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Experience with Tb diagnostics and Scale up of services Botswana, Nigeria, and Tanzania

Experience with Tb diagnostics and Scale up of services Botswana, Nigeria, and Tanzania. Ernest Ekong, MD,MPH National Clinical Coordinator Harvard PEPFAR AIDS Prevention Initiative Nigeria. Current Country Data on TB. INH/ Rifampicin resistance data The Botswana experience.

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Experience with Tb diagnostics and Scale up of services Botswana, Nigeria, and Tanzania

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  1. Experience with Tb diagnostics and Scale up of servicesBotswana, Nigeria, and Tanzania Ernest Ekong, MD,MPH National Clinical Coordinator Harvard PEPFAR AIDS Prevention Initiative Nigeria

  2. Current Country Data on TB

  3. INH/ Rifampicin resistance data The Botswana experience Above are the main results from the Botswana National drug resistance surveys in 1995-96, 1999 and 2002. Another national drug resistance survey (2007-8) finished in April this year. However, results will not be out before towards the end of this year.

  4. INH/ Rifampicin resistance dataThe Nigerian experience • To date, no systematic survey. Extent and pattern not known • 45 cases of MDR TB identified, recently using Hain’s test. • XDR TB may exist in Nigeria, but no case identified. • First national survey of MDR TB & XDR TB, planned for late 2008, expected to yield data on prevalence. • Survey needed for full scale country application to the Green Lights Committee for supply of second line anti-TB drugs

  5. Issues with diagnosticsBotswana, Nigeria and Tanzania • Lack of necessary diagnostic tests for TB/HIV affect provision of therapy • Limited lab capacity and access especially in rural settings • Lack of national standards and systems for accreditation, QA/QC and logistics • Limited technical support • High cost of diagnostic instrumentation and consumables

  6. Strategies for Scale-up of TB diagnosisNigerian situation • DOTS services improved, yet in all LGAs, • Case notification increased • Case detection rate, still below target • Increased lab capacity at all levels • General health workers trained on TB control strategies • Collaboration with tertiary hosps, Specialist clinics, and prison health services • Strengthened supervision of DOTS services from Federal to PHCs

  7. Tb diagnosticsStructure- Pyramidal network of labs • Peripheral labs for smear microscopy for acid and alcohol – fast bacilli at PHC in LGAs • State TB labs • Smear and fluorescent microscopy • Six Zonal Reference Labs • Smear & fluorescent microscopy, culture & isolate Mbact, EQA on state and peripheral labs • Two National Reference Laboratories • Also Drug Susceptibility Testing on isolates • EQA on Zonal Reference labs • Collaborate with identified Supranational Reference laboratories for panel testing and EQA

  8. TB/HIV Coordination • Special unit in NASCAP coordinating TB/HIV • Now has strategic framework • guidelines for implementation of TB/HIV activities • Infection control training manual in progress • Facility co-location of HIV/TB • Many DOTS centres at ART sites collaborating with >25 sites able to do comprehensive HIV/AIDS C&S, and ART • HIV screening for TB patients • Training: TB/HIV co-management • Remodeling of TB clinics to make for effective TB infection control

  9. Intensified TB Case finding • Screening • History and use of clinical questions • Suspected family members and close contacts of co-infected patients • AFB microscopy for sputum and aspirates • Culture - sputum, aspirates for EPTB • Histological examination - Biopsy tissue • Tuberculin test • CXR (alone NOT reliable) • For all patients at enrolment and those suspected of having TB during treatment • Facility co-location of HIV and TB clinics

  10. Successful IPT in BotswanaIssues • How useful to the country: • Helps decentralize intensified Tb case finding • Nationwide rollout, high awareness • Early identification and treatment • Measurement Intervention effectiveness, not yet • Supportive logistics: • Screening for active Tb • Data collection for M&E, drugs, etc • Patient adherence and education • How other countries are encouraged: • Positive, but data not supporting enough

  11. Tb Diagnostics and managementChallenges • Diagnostic problems • IPT issues • MDRTB • Need for new technology eg Hains test • Standardizing reporting and recording systems • 2nd line drugs for TB treatment • Low case detection rates & High default rates impact on treatment success • Absence of negative pressure equipment in labs • TB/HIV co-infection- therapy issues • Irregular supply and distribution of anti-TB drugs • Space constraints

  12. Recommendations for Scale-up • Advocacy/Communication/Coordination • Global: across categorical programs, agencies, foundations, etc. • Regional/National/Local • Physical infrastructure development • Laboratory-accurate, robust & rapid diagnostics • Equipment • Biosafety

  13. Recommendations for Scale-up • Quality Management and Improvement • Management programs • EQA/accountability • Human Capacity Building (education/training) • TA—all levels • Local adaptation • Indigenous plans with timelines • National strategy/plan

  14. Acknowledgements • Phyllis Kanki • Guerino Chalamilla • Tendani Gaolathe • Ric Marlink • Dan Onwujekwe • Rob Murphy • Wafaie Fawzi • Patricia Burns • Sunny Ochigbo • Abel Makubi • Prosper Okonkwo • Oni Idigbe

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