Early and Improved TB case detection through the use of GeneXpert technology in Nepal

About IOM International Organization for Migration (IOM) was established in The principal intergovernmental organization in the field of migration. IOM is committed to the principle that humane and orderly migration benefit migrants and societies. Working in more than 150 countries globally, 155 member states, 11 states and numerous international and non-governmental organizations are observers. Established in Nepal in Implementing several large and small projects in the country with the help of more than 400 national and international staff

TB REACH background IOM, in close collaboration with NTP, has successfully implemented TB REACH WAVE 2 Projects in Nepal “Early and improved case detection of TB through the use of GeneXpert technology in Nepal” –Started implementation in Nepal under W2Y1 (Oct Feb. 2013) –Awarded for rollover to year 2 (W2Y2: Mar Apr. 2014) –Recently awarded for Wave4, with several new interventions in the field (Jun 2014 – May 2015 with possibility of no cost extension)

Objectives 1.To increase case finding by increasing sensitivity of laboratory through the use of GeneXpert instruments. 2.To increase TB awareness and referrals through IEC campaign and referral system

1.TB case finding through use of point-of-care GX instruments 2.Increasing TB awareness and referrals among general population. 3.Increasing TB awareness and referrals among PLHA 4.To establish a referral system of smear- negative specimens for GeneXpert testing and specimen of Rifampicin resistant cases for Culture and DST Interventions

INDIA

Populations PopulationSize of the population Evaluation Population 7,444,602 Target Population 63,895 Control Population 2,858,347

Target groups Smear-negative individuals with high suspicion of TB Individuals with high risk of MDR TB –Retreatment (Failure, Relapse and Return after default) –Close contacts of MDR TB patients HIV+ with high suspicion of TB

Test Algorithm Smear not done

Indicators Process indicatorsTargetAchievement Ach. % TB Suspects screened23,42720,22886% SS-ve suspects referred for GX test17,66819,338109% SS-ve suspects Xpert positive5,219 (30) 3,279 (17) 63% HIV+ve referred for Gene X-pert1, % HIV+ve X-pert positive271 (22) 34 (20) 13% Specimen transported from hilly areas 1,6001,10969% Positive among referred cases250 (16) 138 (12) 55%

MTB/RIF Test Results Smear result Total Tests MTB Detected Test Failure RIF-RIF+RIF Indet.Total S-ve19,3383, ,279 (17%) 1,878 (9.7%) S+ve (85%) 38 (5.4%) Direct XP (20%) 12 (6.4%) Total20,2283, ,914 (19%) 1,928 (9.5%)

GX Centre wise achievement

Positivity Rate

Additionality Clear increase in additionality, 25 % in year 1 and 28% in year 2

Achievements All Nine GeneXpert Centres are functioning well in term of equipment and procedures. NTP staff are trained in testing, data recording and reporting on GX process. Over 25 % increase were noted in SS+/B+ cases. Sensitization and advocacy on GeneXpert: increased Interest and enthusiasm to use the technology in Nepal. National policy on GeneXpert is developed. Around 30 % of MTB positive cases are referred from private sectors.

IOM was awarded the Rana Samudra Trophy by NTP

External factors/Challenges Limited culture and DST facility to confirm Rif+ cases and high number of invalid results from culture. Limited working hours at the GeneXpert Centre Laboratories (4 hours) High number of test failure (nearly 10%) Machinery problems (module break down, calibration) Difficulties in assurance of treatment enrolment for all GeneXpert positive cases The current reporting system does not capture the GX+ cases separately

Lesson Learned Referral mechanism and community mobilisation are crucial to increase number of tests. Strict follow up of algorithm (screening by CXR) increases the Xpert test yield. Regular technical support should be provided to GeneXpert centres. Procurement is important, better planning is needed for formalities for releasing Xpert equipments from the costums.

Lesson Learned (Cont) The life of Cartridges is normally short, so to order two shipments per annum will be beneficial. Tempreture for storage to be less than 30 C Tempreture for calibration to be optimal (16 C) Calibration is important and should be done annually. Xpert is helpful in detecting TB cases early and will increase the bacteriological positive cases but may not necessarily increase all form TB cases.

Some other interesting observations!!! Microscopic Centres (MCs) are normally overburdened and there are inadequate infrastructure at the laboratories. Limited opening hours of health service facilities including microscopic centres. There is no adequate communication and interaction between health care providers and patients. Infection Control is also a issue in microscopic centre.

Acknowledgements ! 1.WHO TB REACH/CIDA 2.Dr. Rajendra Pant, NTC Director and his team for providing full supports and guidance to the project 3.All regional and district level NTP officials 4.WHO Nepal TB team, particularly Dr. Giampaolo Mezzabotta 5.Dr. Bhawana Shrestha and her colleagues at GENETUP 6.IOM Nepal Colleagues

Snapshots

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