TB Screening in the Antenatal Care Setting in MalawiSymposium: Exploring the intersection between TB and maternal and neonatal health: from research to implementationFlorence KayamboSenior HIV/TB Technical AdvisorTB Lung Conference Barcelona, Spain 28th October – 1st November 2014

Presentation Outline

Background Program Objectives Program Activities Achievements Challenges Recommendations Conclusion

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Background: Malawi

Indicator Malawi Population 13.1 million

HIV prevalence in Adults (2010)

10.6%

TB incidence 163 per 100,000

MTCT rate 17,000 infants infected yearly

MMR 675 per 100,000

TB/HIV co-infection 63%

TB case detection rate

65%

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Program Objectives

Increase early TB case detection and management in pregnant women accessing ANC/FANC by 50%

Accelerate integration of TB screening in ANC Accelerate national scale-up of effective and

comprehensive PMTCT services (Option B+) Improve the quality of PMTCT program Contribute to the reduction of maternal and

newborn mortality through strengthening linkages between maternal health and TB management

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Process

Discussion with National TB Control Programme, HIV Directorate, RHD and TB Care II

Procurement of 2 microscopes and IP supplies

Development of job aids to standardize implementation (FANC/TB card and tape measure)

Revised M&E data collection tools

Orientation of service providers 5

Program Activities

One-day orientation for providers

Training of HSAs in TB microscopy

Procurement of microscopes and laboratory supplies

Demand creation and awareness through community mobilization activities

Integration of TB screening into MCH platform

Clinical mentoring Supportive supervision Documentation Operational research

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Program Activities, Continued

Task shifting HSAs trained in TB microscopy

HIV testing and counseling by HSAs

Provider initiated testing and counselling in ANC settings

Initiation of ART in ANC by nurses

Establishment of sputum collection and microscopy sites

Sputum sample collection and slide fixing

Quarterly review meetings

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Monitoring and Evaluation

Expected Outcomes

Outcome IndicatorsTarge

t

Enhanced case finding among ANC attendees

Percentage increase in pregnant women screened for TB signs/symptoms in intervention sites

50%

Number/percentage of mothers screened have symptoms of TB

n/a

Percentage increase in reported TB cases referred from ANC in the district post-intervention

100%

Prompt diagnosis

Percentage of ANC clients with symptoms of TB with at least one sputum sample tested for TB and results returned within 24–48 hours

50%

Percentage increase in ANC clients with symptoms of TB with documented diagnosis and HIV ascertainment

100%

Prompt treatment

Time to initiation of TB treatment from initial symptom screening

< two weeks

Percentage improvement in time to initiation of ART in those women who do or do not have symptoms of TB

50%8

Achievements

Modification of data collection tools to include TB case diagnosis and lead time to treatment initiation

PITC/HTC integrated within ANC setting ART initiation within ANC TB screening, including referral sputum collection to those

eligible TB-positive clients treated according to guidelines and

protocols PMTCT is fully integrated into maternal and child health

services Very high (93%) ANC attendance rate, providing an

exceptional opportunity to identify and reach women in need of TB management

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Achievements

Support from District Health Management Team

Oriented 300 providers in FANC/TB

6 HSAs and 4 laboratory technicians trained in TB microscopy (3 weeks)

Development of job aids: fundal height tape measure with key messages, routine TB screening in ANC

FANC/TB guide Draft TB/HIV training manual

for community

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Summary of Results

Total ANC Attendees 5,474

Women screened for signs/symptoms of TB in ANC

3,920 (71.6%)

Women with signs/symptoms of TB 68 (1.7%)

Women with signs/symptoms of TB diagnosed with TB

4 (5.9%)

Women with signs/symptoms of TB diagnosed with HIV

8 (11.8%)

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Challenges

Human and financial resource High workload in the ANC setting,

average 45–60 on clinic day No laboratory facilities in 3 of the

5 facilities Long distance to treatment

initiation centers 30–50 kms Inadequate documentation (data

quality) Inadequate infrastructure at

health centers No courier system for

transportation of sputum samples/slides

Delays in lead time to access results range 1–3 weeks

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Recommendations

Intensify and regularize follow-up visits from all levels Onsite orientation of all members of staff Define roles and responsibilities of the health center staff Conduct monthly onsite coordination and review meetings

to assess progress Develop ANC/TB screening implementation schedule Use community mobilization and sensitization, key to the

uptake of the program Decentralize TB initiation centers Develop courier system for transportation of sputum

samples/fixed slides, including feedback of results

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Zambia Conclusion

Integration TB screening in ANC setting is feasible Lifelong ART for all HIV-infected pregnant women

will ensure virtual elimination of MTCT is achieved TB diagnosis and management will contribute to

reduction of MMR, reduce number of orphans For sustainability, a concerted effort is needed

from all funding and development partners for development and successful implementation of TB as part of the eMTCT strategy

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“At first I was scared, but after being counselled by Mr. Mbwagha, I started taking the TB drugs. I did not have any problem or labor complication during birth to my twins up until I finished my regime and now I am fine. TB is curable in pregnancy”, Elizabeth said jovially.

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Lesotho PSETuberculosis Specific Tasks

(Skills)

Tuberculosis (TB)

Screen for TB based on patient symptoms

Contact tracing of TB patient family members, including sputum sample collection

Trace lost to follow-up within the communities

Counsel TB patients and immediate contacts, e.g., family on adherence

Train communities and community health workers on the administration to and supervision of patients on DOTS

Administer initial and follow-up DOTS TB treatment

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