Post on 21-Jan-2016
Strengthening specimen referral and transport networks in
resource-limited settings: a Nigerian pilot to improve
diagnosis
The 46th UNION world conference on Lung health Cape Town, South Africa 2nd – 6th December 2015
S. Useni, S. Massaut, M. Gidado, J. Onazi, S. Gande, P. Nwadike, S. Kik
TB Situation – Nigeria (2015 Global TB Report)
Population: 177,000,000 DOTS centers: 5,398 AFB microscopy centers: 1,515 Culture DST laboratories: 6 GeneXpert laboratories: 96 Incidence Rate: 322/100,000 Total notified cases 2014 all forms: 91,354 CNR all forms for TB 2014 (per 100,000): 15.4% HIV prevalence : 3.4 % TB/HIV co-infection: 19% (16,066 cases) ART centers : 491 (85% TB/HIV co-located) MDR among new TB cases: 2.9% MDR among previously treated TB cases: 14%
Why this pilot?
Practical model to demonstrate feasibility of using Xpert MTB/RIF to ↑ TB diagnosis within routine HIV care setting
• Increase number of PLHIV tested for TB with Xpert & put on treatment
• Strengthen accessibility & quality of Xpert testing
• Inform policy & public health practices
The Pilot Model
TB/HIV Services
Intensified Case
Finding
Increase TB mindedness
Strengthen R&R and
Supervision Increase Access to Diagnostic Services
Simplify care and
treatment
Pilot timeline
Nov-Dec 2013Site
Assessments
Jan-Mar 2014Model Design
Apr-May Training
and Preparation
April/May-DecImplementation
Jan-May complete data collection and
analysis
Geographical HIV prevalence by stateNational HIV prevalence – 3.4%National TB/HIV co-infection - 19% (16,066 cases)
Nasarawa statePopulation 2,202,906 HIV Prevalence: 7.5%TB CNR: 128.2/100,000
Pilot Sites:
Niger state
Population 4,670,286
HIV Prevalence: 4.0%
TB CNR: 35.9/100,000
Hub & Spoke Implementation
XPERTPilotSite
1
2
3
4
5
6
7
8
9
10
Nasarawa State
Lafia (Dalhatu Araf Specialist Hospital)
Niger State
Minna General Hospital
Existing Xpert New Xpert
Referral Site Km
1 PHC New Market 5
2 GH Obi 26
3 PHC Doma Road, Lafia 10
4 PHC Kwandere (DOTS) 12
5 Family Health Clinic (FAHCI) 5
6 MCH Care Centre, Shabu 11
7 GH, Akwanga 30
8 GH Nassarawa Eggon 22
9 Ola Hospital, Akwanga 32
10 ERCC Alushi 34
Referral Site Km
1 General Hospital Kuta 80
2 Rural Hospital Sarkin Pawa 84
3 MMM Fuka 60
4 Devine Mercy Hospital 25
5 Sabon Titi PHC Tunga Minna 25
6 Town Clinic Bosso 25
7 General Hospital Kagara 120
8 General Hospital Wushishi 128
9 IBB Hospital 15
10 FMC Gawu 130
Specimen Transportation: Set-up
• Nonexistent at the start of operations
• Required implementation
• Reinforced proper specimen collection procedures
• Trained on triple packaging (cold box)
• Transportation (dispatch) Registry
• Sputa only with Lab request forms
• Variable means of transit (fuel provided)
• Transportation twice per week from 10 peripheral sites
• Included RETURN of test results (TAT= 3-5 days)
Number of samples received from peripheral sites - based on presumptive TB register -
All Nassarawa Niger0
500
1000
1500
2000
2500
3000
1066767
299
1599
5301069
Number of referred specimens for Xpert testing during pilot period (March-Dec 2014)
Referral siteOwn site
Num
ber o
f ind
ivid
uals
60%
41%
82%
40% 59% 18%
Increase in PLHIVs tested for TB (Baseline vs Pilot)
Baseline Pilot
Baseline: 15% of pres. TB cases were known PLHIV418 PLHIV tested
Pilot:42% of pres. TB cases were known PLHIV1534 PLHIV tested
Number of PLHIV tested remarkably increased
3-fold increase in HIV positives tested for TB
1,534 HIV positives tested in pilot period (84% of those registered)
418 HIV positives tested in baseline period (78% or those registered)
Successful Interventions
• Strengthened sputum transportation/referrals by reducing physical movement of clients. 60% (1,066 out of 2,665) of all sputum specimens that were tested with Xpert were from referral sites through hub and spoke model
• Improved access to diagnosis by geographic coverage for TB screening among PLHIV due to implementation of effective specimen referral system (at baseline, only 9 PLHIVs were tested with Xpert and in pilot period 782)
• Intensified case finding among PLHIV of 1.9 fold increase for notified bacteriological confirmed TB cases (at baseline 180 cases compared to pilot of 347 cases)
Overall Challenges
• Changing current testing paradigm (ALL asymptomatic new PLHIV)
• Maintaining overall understanding and motivation• Coordination/communication
- onsite/remotely - staff of separate programs and different interests
• Unpredictable interruptions- Industrial strike action by HCW from Jun. – Aug. 2014 and Nov. – Dec. 2014 (end pilot activities)- Political/civil unrest in Nasarawa state- Fire at Laboratory building in Niger state
• Insufficient tools and commodities- No approval by NTP to print revised National tools - Improvised existing tools to capture indicators - Periodic stock out of cups, R&R tools, and cartridges
Future impact
Lessons learned for scale up…
• raising awareness on GeneXpert among clinicians in relation to TB/HIV case management
• increasing access to GeneXpert testing through a well-functioning sputum sample transportation system
• strengthening supportive supervision
• While the model was successful according to the results, there is need to focus on:
basic elements of TB/HIV case management
data recording at the facility level
A well-coordinated sputum transportation system to Xpert testing sites minimizes the movement of patients and increases access to diagnostic and care services; not only for TB but also HIV.
Conclusion
Acknowledgments
KNCV TB FoundationFMoH – NTBLCP & NASCPMoH Niger state - TBCLP & SASCP MoH Nasarawa state - TBCLP & SASCP