Experience with Tb diagnostics and Scale up of services Botswana, Nigeria, and Tanzania Ernest Ekong, MD,MPH National Clinical Coordinator Harvard PEPFAR AIDS Prevention Initiative Nigeria

Current Country Data on TB BotswanaNigeriaTanzania Country Population2,000,000140,000,00037,626,917 Estimated number of new Tb cases 11,622373,682130,606 Estimated Tb incidence/100,000 pop/yr DOTS Population coverage (%) Rate of new sputum smear positive (SS+) cases/100,000 pop DOTS case detection rate (new SS+) (%) DOTS treatment success rate in 2003 (new SS+) (%) Estimated adult Tb cases HIV+ (%) New multidrug resistant Tb cases (%)

New patients(n=430)(n=638)(n=1182) Any drug resistance3.7%6.3%10.4% Any INH resistance1.6%4.4%4.5% Any rifampicin resistance0.9%0.6%2.0 % Any MDR0.2%0.5%0.8% Previously treated patients(n=121)(n=145)(n=106) Any drug resistance14.9%22.8%22.6% Any INH resistance9.9%26.6%14.2% Any rifampicin resistance8.3%24.2%12.3% Any MDR6.1%9.0%10.4% INH/ Rifampicin resistance data The Botswana experience Above are the main results from the Botswana National drug resistance surveys in , 1999 and Another national drug resistance survey (2007-8) finished in April this year. However, results will not be out before towards the end of this year.

INH/ Rifampicin resistance data The Nigerian experience To date, no systematic survey. Extent and pattern not known 45 cases of MDR TB identified, recently using Hain’s test. XDR TB may exist in Nigeria, but no case identified. First national survey of MDR TB & XDR TB, planned for late 2008, expected to yield data on prevalence. Survey needed for full scale country application to the Green Lights Committee for supply of second line anti-TB drugs

Issues with diagnostics Botswana, Nigeria and Tanzania Lack of necessary diagnostic tests for TB/HIV affect provision of therapy Limited lab capacity and access especially in rural settings Lack of national standards and systems for accreditation, QA/QC and logistics Limited technical support High cost of diagnostic instrumentation and consumables

Strategies for Scale-up of TB diagnosis Nigerian situation DOTS services improved, yet in all LGAs, Case notification increased Case detection rate, still below target Increased lab capacity at all levels General health workers trained on TB control strategies Collaboration with tertiary hosps, Specialist clinics, and prison health services Strengthened supervision of DOTS services from Federal to PHCs

Tb diagnostics Structure- Pyramidal network of labs Peripheral labs for smear microscopy for acid and alcohol – fast bacilli at PHC in LGAs State TB labs Smear and fluorescent microscopy Six Zonal Reference Labs Smear & fluorescent microscopy, culture & isolate Mbact, EQA on state and peripheral labs Two National Reference Laboratories Also Drug Susceptibility Testing on isolates EQA on Zonal Reference labs Collaborate with identified Supranational Reference laboratories for panel testing and EQA

TB/HIV Coordination Special unit in NASCAP coordinating TB/HIV Now has strategic framework –guidelines for implementation of TB/HIV activities –Infection control training manual in progress Facility co-location of HIV/TB –Many DOTS centres at ART sites collaborating with >25 sites able to do comprehensive HIV/AIDS C&S, and ART HIV screening for TB patients Training: TB/HIV co-management Remodeling of TB clinics to make for effective TB infection control

Intensified TB Case finding Screening –History and use of clinical questions –Suspected family members and close contacts of co- infected patients –AFB microscopy for sputum and aspirates –Culture - sputum, aspirates for EPTB –Histological examination - Biopsy tissue –Tuberculin test CXR (alone NOT reliable) –For all patients at enrolment and those suspected of having TB during treatment Facility co-location of HIV and TB clinics

Successful IPT in Botswana Issues How useful to the country: –Helps decentralize intensified Tb case finding –Nationwide rollout, high awareness –Early identification and treatment –Measurement Intervention effectiveness, not yet Supportive logistics: –Screening for active Tb –Data collection for M&E, drugs, etc –Patient adherence and education How other countries are encouraged: –Positive, but data not supporting enough

Tb Diagnostics and management Challenges Diagnostic problems –IPT issues –MDRTB –Need for new technology eg Hains test Standardizing reporting and recording systems 2 nd line drugs for TB treatment Low case detection rates & High default rates impact on treatment success Absence of negative pressure equipment in labs TB/HIV co-infection- therapy issues Irregular supply and distribution of anti-TB drugs Space constraints

Recommendations for Scale-up –Advocacy/Communication/Coordination Global: across categorical programs, agencies, foundations, etc. Regional/National/Local –Physical infrastructure development Laboratory-accurate, robust & rapid diagnostics Equipment Biosafety

Recommendations for Scale-up –Quality Management and Improvement Management programs EQA/accountability Human Capacity Building (education/training) TA—all levels –Local adaptation Indigenous plans with timelines National strategy/plan

Acknowledgements Phyllis Kanki Guerino Chalamilla Tendani Gaolathe Ric Marlink Dan Onwujekwe Rob Murphy Wafaie Fawzi Patricia Burns Sunny Ochigbo Abel Makubi Prosper Okonkwo Oni Idigbe