The district has three sub districts and a total of eight health facilities, made up of three health centers and five Community Based Health Planning and Services (CHPS) compounds. All eight health facilities report on TB to the district. The district does not have a TB diagnostic center thus transports samples to the Sene West District for diagnosis. The district has one TB coordinator who is responsible for coordinating and keeping records of all TB related activities in the district. The TB coordinator also reports monthly and quarterly to the next level (region).

 

Study Population

 

All TB cases reported to the district over the period under review constituted the study population. The study population were records of all TB cases reported between the period of 2015 through 2019 in the Sene East district.

 

Case Definitions

 

Presumptive TB

 

A patient who presents with symptoms or signs suggestive of TB[10].

 

TB case

 

A bacteriologically confirmed TB case: a biological specimen is positive by smear microscopy, culture or WHO-approved rapid diagnostics WRD. All such cases should be notified, regardless of whether TB treatment has started. (previously Definite TB case; now includes explicit mention of WRD) [11].

 

A clinically diagnosed TB case: not bacteriologically confirmed but diagnosed with active TB by a clinician or other medical practitioner who has decided to give the patient a full course of TB treatment. (Previously a case of TB, not considered Definite) [11].

 

Data Collection and Data Collection Tool

 

A data extraction tool was designed to collect data on the following variables: sex, age, community, referring facility, sub district, results of sputa, HIV status, month and year of diagnosis and outcome of treatment of clients. We visited the district TB treatment center and reviewed TB surveillance data as recorded in the TB treatment registers and laboratory registers.

 

We reconciled the primary data with data captured in the District Health Information Management Systems II (DHIMS 2).

 

Data Processing

 

Surveillance data collected were examined for completeness. We calculated summary statistics for continuous data such as age using Microsoft Excel (version 2016). We run frequencies and proportions of categorical data such as sex and treatment outcome. We reconciled gaps in data by tracing client´s folders and treatment cards for some of the variables that were missing. Cases with missing variables were not included from this study. We also checked for duplicate information and deleted them.

 

Data Analysis

 

We analyzed the data on age groups, sex, community, referring facility, sub-district, month and year of diagnosis, result of sputa, HIV status, and treatment outcome descriptively as frequencies and proportions and presented them in the form of tables and graphs using Microsoft Excel 2016. Data for 2019 cohort could not be analyzed since patients were still on treatment at the time of the study. The variables were sub-grouped under person (age, sex), place (community, sub district, referring facility) and time (month and year).

 

Data availability

 

All data generated or analyzed during this study are included in this article and its supplementary information files.

 

Ethical issues

 

The data analysis was carried out as part of the mandate of the Disease Surveillance Department of the Ghana Health Service to conduct surveillance activities. Permission was obtained from the Bono East Regional Health Directorate, the District Health Directorate and the facilities in the district before data were collected. We left out personal identifying information such as name and contacts to protect the identity of the clients. We also kept the data extracted on a computer with password to prevent unauthorized access.

 

 

Description of Participants

 

From 2015 to 2019, a total of 236 persons were referred for diagnosis of which 18.2% (43/236) of them were reported as cases with Pulmonary TB (sputum smear positive and sputum smear negative). Of the total number of cases reported, 60.5% (26/43) of them were smear sputum positive. The highest proportion, 74.4% (32/43), of cases recorded were among males. The mean age of TB cases in the district was (48.5±18.8) years and a margin of error of 5.6. We observed an irregular decline in TB cases over the period under review with a peak in 2018 Figure 1.

 

Age and sex distribution of TB cases

 

For all the years under study, males were most affected 74.4% (32/43) whilst the age-group 40 years and above had the highest number of cases, that is, 69.8% (30/43) Figure 2.

 

Cumulative TB case detection by sub districts

 

More than half, 53.5% (23/43) of the cases detected were from the Kajaji sub district, with Kojokrom sub district recording the least, 18.6% (8/43) cases Figure 3.

 

Number of cases recorded monthly

 

Cases were recorded all year round, with generally more cases recorded between November and April, which is usually the dry season Figure 4.

 

Trend of Treatment outcome of TB

 

Successful treatment outcome of TB cases in the Sene East district has been on the decline since 2015. Successful outcomes reduced from 100% in 2015 to 45.5% in 2018 Figure 5.

 

Data on 2019 was not analyzed as cohort treatment outcomes were not available.

 

TB-HIV Positive Treatment Outcomes

 

Of the total number of TB cases notified, six of the 43 were HIV positive (coinfection). One-third (2/6) of these, had successful treatment outcome, one had treatment failure and half (3/6) did not have their treatment outcomes documented.

 

 

This study analyzed TB surveillance data in the Sene East District for the period of January 2015 to December 2019. First and foremost, the analysis of the Sene East TB surveillance data revealed that case detection rate of the disease in the district has been consistently low for the period under study. This could be due to the absence of a diagnostic center in the Sene East district. A study in Ethiopia on barriers to TB case finding conducted among patients and providers found that limited access to diagnostic center served as a barrier to TB case detection [11]. Each time, samples of suspected cases were transported to the Sene West district for diagnosis. Feedback on samples were not relayed to the health facilities that delivered the samples. Absence of feedback on status of samples could have demoralized health staff from putting in their best in detecting TB cases in those facilities. Consequently, a lot of TB cases may go unsuspected leading to low TB case notification in the district. Other studies on TB conducted in the Nkwanta South district in the Oti Region of Ghana and the Sissala East district in Upper West Region also found that stigma against persons diagnosed with TB played a role in low case detection rate [12,13]. Fear and/or embarrassment of being seen at a TB clinic may lead individuals with symptoms of TB attributing it to other non-stigmatizing conditions [14]. This observation by the study conducted by Noora et al, could also be one of the reasons that accounted for the low case detection rate in the district. We found that treatment outcomes of TB cases in the district was on the decline, going below the target set by WHO in the End TB strategy of 90% [15,16]. This may be due to the poor documentation of case information as some of the cases did not have their treatment outcomes well documented during data review.

 

Of the total number of cases detected, males constituted the highest proportion and this is consistent with the global report of TB cases with a male to female ratio of 2:1 [5]. Men may be at a higher risk of developing TB as they indulge in activities that increase risk of developing TB such as smoking [17]. The low cases recorded among women may also be due to the socio-cultural constraints some women face in their communities. Studies conducted in Ghana and Kenya found that the ability of some women to seek health care depended on their partners. Women would have to consult their male partners before they decide on who and where to seek health care from, and if the man ask her to postpone the health facility visit or visit a traditional healer, then she must comply [18,19].Cases were more prevalent among older adults above 50 years. This may be due to the low immunity of the older adults, coupled with their poor attitude towards seeking health, predisposing them to infections such TB [20,21]. There were no cases detected for children under 10 years old. The diagnosing of TB in children is challenging usually due to insufficient specimen material and scarcity of bacilli in specimen. This may require sensitive test such as Gene Xpert. However, the district does not have a diagnostic center. Children, just like mothers, are also affected by some socio-cultural practice that leaves the decision on health seeking to the father only [18,19].

 

Majority of the cases reported were from the Kajaji sub district. Kajaji is the district capital where the District Health Directorate (DHD) is situated. The office had an average of four disease control officers who go on active case search in the sub district. On the other hand, the other sub-districts have lesser numbers of disease control officers and are not able to actively search for cases as the Disease control officers in the district capital do. This could have been be the reason why more cases were detected in the Kajaji sub district compared to the other two sub districts.

 

A seasonal trend of cases was seen during the period of study, with more cases seen in the dry season (November to April). Due to the poor road networks coupled with the untarred roads, the district becomes dusty during the dry season, increasing the risk for Respiratory Tract Infections (RTI) in the district. RTIs may prompt the suspicion for TB when they report to the facilities and may account for the high number of TB cases detected during the dry season. A study in Korea also observed that TB is a seasonal disease as they saw more TB cases in the summer [22]. Another study also confirms that TB is a seasonal disease but saw more cases recorded in the winter [23].

 

TB-HIV incidence was found to be in the same range as the global statistics from WHO [5]. Studies confirm that HIV has a toll on the treatment outcomes of HIV positive TB cases [24]. TB-HIV positive cases are expected to have a lower successful treatment outcome compared to TB cases who are HIV negative. Even with this lower expected outcome, the outcome in the Sene East district on TB-HIV positive cases is very low compared to another study on the TB-HIV positive treatment outcome in the Volta Region of Ghana [25]. This may be due to poor tracing of defaulters and poor record keeping as a number of TB-HIV positive cases did not have their treatment outcomes documented.

 

Limitations

 

There were some minor issues with the data such as missing variables on age/date of birth, sex, referring facility and results on microscopy. This may have affected our findings, leading to overestimating or underestimating our results. However, some of these were addressed during the cause of the exercise by tracing the treatment cards and folders of TB cases with missing variables. The findings and conclusions from this study might only be applicable to this study setting and cannot be generalized to the entire population of the Bono East Region, nor to Ghana.

 

 

The district had a consistently low TB case detection rate over the period with people aged 40 years and above and men being most affected. The successful treatment outcomes of TB in the district have a declining trend for the period of study. TB-HIV coinfection treatment outcomes were low with some outcomes not documented. We sensitized the District TB coordinator on the need to provide feedback on TB samples sent for diagnosis to the health facilities that suspected the cases. We recommend that the District Director of Health Services (DDHS) advocates for a TB diagnostic center in the district since this will help increase the case notification rate.

 

 

The authors declare no competing interest.

 

 

Conceptualization: RGA, JAF, SD, EK. Data collection: RGA, SD. Analysis: RGA, SD, DB, JAF. Report writing: RGA, SD. Manuscript development: RGA, SD, DB, JF, EK. Manuscript finalization: RGA, SD, DB, JF, EK. All authors have read and approved of the manuscript.

 

 

The authors gratefully acknowledge the following organizations for their support; Ghana Field Epidemiology and Laboratory Training Program (GFELTP), African Field Epidemiology Network (AFENET), Korea International Cooperation Agency (KOICA), and the United States Centers for Disease Control and Prevention (US-CDC) for supporting the FETP Intermediate Training. We are also grateful to the Health Directors of the Bono East Region and the Sene District for granting us access to their facilities and support during the training. We are also grateful to all the staff of the Sene East district for their support.

 

 

Figure 1: Trend of TB Case Notification Rate in the Sene East District 2015 to 2019

Figure 2: Age and sex distribution of TB cases in the Sene East District, 2015 to 2019

Figure 3: Cumulative TB case detection by sub districts in Sene East, 2015 to 2019

Figure 4: Number of cases recorded monthly in the Sene East District, 2015 to 2019

Figure 5: Trend of Treatment outcome of TB in the Sene East district, 2015 to 2018

 

 

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