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

About IOM

• International Organization for Migration (IOM) was established in 1951.

• 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 2006.

• 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. 2011- Feb. 2013)

– Awarded for rollover to year 2 (W2Y2: Mar. 2013 - 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

INDIA

Populations

Population Size 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

Microscopy

SS+SS-

Xpert/ Rif

Treat with FLD

Confirm result with LPA or Conventional DST

Treat with SLD

Further ClinicalManagement

No MTB MTB+ / Rif SenMTB+ / Rif Res

CXR

Abnormal CXRNormal CXR

Smear not done

Indicators

Process indicators Target AchievementAch.

%

TB Suspects screened 23,427 20,228 86%

SS-ve suspects referred for GX test 17,668 19,338 109%

SS-ve suspects Xpert positive 5,219 (30) 3,279 (17) 63%

HIV+ve referred for Gene X-pert 1,257 173 14%

HIV+ve X-pert positive 271 (22) 34 (20) 13%

Specimen transported from hilly areas

1,600 1,109 69%

Positive among referred cases 250 (16) 138 (12) 55%

MTB/RIF Test Results

Smear result

Total Tests

MTB DetectedTest

FailureRIF- RIF+ RIF Indet. Total

S-ve 19,338 3,031 131 117 3,279(17%)

1,878(9.7%)

S+ve 702 450 139 8 579(85%)

38(5.4%)

Direct XP 188 34 2 2 38(20%)

12(6.4%)

Total 20,228 3,515 272 127 3,914(19%)

1,928(9.5%)

1567

1920

1020

1906

1373

18101634 1709

1450

230

198

103

240

134

189243 219

372

193

481

203

605

345

370306

753658

Ilam Jhapa Mangal Morang Sunsari Saptari Sirha Bhaktapur Parsa

Te

sts

Re

su

lts

MTB Negative Test Failure MTB Positive

GX Centre wise achievement

Positivity Rate

Additionality

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

0

200

400

600

800

1000

1200

1400

1600

1800

T1 T2 T3 T1 T2 T3 T1 T2 T3 T1 T2 T3

2010 2011 2012 2013

Bacteriologicaly positive cases

Control pop Evaluation pop

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

stop TB

Complete treatment

Early

Case

Detection

For more information, please contact:E-mail: birai@iom.int

THANK YOU