HERD Team

Using Xpert to Reach the Unreached: Mobile Diagnostics Case Finding in Nepal May 2013 – April 2015

Objectives: To identify over 2 years an Additional cases of MTB+ (3136). Ensure rapid diagnosis and treatment of all TB and MDR cases. To continually monitor and reflect on case finding and referral strategies. Aim : Contribute to NTPs aim of achieving case detection rate of 82% nationally

Project Target Areas and Districts 22 districts and 29 municipalities & cities Kathmandu, Lalitpur, Bhaktapur, Kavre, Chitwan, Makwanpur, Parsa, Bara, Rautahat, Sarlahi, Mahottari, Dhanusha, Kaski, Rupandehi, Kapilbastu, Dang, Banke, Bardiya, Kailali, Accham, Doti and Kanchanpur

TB REACH Projects in Nepal

Major Activities by Target Population: Urban Slum: Door to Door Screening, Mobilization of urban health volunteers (UHV), Urban slum health camp, continual case finding activities PLHA: Strong communication and coordination with VCT and ARV centres, distribution of TB/HIV IEC materials, Screening of PLHAs Household Contacts: Identifying and recording and follow up of household contacts and screening and sputum collection Prisoners: Screening and sputum collection Factory Workers: Screening and sputum collection Refugees, Monks and Nuns: Screening and sputum collection Diabetics (In Kathmandu Valley Only): Coordination and communication with diabetic clinics, screening patients for symptoms and referring patients for microscopy

Strategies Coordination with local RHD/DPHO/DHO and health institutions. Coordination with respective target groups and populations. Mobilization of outreach workers and volunteers Mobilization of van. Conduction of microscopic camps. Case finding and referral strategies

Implementation Strategy Case findings with the help of mobile van Gene x-pert and Regular Microscopy Coordination with respective stakeholders NTP Respective D(P)HOs TB Reach Partners Target groups Selection of outreach workers and volunteers Training of outreach workers and volunteers for active case findings

Data Monitoring Flow chart cont… Volunteer Screening Identification of Symptomatics Lab test (Microscopy and Gene X-pert Positive cases Negative cases Treatment and follow up Outreach workers

Location of GX Machines Four static units with 2 module Xpert machines in 1) HERD, Kathmandu 2) Manohara Clinic, Bhaktapur 3) Doti Hospital (FW) 4) Chitwan Hospital (Terai) Two mobile van with 4 module Xpert machines.

Tools / Guide 1.Screenings register 2.Monthly reporting form 3.Sputum smear request form 4.HH screening form. 5.Xpert request form 6.Xpert Register 7.Xpert users guide 8.Program guide for vulnerable population

Kit Box and supporting Materials for UHV

Gene xpert installation DHO Doti - 19 September 2013

Mobile TB Diagnostic service

Selection and Training of ORW/UHVs Urban slum Kathamandu - 21 November 2013 Kathmandu and Nepalgunj - 3 December 2013 Mahendranagar - 20 Feb Field implementation

External M & E Revision of TBR indicators Kathmandu and Nepalgunj - 1 December 2013

TBR Project (Grant Period ) 15 February 2013 – 15 April 2015 DetailsDateGap TBR Project Case detection start ( As per application ) May 2013 Xpert received23 July Months Xpert Installation19 September Months Field Implementation start3 December Months External M& E1 December 2013 Remaining grant period - 10 Months, No cost extension - 8 Months

Current Progress end of Baisakh 2071 TARGET Total Screening Total Symptoma tic Total Microscop y Tests Total Microscop y Positive Cases Total Gene Xpert Tests Total Gene Xpert Positive Cases Total Positive Cases Slum PLHIV Household contacts Prisoners Factory Workers Refugees/ Monasteri es Diabetics TOTAL

Indicators for Slum Indicators Annual Planned Target Achieved till end of Baishak Achieved % Slum: Number of people screened159,00037, % Slums: Number of people identified with TB symptoms 19,0801, % Slums: Number of people identified with TB symptoms examined for TB by smear microscopy 17,1721, % Slums: Number of confirmed SS+/B+ TB cases (SS+) from microscopy % Slums: Number of SS- suspects examined for TB with Xpert 13, % Slums: Number of SS- suspects examined for TB with Xpert and positive with Xpert : Xpert % Slums: total SS+/Xpert % Slums Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment %

Indicators for PLHA Indicators Annual Planned Target Achieved till end of Baishak Achieved % PLHA: Number of people contacted/screened 7, % PLHA: Number of people identified with TB symptoms 1, % PLHA: Number of people identified with TB symptoms examined for TB by smear microscopy or Xpert 1, % PLHA: Number of confirmed SS+/B+ TB cases (SS+) from microscopy or Xpert % PLHA: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment %

Indicators for HH Contacts Indicators Annual Planned Target Achieved till end of Baishak Achieved % HH Contacts: Number of identified Index Cases3,026- HH Contacts: Number of Index Cases of which Contact Tracing was performed 1,815- HH Contacts: Number of people screened7, % HH Contacts: Number of people identified with TB symptoms % HH contacts: Number of people identified with TB symptoms examined for TB by smear microscopy % HH contacts: Number of confirmed SS+/B+ TB cases (SS+) from microscopy % HH Contacts: Number of suspects examined for TB with Xpert % HH Contacts: Number of suspects examined for TB with Xpert and positive with Xpert : Xpert % HH Contacts: total SS+/Xpert % HH Contacts:Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment %

Indicators for Prisons Indicators Annual Planned Target Achieved till end of Baishak Achieved % Prisons: Number of people screened3, % Prisons: Number of people identified with TB symptoms % Prisons: Number of people identified with TB symptoms examined for TB by smear microscopy % Prisons: Number of confirmed SS+/B+ TB cases (SS+) from microscopy % Prisons: Number of SS- suspects examined for TB with Xpert % Prisons: Number of SS- suspects examined for TB with Xpert and positive with Xpert : Xpert % Prisons: total SS+/Xpert % Prisons: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment %

Indicators for Factories Indicators Annual Planned Target Achieved till end of Baishak Achieved % Factories: Number of people screened120, % Factories: Number of people identified with TB symptoms 24, % Factories: Number of people identified with TB symptoms examined for TB by smear microscopy: 21, % Factories: Number of confirmed SS+/B+ TB cases (SS+) from microscopy % Factories: Number of SS- suspects examined for TB with Xpert 17, % Factories: Number of SS- suspects examined for TB with Xpert and positive with Xpert : Xpert % Factories: total SS+/Xpert % Factories: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment %

Indicators for Refugees/Monasteries Indicators Annual Planned Target Achieved till end of Baishak Achieved % Refugees, Monasteries:(R/M) Number of people screened 10, % R/M: Number of people identified with TB symptoms 2, % Refugees/Monasteries: Number of people identified with TB symptoms examined for TB by smear microscopy: 1, % R/M: Number of confirmed SS+/B+ TB cases (SS+) from microscopy 20210% R/M: Number of SS- suspects examined for TB with Xpert 1, % R/M: Number of SS- suspects examined for TB with Xpert and positive with Xpert : Xpert % R/M: total SS+/Xpert % R/M: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment %

Indicators for Diabetics Indicators Annual Planned Target Achieved till end of Baishak Achieved % Diabetics: Number of people screened:2, % Diabetics: Number of people identified with TB symptoms % Diabetics: Number of people identified with TB symptoms examined for TB by smear microscopy % Diabetics: Number of confirmed SS+/B+ TB cases (SS+) from microscopy % Diabetics: Number of SS- suspects examined for TB with Xpert 30000% Diabetics: Number of SS- suspects examined for TB with Xpert and positive with Xpert : Xpert+ 4500% Diabetics: total SS+/Xpert % Diabetics: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment %

District wise MTB+ cases at end of Baisakh 2071 SNDistrictSputum smear Positive Gene xpert Positive Total 1Kathmandu valley Doti Banke Dang8614 5Makwanpur Chitwan5510 7Dhanusa909 8Mahottari404 9Bara303 10Kanchanpur202

District wise MTB+ cases at end of Baisakh 2071 SNDistrictSputum smear Positive Gene xpert Positive Total 11Kailali011 12Kapilbastu101 13Kaski101 14Rautahat101 15Rupandehi000 16Bardiya000 17Parsa000 18Sarlahi000 19Kavre000 20Acham000 Total

TARGET Assumption Microscopy positivity Finding Assumption GX positivity Finding Slum 1 %2.54%2.5%3.89% PLHIV -1.09%15%17.52% Household contacts 3.5%6.26%15%16.55% Prisoners 2%0.78%10%2.49% Factory Workers 1%0.78%2.5%1.26% Refugees/Monaste ries 1%0.34%2.5%2.76% Diabetics 3%-15%- Current Progress – end of Baisakh Assumption base on external M& E.

Indicators of GX end of Baisakh 2070 GX Site GX Positivity% of error Error Types 5006/5007 % of invalid% of no result DPHO Chitwan DHO Doti Van Van HERD Lab HERD Lab Manohara Total

TB REACH on NEWS

Challenges To supervise field workers ( ORW/UHVs),who are working in municipalities and cities. ( Routine work, payment, data/report collection and logistics management ). To establish e-data system in limited period. To track SS+/MTB+ TB patient including RR on treatment..

What next ? Analysis of progress at end of 3 rd trimester. Revise working modality and discussion with respective RHD and DHO/DPHO.