Assessment of the laboratory capacity for testing Sexual Transmitted Infections at 14 health facilities in Moshi Municipality, Tanzania

A 2023 cross-sectional study of 14 health facilities in Moshi Municipality, Tanzania, reveals a critical lack of advanced laboratory capacity for diagnosing sexually transmitted infections and monitoring antimicrobial resistance, highlighting an urgent need for infrastructure investment and training to improve STI management.

The Gist

Imagine the healthcare system in Moshi, Tanzania, as a large team of mechanics trying to fix cars (patients) that have broken down due to specific engine problems (Sexually Transmitted Infections, or STIs). This paper is like a report card checking if these mechanics have the right tools, the right manuals, and the right skills to diagnose exactly what is wrong before they start fixing it.

Here is the breakdown of what the study found, using simple analogies:

The Big Picture: Guessing vs. Knowing

For a long time, doctors in this area have been using a "guessing game" approach called syndromic management. Imagine a mechanic seeing a car make a strange noise and immediately replacing the whole engine because they think it's the engine, without actually looking under the hood. This is cheap and fast, but it often leads to mistakes. They might fix the wrong part, or worse, they might miss the real problem entirely because some car troubles (like certain STIs) don't make any noise at all.

With bacteria becoming "superbugs" that are harder to kill with standard medicine (Antimicrobial Resistance), guessing is becoming dangerous. We need to open the hood and look at the specific part that is broken. This study checked if the clinics in Moshi had the tools to do that.

The Toolkit Check: What They Have vs. What They Need

The researchers visited 14 different "garages" (5 hospitals and 9 health centers) to see what tools were in their boxes.

• The Basic Tools (The Good News): Every single garage had the basic tools to check for HIV and Syphilis. It's like every mechanic having a standard oil dipstick. They also had tools to look for a specific parasite called Trichomonas under a microscope.
• The Missing High-Tech Tools (The Bad News): When it came to the two most common bacterial infections, Gonorrhea and Chlamydia, the garages were empty-handed.
  • Chlamydia: None of the 14 facilities had a single test for this. It's like a mechanic having no way to detect a specific type of fuel leak.
  • Gonorrhea: While a few hospitals said they had the equipment to grow bacteria in a lab (like a special oven to culture the bug), none of them actually successfully found the bacteria in the past year. It's like having a high-tech engine scanner that is plugged in but never actually turned on or working.
  • Confirming Syphilis: None of the hospitals had the advanced tools needed to confirm a syphilis diagnosis if the initial quick test was positive. They could find a suspect, but they couldn't get the fingerprint evidence to prove it.

The Workshop Condition: Manuals and Maintenance

Having the tools isn't enough; you also need to know how to use them and keep them working. The study found some worrying gaps here:

• Missing Manuals: Most clinics didn't have written instruction manuals (Standard Operating Procedures) for how to run these tests. It's like trying to fix a complex car without the owner's manual.
• Broken Tools: Many facilities didn't have records of when they last serviced their microscopes or incubators.
• Running Out of Supplies: A major complaint was that they often ran out of the "oil and filters" (reagents) needed to run the tests.

The "Why" Behind the Failure

The paper explains that even when the equipment is there, it often doesn't work because:

1. The bacteria are picky: Growing Gonorrhea in a lab is like trying to grow a very delicate orchid; it needs perfect temperature, perfect air, and special soil. If the sample sits too long or the soil is wrong, the plant (bacteria) dies before you can see it.
2. Lack of Training: The mechanics (lab staff) haven't been trained recently on how to handle these delicate tests.
3. Cost: The fancy, modern tests that could solve these problems (like rapid point-of-care tests) are too expensive or require electricity and storage conditions that these clinics can't afford or maintain.

The Bottom Line

The paper concludes that while the clinics in Moshi are good at the basics, they are currently flying blind when it comes to the most common bacterial STIs. They are treating patients without knowing exactly what they are treating.

To stop the spread of these infections and the rise of "superbugs," the paper argues that we need to invest in better "garages." This means buying working tools, writing clear instruction manuals, training the mechanics, and ensuring they have a steady supply of parts. Without this, we can't accurately diagnose the problem, and we can't stop the spread of these infections effectively.

Technical Summary

Technical Summary: Assessment of Laboratory Capacity for STI Testing in Moshi Municipality, Tanzania

Problem Statement
Sexually transmitted infections (STIs) remain a significant global public health burden, with rising rates of antimicrobial resistance (AMR) in pathogens such as Neisseria gonorrhoeae (Ng) complicating treatment. While the World Health Organization (WHO) and the Tanzania National Standard for Medical Laboratories (2017) advocate for etiological diagnosis to guide treatment and monitor AMR, many low-resource settings rely on syndromic management. This approach, while cost-effective, often leads to misdiagnosis, overtreatment, and the inability to detect asymptomatic infections or emerging resistance patterns. There is a critical lack of documented data regarding the actual laboratory capacity to perform recommended STI diagnostics in Tanzanian health facilities, particularly concerning the gap between national guidelines and on-the-ground reality.

Methodology
This study employed a cross-sectional design conducted between May and July 2023 in the Moshi Municipal Council, Kilimanjaro region, Tanzania. The assessment covered 14 health facilities: five hospitals (including zonal, regional, and district levels) and nine health centers. Data collection involved:

• Questionnaires: Administered to laboratory scientists or technologists to gather data on facility type, available STI tests, equipment, and training records.
• Observations: Direct verification of equipment maintenance records, availability of Standard Operating Procedures (SOPs), and inventory systems.
• Document Review: Examination of quality control programs, reagent validation/verification logs, and SOPs for reagent storage and usage.
• Analysis: Descriptive statistics (frequencies, percentages, medians, and interquartile ranges) were used to analyze the availability of tests, adherence to standards, and reported challenges.

Key Contributions and Results
The study provides a granular assessment of STI diagnostic capabilities against the 2017 Tanzania National Standard for Medical Laboratories.

• Diagnostic Capacity Gaps:

  • Universal Availability: All 14 facilities (100%) could perform Rapid Diagnostic Tests (RDTs) for HIV and Syphilis.
  • Microscopy: Wet mount microscopy for Trichomonas vaginalis (TV) was available in 80% of hospitals and 100% of health centers.
  • Critical Deficiencies:
    • Chlamydia and HPV: No facility (0%) offered testing for Chlamydia trachomatis (CT) or Human Papillomavirus (HPV).
    • Syphilis Confirmation: No facility performed confirmatory serological tests (TPHA/TPPA) for syphilis.
    • Gonorrhea Culture: Only 3 out of 5 hospitals (60%) possessed the capacity for N. gonorrhoeae culture using chocolate and blood agar. Crucially, none of these facilities reported isolating N. gonorrhoeae in the past year, indicating a lack of functional culture capability despite nominal equipment availability.
    • Hepatitis: Hepatitis B and C testing was available in 80% of hospitals but only 44% of health centers.

• Operational and Quality Standards:

  • SOPs and Training: Only 29% of facilities had SOPs for equipment operation, and 57.1% reported a lack of on-the-job training programs.
  • Quality Control: While 71% of facilities had quality control programs for reagents, only 14% conducted reagent validation or verification.
  • Inventory: 71% had inventory systems, but only 36% had SOPs for inventory management.

• Reported Challenges:
  The primary barriers identified by facility staff were the lack of testing guidelines (85.7%) and lack of SOPs (71.4%), followed by reagent shortages (64.3%) and the absence of training programs (57.1%).

Significance and Claims
The paper asserts that the findings underscore a "concerning lack of STI testing capacity" within the surveyed healthcare facilities, which poses significant barriers to effective STI management and exacerbates the threat of AMR in Tanzania.

• Impact on AMR Surveillance: The inability to culture N. gonorrhoeae and perform antimicrobial susceptibility testing (AST) severely compromises the ability to track and monitor AMR trends. The authors note that while culture capacity exists nominally in some hospitals, it is not functionally operational, reflecting a broader challenge across sub-Saharan Africa where less than 1% of clinical laboratories are designated for bacteriological testing.
• Need for Aetiological Diagnosis: The study highlights that the current reliance on syndromic management is insufficient given the rise of AMR and the prevalence of asymptomatic infections. The absence of testing for CT and HPV, and the lack of confirmatory syphilis tests, leaves a major gap in the national response.
• Future Implications: The authors argue that urgent investment in laboratory infrastructure, training, and quality systems is imperative. They suggest that without robust diagnostic capacity, the implementation of new interventions—such as Doxycycline post-exposure prophylaxis (DoxyPEP) or potential vaccines for gonorrhea and chlamydia—cannot be properly monitored or evaluated for safety and efficacy in the Tanzanian context. The study concludes that strengthening laboratory capacity is a prerequisite for curbing transmission and mitigating the impact of AMR.