A shift of gears in the diagnosis of Tuberculosis (TB) is expected after modern technologies capable of changing the game for TB were introduced and distributed nation-wide in 2018.
The introduction of 28 Gene X-pert machines and over 20 LED microscopes in all six administrative zones and all levels of the three-tier health system are suggestive of the country’s support to ending the global TB epidemic by 2035, set forth by the WHO’s End TB Strategy in 2014. In addition to that, this innovatory step is also in line with the Sustainable Development target for 2030 of Universal Health Coverage among others (NTP 2018 and GTR 2018).
These state-of-the-art technologies will help increase the national detection rates of TB cases, promote early and accurate diagnosis of patients, decrease case-fatality and transmission rates as well as improve patient outcomes and treatment delays (WHO implementation manual, 2014). According to the WHO’s implementation manual, the Gene X-pert machine is a molecular test capable of the simultaneous detection of Mycobacterium tuberculosisbacilli and resistance to rifampicin. Thus, this innovation comes in handy in the timely context of the alarming global rise of Multi-Drug-Resistant TB (MDR-TB) and the very scant treatment successes of people with MDR-TB. Furthermore, the Gene X-pert machine is capable of producing results for samples in less than 2 hours, contrary to other diagnostic methods which take days or even months in some instances to confirm the disease giving TB a chance to spread even more (WHO implementation manual, 2014).
Before its substitution with new technology, smear-sputum microscopy was the most widely used traditional laboratory test for TB in Eritrea, which, albeit being time-tested and very cost-effective, proved to have many limitations such as lack of sensitivity, dependence on proficiency of personnel and incapability to identify drug resistance (WHO implementation manual, 2014). Cases of treatment failures used to be empirically diagnosed as MDR-TB and treated accordingly, incurring harm and losses due to provisions of unnecessary, incorrect or suboptimal treatment. Afterwards, culture of Mycobacterium tuberculosis bacilli was introduced for diagnostic purposes. Although a gold standard method, culture was demonstrated to be virtually impossible for routine diagnostic tests in resource-constrained countries like Eritrea as it demands highly skilled personnel, costly infrastructure and complex procedures not to mention the tremendous amount of time it consumes. Thus, the adoption of the Gene X-pert alleviates many of these restrictions by offering the most advantageous qualities of both laboratory tests. That is, the X-pert machine has the same infrastructure and skilled personnel requirements of smear-sputum microscopy while having a sensitivity close to the culture method.
Although Eritrea, along with other countries, is phasing out the use of smear-microscopy for diagnostic purposes, microscopy is still necessary in treatment monitoring for patient follow-up. However, Eritrea has also pioneered this area of TB control by introducing LED microscopes, which have higher sensitivity and specificity than the traditional light microscopes (NTP, 2018). Hence, better results in patient follow-up will be expected, which will further imply better treatment outcomes, improved detection of treatment failures as well as decreased transmission rates.
Training courses for the operational functioning of Gene X-pert machines and LED microscopes have been given to interested health cadres in all six zones of the country under the auspices of the National Health Laboratory in the year of 2018 and are still continuing in 2019, as stated by the National TB Program.
The synergistic effect of these two modern diagnostic tests will aid Eritrea in turning the tables in the fight against one of the all-time killer diseases in the world. According to the WHO Global TB Report of 2018, TB ranked as one of the top 10 causes of death in the world as well as the leading cause of death from a single infectious agent (above HIV/AIDS) in 2017. About 10 million people developed TB and over 1 million deaths have been recorded in 2017 (GTR, WHO 2018). One of the regions greatly contributing to this global burden is the Sub-Saharan Africa with an estimated incidence rate of 150-300 cases per 100,000 people (NTP 2018). As a matter of fact, TB is also called “the disease of the poor”, as it usually prevails in middle and low-income countries such as those characterizing this region. Different forms of poverty including lack of knowledge, inappropriate housing, low income and poor nutrition facilitate the spread of this disease. Therefore, controlling TB doesn’t just rely on breakthroughs in laboratories but a multisectoral approach.
Eritrea is aware of this fact and has, in fact, instituted guideline changes in the criteria for patients to undergo a Gene X-pert test. According to the Ministry of Health, anyone with a cough of 2 weeks or beyond is eligible to a Gene X-pert test as of the year 2019. Health facilities lacking this kind of technology have been furnished with vehicles for transportation, cold boxes for the storage of sputum and drivers (MoH, 2018). Moreover, Eritrea allows access to these high-quality diagnosis and treatments without incurring catastrophic costs to patients and families, which is in tune with the End TB Strategy. In fact, it delivers TB diagnostic and treatment services free of charge or with a nominal fee in addition to providing an allowance of 1,500 Nakfa every month to families of MDR-TB in-patients in the process of treatment at Merhano Hospital as reported by the Ministry of Health.
The world as a whole has been battling this disease for over a century now, but TB’s persistent nature has helped it to persevere to date. The war against TB, however, is on-going and will not abate until the vision endorsed by the world in 2014 of “zero deaths, disease and suffering due to TB”is ensured.