Tuberculosis Control Program in Zahedan University of Medical Sciences: a report of 10 years achievements & Challenges

Tuberculosis Control Program in Zahedan University of Medical Sciences: a report of 10 years experience

Report from: ZAUMS Communicable Diseases Control Department

Published on: 8 April 2018

In 2005 Zahedan University of Medical Sciences (ZUMS) along with its Iranshahr Campus provided health coverage for 8 cities/towns and their subordinate districts including Zahedan, Khash, Saravan, Sarbaz, Nikshahr, Iranshahr, Chabahar and Konark. The region under the coverage of ZUMS shares land border of 1200 km with Pakistan and Afghanistan and 300 km sea border with Oman and Pakistan.
The region was totally different in terms of demographical characteristics in a way that urbanism pattern in ZUMS subordinate districts ranged from 86% in the city of Zahedan to 10.8 in Sarbaz district. It should be noted that urbanism in other subordinate towns was 50%. The literacy rate ranged from 86% in the city of Zahedan to 58% in the city of Chabahar. The average household size in all subordinate towns/cities was higher than 5, with an average university figure of 5.2, which was much higher than average country household size.

In 2005 each town/city had only one TB unit with one coordinator physician and each town/city had one central laboratory with diagnostic facilities for direct TB smear microscopy in all cities/towns and smear culture was possible only in Zahedan. At that time there were seven laboratories in Saravan, Zahedan, Sarbaz and Chabahar. Radiology facilities were available in all towns/cities of the province except Sarbaz

To ensure the decline in the incidence of TB, the following interventions were undertaken by ZAUMS:
1. An increase in the coverage of environmental TB laboratories (taking into consideration highly dispersed population in the region under coverage).
2. Setting a higher expected case detection goal for cities/towns covered by ZAUMS, taking into account the average country figure and neighboring countries incidence rates.
3. Designing and developing TB patient files for better recording and improving TB surveillance system of patients and their close contacts.
4. Implementing intensified TB case-finding in high risk population (TB patient close contacts, regions with mobile population, border area residents, prisoners, those seeking assistance from Imam Khomeini Relief Committee, active TB case finding diabetic patients and those affected with HIV/AIDS.
The outcome of these changes emerged as an increase in TB case detection rate during these years. Following these changes and taking into account success rate of more than 85% during these years, 9 more active interventions in high risk population were designed and carried out. One of the most important impacts of these interventions was a decline in the average delayed diagnosis from 176 days in 2005, down to 70 days in 2010. However, considering the fact that 70 days delayed diagnosis was not desirable, investigations of the underlying reasons for delayed diagnosis was conducted in ZAUMS. The Health and Treatment system played a more important role in the delayed diagnosis, contributing to a share of 65%, as compared with 35% from patients" side.

In order to achieve these objective and to actively engage the private sector, training process was undertaken and was sustained with setting workshops and annual seminars as well as information dissemination measures. A news bulletin was published by Communicable Diseases Department of Vice Chancellor for Health, and all private clinics were provided with necessary information.
One of the most important methods for accurate planning to achieve the goals for the End TB Program, was periodic and regular statistical analysis of the program, which was conducted in time period of three, six and nine months as well as on annual, three and five year basis.

In preparation for TB eradication program, an analysis was carried out using the 10 years surveillance data and relevant interventions were planned. It should be noted that the analysis was also undertaken in TB laboratories sphere performance and were discussed in joint meetings.According to ten- year analysis of TB program, major problem lies in weakness in TB case-finding in some population including male and prisoner as well as surge in treatment failure, particularly in urban and foreign population which resulted in designing training campaign and TB screening in suburban(mostly poor), rural and mobile population in Zahedan city which accounts for 40% of the total cases of the region under coverage of Zahedan University of Medical Sciences. In this campaign the potential of volunteers for Health was utilized. In the current year the above mentioned measures have had a noticeable impact on TB incidence index rise in the city of Zahedan. :

Some of the achievements of ZUMS TB Program are as follows

1. Free hospitalization of TB patients.
2. Resorting to Imam Khomeini Relief Committee to provide underprivileged TB patients with nutritional support.
3. Establishment of regional reference laboratories with direct smear investigation service, culture antibiogram by two methods: proportional and Gene expert, PCR. It should be noted that ZUMS TB reference laboratory is the sole regional reference laboratory in the country which has the honor of winning High Quality Control certificates from Supranational Quality Control Certificate of Sweden.
4. Setting up TB culture laboratory in Chabahar and Iranshahr
5. Publishing a book entitled, "Familiarization with TB Concept for Health Workers and Technicians.
6. Presentation and publication of 7 articles at national congresses and journals.
7. Promotion of infrastructure with potential assistance of TB Global Fund Project including equipment purchase for office and laboratories and purchasing 9 vehicles for subordinate districts.
8. TB Information dissemination and training at senior and junior high schools affiliated to the university for four consecutive years in line with Global Fund Programs.
9. One- week TB workshop for an Iraqi delegation in coordination with World Health Organization and Center for Management of Communicable Diseases of Health Ministry of Iran.