Evaluation of the tuberculosis surveillance system in the Ashaiman municipality, in Ghana

Introduction Tuberculosis (TB) was the leading cause of death from an infectious illness globally with an estimated 10.4 million new cases and 1.4 million deaths in 2015. In Ghana, from the 2013 TB prevalence survey conducted by the National Tuberculosis Control Programme, the incidence is estimated as 165 per 100,000 population and a mortality rate of 7.5 per 1,000 infected people. The Tuberculosis surveillance system is part of the general framework of the Integrated Disease Surveillance and Response. This evaluation was to assess whether the system is meeting its set objectives, assess its usefulness and describe its attributes. Methods The TB surveillance system of the Ashaiman municipality was evaluated using Centre for Disease Control and Prevention updated guidelines for evaluating public health surveillance systems 2006. Records review from 2014 to 2016 was done to assess objectives of the system and surveillance data source of 2016 was used to assess attributes. Interviews were conducted at the various levels using semi-structured questionnaire and data analysis done with Epi info 7 and Microsoft Excel to run frequencies and percentages. Results The surveillance system is well structured with standardized data collection tools. The system was found to be useful, though it just partially met its objectives. It was also found to be simple, flexible and fairly stable with average timeliness. It had low acceptability and is not geographically representative. It had low sensitivity of 45/100,000 and a low predictive value positive of 6.6%. Conclusion The surveillance system was found to be useful but partially met its objectives. There is the need to improve the sensitivity, predictive value positive timeliness and acceptability.


Introduction
Tuberculosis (TB) remains a major global health problem [1]. It causes ill-health in millions of people each year and is one of the top 10 causes of death worldwide [2]. Globally, an estimated 10.4 million people fell ill with the disease in 2015 with 1.4 million deaths [3]. The global pandemic of TB is growing as a result of the spread of Human Immuno Virus (HIV) infection, breakdown in health services and emergence of multidrug resistant TB [4,5]. Many people who have been exposed to the bacilli and have strong immunity have latent TB infection and do not have symptoms [6,7].
A number of factors make people more susceptible to TB infections.
People who have HIV infection, chronic lung disease, smoking cigarettes, excessive drinking of alcohol and diabetics have an increased risk of developing tuberculosis [8][9][10]. The most important risk factor however is HIV [11]. Tuberculosis is closely linked to both overcrowding and malnutrition, making people in confinement e.g. prisoners [12] or those in hostels e.g. students, high risk groups.
People who live in resource poor communities like slums and children who are in close contact with infected patients as well as health care workers attending to these patients are also at risk [13][14][15]. TB is more common among men than women and affects more people in the economically productive age group (15-59 years) [16].
The African Region has approximately one quarter of the world's cases, and the highest rates of cases and deaths relative to population [17]. Public health surveillance is a critical element in disease prevention and control, providing essential epidemiological data on which public health action can be based. Such data, not only identify areas of need for intervention, research and policy change, but can also be used to evaluate the impact of these actions [18]. Evaluation of public health programs is vital to ensure efficient program operation and, ultimately, health improvement.
Surveillance evaluation seeks to ascertain whether a health event is monitored efficiently, and how well the purpose and objectives of the system is being met [19].
Tuberculosis prevalence survey conducted in Ghana by the National Tuberculosis Control Programme in 2013 revealed that there were 165 incident cases per 100,000 people. This is higher than World Health Organization (WHO) estimates of about 92 per 100,000 people [20]. The results showed that there were more undetected cases than previously estimated. The high prevalence of TB was as a result of the high number of TB cases among people living with HIV and Acquired Immune Deficiency Syndrome (AIDS). TB mortality rate in Ghana is considered high at 7.5 per 1,000 infected people [21]. To reduce this burden, detection and treatment gaps must be addressed, funding gaps closed and new tools developed.
The socioeconomic burden of TB ranges from stigmatization from family and community to poverty. The Ashaiman municipality is one of the high incidence tuberculosis districts in the greater Accra region of Ghana based on a case notification rate of 72 per 100, 000 population in 2013 [22]. The objectives of the Ashaiman TB surveillance system is to early detect persons with infectious lung disease to improve chances of cure and reduce transmission of TB and to improve percentage of TB cases confirmed by microscopy.
This evaluation was carried out from January to March 2017 to assess whether the system is meeting its set objectives, assess its usefulness and describe its attributes.

Methods
This was a descriptive, evaluative study of the TB surveillance system using Centers for Disease Control and Prevention (CDC) updated guidelines for evaluating public health surveillance Systems were used. Attributes with scores greater than 60% were ranked as good, those between 51% and 60% were ranked as average and those below 50% were ranked poor.

Ethical issues:
This study was carried out as part of an operational research to determine the effectiveness of the TB surveillance system in the country and used mostly already existing health service records. Relevant administrative approvals were obtained from all the institutions involved before data was obtained.

Results
Purpose and operation of the system: TB is a notifiable disease. The mandate of the National Tuberculosis Control Programme (NTP) is to provide leadership for the health sector response to fight tuberculosis in Ghana. It was launched in 1994 and aims at reducing the transmission of the disease to a level that is no longer a major public health problem. In terms of administration the Health Service is organized into a three-tiered system: National, Regional and District levels but is a five-tiered system in terms of service delivery: National, Regional, District, Subdistrict and Community. hardcopies) by the district TB coordinator. Data are sent from the regional level electronically to the national level quarterly by the regional TB M&E officers. The regional and national levels also receive data from some NGOs when necessary. The DHIMS forms for data entry was initially different from the NTP forms but that was corrected in 2015. The municipal TB coordinator receives data on the drugs given to patients from the polyclinic pharmacy only, since all the facilities collect their TB medication from there. The Regional External Quality Assurance Team (EQA) collects data from the TB04 (the laboratory TB registers) quarterly. The parameters used to assess sputum smear microscopy centres by EQA include sputum size (1-3mls), sputum thickness, cleanliness, sputum quality, microscopy results.

Data validation and feedback:
Data validation is done at the district, regional and national levels. Feedback is given at periodic meetings, via social media (WhatsApp) or verbally.  Table 1 Usefulness of the surveillance system: The TB surveillance system was found to be useful in detecting cases on time for  Quarterly report forms on TB case registration (TB 07) and treatment results (TB 08) have been redesigned for easy data analysis. TB 07A and TB 08A are for adults whereas TB 07P and TB 08P are for children less than 15 years. There were regular meetings between Regional level and local-level officials (monitoring and evaluation and support visits) to discuss surveillance, conduct training, and discuss strategies to increase case detection and efficiency in the reporting system. These suggest that the system is flexible.

Performance of the system
Stability: The TB surveillance system is able to collect, manage and provide data properly without failure and also the system is mostly operational when it is needed. Absence of enabler packages have however made home visits and home verification difficult.

Discussion
The findings of the evaluation shows that the TB surveillance system of Ashaiman municipality is well structured with specific roles assigned to different stakeholders and with good channels of communication. This was demonstrated in the flow of information and the levels of reporting as well as the feedback from the district and regional levels. The results are comparable to other TB surveillance systems in the country [23,24]. A public health surveillance system is useful if it contributes to the prevention and control of adverse health-related events and also contributes to This may be due to the fact that private health facilities are profit oriented but TB diagnosis and treatment is free. This means that the staff that are paid at the private facilities would use the man hours to provide free service for TB at the expense of income generating services. Again all the staff at private facilities are paid directly by their employers. Low acceptability of TB surveillance system from Private Health facilities is common in other parts of the country [25].
Representativeness is also low. Four(4) out of the six(6) treatment centres in the municipality are located in one sub-district and this means that clients have to travel some distance before assessing TB services. The sensitivity of the surveillance system is low. This is similar to the situation in other districts in the Greater Accra Region and the country as a whole [24,25]

Conclusion
The tuberculosis surveillance system in the Ashaiman Municipality is well structured with standardized data collection tools. The system was found to be partially effective in meeting its objectives. It is useful as it has led to improved clinical practices, flexible, simple and of good data quality but needs to improve on sensitivity, acceptability, timeliness and predictive value positive. It was found to be useful and has led to improved clinical practices and informed decision making. It is recommended that to improve on case detection more screening activities should be carried out in communities, within facilities and departments. The district health management Team should encourage private facilities to be involved in TB surveillance as well as get a deputy for the district disease control officer to support surveillance activities. In the absence of enabler's package, facilities should support sputum transport, home verification and home visits. This can be done when surveillance activities are budgeted for.
What is known about this topic  It is well known that the tuberculosis surveillance system is necessary for the early detection of cases, improvement in the cure rate and reduction in the transmission of TB.