1. HERD Team

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

3. 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

4. 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

5. TB REACH Projects in Nepal

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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

12. Kit Box and supporting Materials for UHV

13. Gene xpert installation DHO Doti - 19 September 2013

14. Mobile TB Diagnostic service

15. Selection and Training of ORW/UHVs Urban slum Kathamandu - 21 November 2013 Kathmandu and Nepalgunj - 3 December 2013 Mahendranagar - 20 Feb. 2014 Field implementation

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

17. TBR Project (Grant Period ) 15 February 2013 – 15 April 2015 DetailsDateGap TBR Project Case detection start ( As per application ) May 2013 Xpert received23 July 2013 3 Months Xpert Installation19 September 2013 2 Months Field Implementation start3 December 2013 2 Months External M& E1 December 2013 Remaining grant period - 10 Months, No cost extension - 8 Months

18. 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 3770017881416366432561 PLHIV 369184 21372426 Household contacts 1982492479301452454 Prisoners 16007787746241612 Factory Workers 4719833769247568 Refugees/ Monasteri es 246561159124341214 Diabetics 104221001 TOTAL 489394688421579207597176

19. Indicators for Slum Indicators Annual Planned Target Achieved till end of Baishak Achieved % Slum: Number of people screened159,00037,70023.7% Slums: Number of people identified with TB symptoms 19,0801,7889.37% Slums: Number of people identified with TB symptoms examined for TB by smear microscopy 17,1721,4168.25% Slums: Number of confirmed SS+/B+ TB cases (SS+) from microscopy 1723620.93% Slums: Number of SS- suspects examined for TB with Xpert 13,6006434.73% Slums: Number of SS- suspects examined for TB with Xpert and positive with Xpert : Xpert+ 340257.35% Slums: total SS+/Xpert+5126111.91% Slums Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment 4615812.58%

20. Indicators for PLHA Indicators Annual Planned Target Achieved till end of Baishak Achieved % PLHA: Number of people contacted/screened 7,7853694.74% PLHA: Number of people identified with TB symptoms 1,55718411.81% PLHA: Number of people identified with TB symptoms examined for TB by smear microscopy or Xpert 1,55718411.81% PLHA: Number of confirmed SS+/B+ TB cases (SS+) from microscopy or Xpert 1992613.06% PLHA: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment 1792513.97%

21. 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 screened7,260198227.3% HH Contacts: Number of people identified with TB symptoms 66049274.5% HH contacts: Number of people identified with TB symptoms examined for TB by smear microscopy 59647980.37% HH contacts: Number of confirmed SS+/B+ TB cases (SS+) from microscopy 2030150% HH Contacts: Number of suspects examined for TB with Xpert 46114531.45% HH Contacts: Number of suspects examined for TB with Xpert and positive with Xpert : Xpert+ 692434.78% HH Contacts: total SS+/Xpert+895460.67% HH Contacts:Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment 805467.5%

22. Indicators for Prisons Indicators Annual Planned Target Achieved till end of Baishak Achieved % Prisons: Number of people screened3,680160043.48% Prisons: Number of people identified with TB symptoms 736778105.7% Prisons: Number of people identified with TB symptoms examined for TB by smear microscopy 662774116.92% Prisons: Number of confirmed SS+/B+ TB cases (SS+) from microscopy 13646.15% Prisons: Number of SS- suspects examined for TB with Xpert 51924146.44% Prisons: Number of SS- suspects examined for TB with Xpert and positive with Xpert : Xpert+ 52611.54% Prisons: total SS+/Xpert+651218.46% Prisons: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment 591220.33%

23. Indicators for Factories Indicators Annual Planned Target Achieved till end of Baishak Achieved % Factories: Number of people screened120,60047193.91% Factories: Number of people identified with TB symptoms 24,1208333.45% Factories: Number of people identified with TB symptoms examined for TB by smear microscopy: 21,7087693.54% Factories: Number of confirmed SS+/B+ TB cases (SS+) from microscopy 21720.92% Factories: Number of SS- suspects examined for TB with Xpert 17,1934752.76% Factories: Number of SS- suspects examined for TB with Xpert and positive with Xpert : Xpert+ 43061.4% Factories: total SS+/Xpert+64781.23% Factories: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment 58271.2%

24. Indicators for Refugees/Monasteries Indicators Annual Planned Target Achieved till end of Baishak Achieved % Refugees, Monasteries:(R/M) Number of people screened 10,981246522.45% R/M: Number of people identified with TB symptoms 2,19661127.82% Refugees/Monasteries: Number of people identified with TB symptoms examined for TB by smear microscopy: 1,97759129.89% R/M: Number of confirmed SS+/B+ TB cases (SS+) from microscopy 20210% R/M: Number of SS- suspects examined for TB with Xpert 1,56543427.73% R/M: Number of SS- suspects examined for TB with Xpert and positive with Xpert : Xpert+ 391230.77% R/M: total SS+/Xpert+591423.73% R/M: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment 531426.42%

25. Indicators for Diabetics Indicators Annual Planned Target Achieved till end of Baishak Achieved % Diabetics: Number of people screened:2,1491044.84% Diabetics: Number of people identified with TB symptoms 43020.47% Diabetics: Number of people identified with TB symptoms examined for TB by smear microscopy 38720.52% Diabetics: Number of confirmed SS+/B+ TB cases (SS+) from microscopy 1218.33% 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+5711.75% Diabetics: Number of confirmed SS+/B+ (SS+ and Xpert+)TB cases put on treatment 5211.92%

26. District wise MTB+ cases at end of Baisakh 2071 SNDistrictSputum smear Positive Gene xpert Positive Total 1Kathmandu valley125062 2Doti122436 3Banke111021 4Dang8614 5Makwanpur10111 6Chitwan5510 7Dhanusa909 8Mahottari404 9Bara303 10Kanchanpur202

27. 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 Total7997176

28. 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.

29. Indicators of GX end of Baisakh 2070 GX Site GX Positivity% of error Error Types 5006/5007 % of invalid% of no result DPHO Chitwan41.6718.3012.422.610.65 DHO Doti30.0715.265.263.680.53 Van 14.125.424.162.900.00 Van24.499.623.582.340.12 HERD Lab4.6111.246.183.370.00 HERD Lab Manohara3.2910.337.851.240.41 Total8.279.425.112.620.17

30. TB REACH on NEWS

31. 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..

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