TANZANIA: USE OF DRIED BLOOD SPOT (DBS) FOR SURVEILLANCE

Dr. T.TULLI
National AIDS Control Programme Ministry of Health, Tanzania

BACKGROUND
Sentinel surveillance of HIV/AIDS and Syphilis was initiated in one region late 80s. In early 90s the NACP developed a protocol for ANC HIV/AIDS and Syphilis surveillance which expanded surveillance activities to 55% of the country (11/20 regions) From mid to late 90s HIV/AIDS and syphilis ANC surveillance in Tanzania occurred irregularly and few surveillance sites collected data with quality assurance mechanisms in place.

Background continue...
Because of this inconsistent process, it yielded data that were of limited use for National planning purposes. In 1999 NACP undertook a comprehensive review and phases implementation of improved methods and logistics for HIV/AIDS and syphilis surveillance. This step of the Ministry of Health in the advance towards second generation surveillance has resulted in quality HIV/AIDS and syphilis data.

REVISED METHODS OF HIV/AIDS and Syphilis sero surveillance.

The improvement process began with a situational analysis conducted in 1999 that examined strengths and weaknesses of the existing system. Major weaknesses identified included: irregular adherence by surveillance sites to the methods in the national surveillance protocol. - inadequately supervised surveillance personnel. - lack of human and financial resources, and inconsistent availability of necessary surveillance supplies throughout
the study period.

Revised methods continue...

This analysis was used in June 2000 by multidisciplinary team to develop guidelines for monitoring and evaluation of AIDS during mid term plan III, 2000-2002 that proposes a strategy to improve and intensify HIV/AIDS and syphilis surveillance in Tanzania.

NACP revised the 1990 surveillance protocol. Key surveillance design and testing revision are duration of three months of data collection instead of a full year the introduction of Dried Blood Spot sampling at surveillance ANCs and centralized testing at the National HIV Reference laboratory. The protocol was also translated into local language (Kiswahili) to facilitate its use in the field.

Revised methods continue.

To insure that all staff adhered to methods in the revised National surveillance protocol, a centralized training of surveillance personnel from all the sites, implementing this activity was organized. The three days training included a review of surveillance methods and practical sessions demonstrating how to collect RPR samples, DBS preparation, store and posting.

Revised methods continue.

The Health workers collected DBS sample on a filter paper from a collected blood sample. Each DBS sample was given a unique surveillance number similar to that entered in the questionnaire of that particular woman. The filter papers were dried after which the health worker packed them in a ziplock bag. The blood samples were then transported to MUCHS for HIV testing.

laboratory and Supervision continue...

At the laboratory the DBS samples were kept frozen until testing started. To ensure adequate supervision, the NACP assembled a study team of laboratory and surveillance staff to monitor adherence to the protocol, DBS preparation and availability of supplies at all sites. Team member visited each site according to regular timetable.

laboratory and Sites continue...

The number of DBS received by post at Muhimbili National HIV reference laboratory was monitored directly by the NACP and the study team would then contact sites that had DBS posting lower or unexpected number. During monitoring visits, sites were provided with funds for courier posting of DBS and filled data forms to the National Reference Laboratory. At the end of three months data collection DBS testing was done.

At laboratory continue...
The department of Microbiology and Immunology of the MUCHS in collaboration with CDC developed a protocol for DBS testing and quality assurance. Since the DBS Specimen are many, Regional laboratory technologist from the surveillance regions joined MUCHS laboratory technologists in testing the samples.

Lessons learned
Availability of solid study protocol in both English and local (Kiswahili) languages as a reference material in all ANC sites facillitated understanding of study methods and hence improve the quality of collected data. Live demonstration and hand on experience with blood collection, motivated ANC surveillance personnel and hence enhanced quality and uniformity/standardization in data collection.

Lessons learned continue...

Use of innovative technique has resolved problems of cold storage for serum in rural areas where electricity to run refrigerators is not available and evaded the task of separation of blood sample that would require additional human time. A full stock of surveillance supplies should be procured and distributed before commencement of the survey.

Lessons learned continue...

Supervision and monitoring of surveillance activities should not necessarily be undertaken by NACP alone. The cooperation and commitment shown by the surveillance study team indicate that partners are potential surveillance resources when they are empowered.

Lessons learned continue...

Regular supervision enhanced quality and uniformity of data collection and adherence to the protocol of methods. Decentralization of activities and empowering of actors at all levels is essential in order to spread the workload and therefore human resources needs.MUCHS was overwhelmed by DBS, which accumulated and necessitated bringing laboratory Technicians from the regions to add forces.

CHALLENGES:
Human resources- Most of the time nurses move from one health facility to the other resulting into training of new participants each year. Weather changes in the country- Moist humidity cards and desiccant packs can be re-used by simply place in a 65C oven over night until the color indicator returns to a blue color. This is not possible in rural settings where electricity or supply of the oven is available. Therefore this lead to use of a lot of these supplies.

WAY FORWARD
Decentralization of DBS testing in the zonal and regional laboratories There is a need to improve the quality of these laboratories including provision of necessary equipment including ELISA testing equipment's and capacity building among laboratory staff in Kilimanjaro Christian Medical Centre, Bugando Medical Centre, Mbeya Refferal Hospital and Amana Municipal hospital.