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. 2011Feb. 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
Interventions
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 smearnegative specimens for GeneXpert testing and
specimen of Rifampicin resistant cases for
Culture and DST
INDIA
INDIA
Populations
Population
Evaluation Population
Size of the 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+
Smear not done
CXR
Normal CXR
Abnormal CXR
Xpert/ Rif
No MTB
Further Clinical
Management
MTB+ / Rif Res
Confirm result with LPA or
Conventional DST
Treat with SLD
MTB+ / Rif Sen
Treat with
FLD
Indicators
Target
Achievement
Ach.
%
TB Suspects screened
23,427
20,228
86%
SS-ve suspects referred for GX test
17,668
19,338
109%
5,219 (30)
3,279 (17)
63%
1,257
173
14%
271 (22)
34 (20)
13%
1,600
1,109
69%
250 (16)
138 (12)
55%
Process indicators
SS-ve suspects Xpert positive
HIV+ve referred for Gene X-pert
HIV+ve X-pert positive
Specimen transported from hilly
areas
Positive among referred cases
MTB/RIF Test Results
Smear
result
Total
Tests
MTB Detected
Test
Failure
RIF-
RIF+
RIF Indet.
Total
S-ve
19,338
3,031
131
117
3,279
1,878
(17%)
(9.7%)
S+ve
702
450
139
8
579
38
(85%)
(5.4%)
Direct XP
188
34
2
2
38
12
(20%)
(6.4%)
20,228
3,515
272
127
3,914
1,928
(19%)
(9.5%)
Total
GX Centre wise achievement
MTB Negative
Test Failure
MTB Positive
605
481
753
Tests Results
370
658
306
240
198
189
193
230
243
345
219
372
134
203
103
1920
1906
1567
1810
1634
1709
Sirha
Bhaktapur
1450
1373
1020
Ilam
Jhapa
Mangal
Morang
Sunsari
Saptari
Parsa
Positivity Rate
Additionality
Clear increase in additionality, 25 % in year 1 and 28% in
year 2
Bacteriologicaly positive cases
1800
1600
1400
1200
1000
800
600
400
200
0
T1
T2
2010
T3
T1
T2
2011
Control pop
T3
T1
T2
2012
Evaluation pop
T3
T1
T2
2013
T3
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
THANK YOU
For more information, please contact:
E-mail: birai@iom.int
Case
Detection
stop
TB
Complete treatment