1. Strengthening TB and HIV&AIDS Responses in East Central Uganda Strengthening Laboratory TB diagnostic capacity of peripheral laboratories in East Central Uganda- A key contributing factor to increasing TB Case Detection Rate ICASA Addis Abbaba Ethiopia 5 th December 2011 Abstract No. MOACO201 By Mashate Silver

2. Strengthening TB and HIV&AIDS Responses in East Central Uganda STAR-EC program:  Five years (2009-2014) program funded by USG through USAID  Implemented by JSI Research &Training Institute Inc in collaboration with Ministry of Health-Uganda  Serves about 9% of the country’s population (Approx. 3M people)  Works through district based structures  Operates in 9 Districts of East Central Uganda Background The 9 districts served: Bugiri, Buyende, Namutumba, Namayingo, Mayuge, Iganga, Luuka, Kamuli & Kaliro Project Aim: To increase access to, coverage of, and utilization of quality and comprehensive HIV&AIDS and TB prevention, care and treatment services

3. Strengthening TB and HIV&AIDS Responses in East Central Uganda TB burden (WHO 2011)  Globally, TB remains a public health concern; ranked 8 th among the 10 leading causes of death  Worldwide, 9.7 million children were orphaned by parental death caused by TB in 2010  Uganda is among the 22 TB high burden countries globally 2010 TB Statistics (WHO 2011 TB Global Report, Page 12) IndicatorsGlobal (N=6.9 Billion) Uganda (N=33.4 Million) Prevalence12M (0.17%)64,000 (0.19%) No. Diagnosed & notified TB cases 6.2M70,000 Case detection rate65%61% Mortality among HIV negative persons 1.1M*51,000 Mortality among HIV positive persons 0.35M * Although TB is a leading cause of mortality among persons living with HIV, it killed more HIV negative than HIV positive people in 2010

4. Strengthening TB and HIV&AIDS Responses in East Central Uganda Tuberculosis Case Detection Rate (TB CDR)  Calculated as: Newly detected TB cases X 100% Estimated incidence cases [in a given period of time]  WHO TB CDR Target = 70%  Uganda TB CDR Target = 70% (MoH/NTLP)

5. Strengthening TB and HIV&AIDS Responses in East Central Uganda Issue In 2009, TB CDR in East Central Region = 32% (MoH/NTLP), far below the national target of 70% Issue In 2009, TB CDR in East Central Region = 32% (MoH/NTLP), far below the national target of 70% Objective: To support increase the regional TB CDR from 32% in 2009 to 70% by 2014 Objective: To support increase the regional TB CDR from 32% in 2009 to 70% by 2014 Result 1 TB CDR increased by 7% (32-39%) in a period of 18 months Result 1 TB CDR increased by 7% (32-39%) in a period of 18 months Intervention 1 (Mar 2009-Sept 2010)  Health workers trained and facilitated to intensify TB screening, new treatment guidelines  TB case finding activities scaled up (use of local leaders, use of ICF tools, etc)  Sensitization of communities to seek TB diagnostic and therapy conducted (local radio talk shows, drama) Intervention 1 (Mar 2009-Sept 2010)  Health workers trained and facilitated to intensify TB screening, new treatment guidelines  TB case finding activities scaled up (use of local leaders, use of ICF tools, etc)  Sensitization of communities to seek TB diagnostic and therapy conducted (local radio talk shows, drama)

6. Strengthening TB and HIV&AIDS Responses in East Central Uganda After implementation of Intervention 1….. Observation: A low increase in TB CDR (of 7%) was attained in 18 months despite the enormous effort Questions: Where were the missing links? In the testing laboratories? Low clinical suspicion? Few suspects sent to laboratories? General low prevalence of TB in the region? Innovation: Changed strategy to focus on health facility laboratories that performed TB testing

7. Strengthening TB and HIV&AIDS Responses in East Central Uganda Intervention 2………….. Strategy To determine and strengthen the capacity of health facility laboratories in the East Central Region to perform TB diagnosis by Sputum microscopy Approach Conducted a comprehensive laboratory needs assessment in collaboration with Ministry of Health Purpose Establish the coverage of TB diagnostic units in the region Assess the participation in TB National External Quality Assurance Schemes (NEQAS)

8. Strengthening TB and HIV&AIDS Responses in East Central Uganda Findings of the Laboratory Needs Assessment…………. **NEQAS: National External Quality Assurance Scheme (conducted by the National TB Reference Laboratory)  21% (n=52) HCs did not participate in TB NEQAS**  31% (n=75) HCs were not performing TB laboratory testing  33% (n=75) HCs lacked microscopes  2 of the HCs referred sputum to other laboratories for TB testing* *

9. Strengthening TB and HIV&AIDS Responses in East Central Uganda Targeted interventions implemented……….  HCs with functional microscopes increased from 50 to 68  TB diagnostic sites increased from 52 to 70  HC Laboratories participating in TB NEQAS increased from 41 to 70  Distance travelled by community reduced since TB testing service were closer  HCs with functional microscopes increased from 50 to 68  TB diagnostic sites increased from 52 to 70  HC Laboratories participating in TB NEQAS increased from 41 to 70  Distance travelled by community reduced since TB testing service were closer 1. Provided binocular microscopes (Olympus CX 21) to 18 out of 25 HCs that lacked 2. Strengthened implementation and participation in NEQAS TB testing 3. Provided refresher training in TB microscopy to laboratory staff and essential TB diagnostics to the HCs Olympus CX21 Binocular

10. Strengthening TB and HIV&AIDS Responses in East Central Uganda Result 2: Number of TB tests performed (Intervention 1 Vs Intervention 2) Intervention 1: TB tests performed Intervention 2: TB tests performed The 18 HCs that received microscopes performed 26% of the tests (n=13838) and detected 17% (n=1468) of the TB positive tests Intervention 2: TB tests performed The 18 HCs that received microscopes performed 26% of the tests (n=13838) and detected 17% (n=1468) of the TB positive tests

11. Strengthening TB and HIV&AIDS Responses in East Central Uganda Performance in MoH/NEQAS (TB sputum smear blinded rechecking) by HCs in the supported Districts (as at end of Mar 2011) Source: MoH/NTRL records Accuracy (%)

12. Strengthening TB and HIV&AIDS Responses in East Central Uganda Result 3: Increase in CDR (Intervention 1 Vs Intervention 2) Intervention : TB CDR increased by 7% (32-39%) in 18 months *Only 52 TB Diagnostic units TB CDR%

13. Strengthening TB and HIV&AIDS Responses in East Central Uganda Lesson learnt & Recommendations Lesson learnt  Strengthening the peripheral health facility laboratories leads to increased community access to TB diagnostic services and is a critical factor in increasing TB CDR Lesson learnt  Strengthening the peripheral health facility laboratories leads to increased community access to TB diagnostic services and is a critical factor in increasing TB CDR Concurrent implementation of cross cutting interventions alongside functioning laboratories should be emphasized Recommendations Increase TB CDR Increase TB CDR

14. Strengthening TB and HIV&AIDS Responses in East Central Uganda Acknowledgement 1.Uganda Government (Ministry of Health)  Central Public Health Laboratories  National TB Reference Laboratory 2.US Government  USAID 3.Ministry of Local Government of the 9 supported districts 4.Health workers at the STAR-EC supported HCs 5.JSI/STAR-EC Team

15. Strengthening TB and HIV&AIDS Responses in East Central Uganda Visit our website www.starecuganda.org