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