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

Botswana Nigeria Tanzania

Country Population 2,000,000 140,000,000 37,626,917

Estimated number of new Tb cases

11,622 373,682 130,606

Estimated Tb incidence/100,000 pop/yr

551 290 347

DOTS Population coverage (%) 100 65 100

Rate of new sputum smear positive (SS+) cases/100,000 pop

218 26 69

DOTS case detection rate (new SS+) (%)

73 21 47

DOTS treatment success rate in 2003 (new SS+) (%)

78 79 81

Estimated adult Tb cases HIV+ (%)

54 27 44

New multidrug resistant Tb cases (%)

10 1.7 1.3

1995-96 1999 2002

New patients (n=430) (n=638) (n=1182)Any drug resistance 3.7% 6.3% 10.4%Any INH resistance 1.6% 4.4% 4.5%Any rifampicin resistance 0.9% 0.6% 2.0 %Any MDR 0.2% 0.5% 0.8%

Previously treated patients (n=121) (n=145) (n=106)Any drug resistance 14.9% 22.8% 22.6%Any INH resistance 9.9% 26.6% 14.2%Any rifampicin resistance 8.3% 24.2% 12.3%Any MDR 6.1% 9.0% 10.4%

INH/ Rifampicin resistance dataThe 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.

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

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

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

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

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

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

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

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

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

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

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