Strengthening Urban Health Extension Program in Addis Ababa to find the missing persons with TB
Getachew Wondimagegn Desalegn (CTB Addis Ababa,/Diredawa /Harrari/ cluster TB team) Coordinator: email@example.com
Other persons involved: Zerihun Yaregal (CTB TB Advisor), Chaltu Muleta (TB Officer), Ben Tegegn (Addis Ababa City Administration Health Bureau TB/HIV, MDR-TB Coordinator), Beza Kifle (Addis Ababa City Administration Health Bureau-Addis Ketema S/city Health Office-TB/HIV Officer), Lemessa (Addis Ababa City Administration Health Bureau-Yeka S/city Health Office-TB/HIV Officer)
Ethiopia is one of the 30 countries with a high TB burden. According to the 2017 WHO report, 182,000 people in Ethiopia (including approximately 24,000 children) were estimated to have developed TB in 2016.In the same period however, only around 127,500 patients were enrolled in the TB program. This equates to over 30% of persons with TB being missed (around 55,000 patients, including around 9,000 children).
Addis Ababa, the capital and largest city in Ethiopia, has an estimated population of 3,384,569, 50% of whom are living in overcrowded slums and informal settlements. Community Based TB Care (CBTBC) using Urban Health Extension Workers (UHEWs) has been identified as one of the critical strategies for early identification of TB presumptive patients, especially in densely populated settings like urban slums. However, in two overcrowded urban districts (known as woreda), namely Addis Raey with 35,272 inhabitants and Yeka Woreda 12 with 41,048 habitants, the contribution of the UHEWs in case finding was low.
UHEWs, who are employed by the government, receive a one-year training course in primary health care, including field work. Their limited TB control tasks are to identify presumed TB patients in the community and refer them to the health center. Each UHEW is attached to a specific health center and supervised by Environmental Health officers.
FTMP implementation area: Community Engagement
Description of the intervention
The KNCV led, Challenge TB project, in collaboration with the Addis Ababa Health Bureau, selected three woreda (Addis Raey, Yeka W12, Kolfe W3) based on the following criteria:
- A high TB notification rate
- The presence of informal settlements that are underserved by the routine public health structure and other sectors.
- Inadequate performance of the UHEWs in TB active case finding.
A baseline assessment was conducted together with the regional health bureau & sub-city to obtain insight into the status of CBTBC activity in the selected districts.
The main findings of the assessment were:
- Community based TB activities were not included in the UHEWs activity plan, even though community TB Care is part of the UHEW package.
- The UHEWs were not routinely involved in contact investigation (CI).
- The number of presumptive TB patients referred by UHEWs was very low. For example, of the 420 expected presumptive TB patients, only 45 were referred by UHEWs in the 6-month period before the intervention.
- UHEWs were not making use of the presumptive TB logbook which made reporting UHEWs contribution to case finding activities difficult.
- Despite available columns in Health Centre (HC) Unit TB registers, reporting on the contribution of UHEWs in TB case finding was minimal.
- There was a weak referral linkage between HC and Health Extension Program (HEP); the HEP guidelines, describing the referral, communication and feedback between the HEP and the HC center was not put in practice.
Actions taken after baseline assessment findings
- Introduce TB screening in the UHEWs’ house-to house visits.
- The TB clinic became the initial entry point for UHEWs’ referred presumptive TB patients (with a referral slip), hence bypassing the OPD. This resulted not only in a shorter patient pathway but also minimalized the risk of losing the referred presumptive TB patients.
- A mass house-to-house, 7-day TB screening campaign was implemented to create TB awareness in the selected woreda and find persons with TB.
Mass screening approach
Mass screening results
The results of the one-week mass screenings are presented in table 1. This depicts a significant improvement compared with the results from the previous quarter of the same year (Q2) when UHEWs identified and referred only 3 of the 102 TB patients detected in the selected HCs.
|Activities in 7 days, in quarter 3 of 2010 Ethiopian Calendar (EC)||Results|
|Total number of people screened||15,800|
|Number of presumptive TB patients identified and referred to nearby HC||262 (1.6%)|
|Number of presumptive TB patients tested with Xpert||262 (100%)|
|Number of bacteriologically confirmed with TB among those tested with Xpert||19/262 (7%)|
|Number of DS-TB and RR-TB patients initiated on correct TB treatment from the diagnosed TB patients||18 DS-TB and 1 RR-TB|
Table 1: Mass screening results in Q3 of 2010 EC (Q1 2018)
- This combined intervention clearly demonstrates the positive contribution UHEWs can have in finding the missing patients, via a house-to-house mass screening approach, improvement to the referral mechanisms to fast track referred patients and improving the recording and registration system linking the HC and UHEP systems.
- Committed coordination between the UHEWs supervisor and the TB focal person as well as regular supervision of the UHEWs was key.
- Following-up of UHEW’s referred patients, including cross checking with the relevant TB clinic records, helps to minimize the loss of referred patients.
- Such periodic targeted screening interventions are necessary to find missing persons with TB in slum areas and to raise awareness about TB. However when UHEWs TB control activities become more efficient and sustainable, these interventions could possibly become redundant.
Action taken to sustain the initiative
The Regional Health Bureau and Sub-Cities agreed to, routinely involve UHEWsin TB contact investigation, improve communication and collaboration between the health centres and the UHEWS, use the mass screening approach in other districts and to strengthen the monitoring system of UHEP.
Patient Centered TB-HIV care in a one-stop-shop
Dr. Mary Ann A. Evangelista, Hivos, Program Manager, firstname.lastname@example.org
Dr. Andre Daniel E. Villanueva, KNCV, Technical Coordinator, email@example.com
Other persons involved: Kathy Fiekert, KNCV, Senior TB Consultant/Team Coordinator Health Systems & Key Populations
The NGO LoveYourself is the pioneer in creating 3 community HIV testing centers in Metro Manila, the Philippines, designed with particular focus on Men-having-Sex-with-Men (MSM). They provide free HIV screening, counseling and education. The very LGBT+ friendly space afforded to patients promotes trust to the clients. In 2016, the Philippine Department of Health (DOH) reported that LoveYourself identified 42% (1,452/3,477) of newly diagnosed People Living with HIV (PLHIV) in Metro Manila or 17% contribution nationwide (1,452/8,514). LoveYourself then began screening for TB among its PLHIV clients. Presumptive TB patients were referred to TB DOTS facilities. Monitoring of these referrals was not part of the protocol. LoveYourself remained unaware of their referrals’ TB status, treatment status, follow-up examinations and outcome, adherence to daily TB medications and contact investigations.
FTMP implementation area: Matching the Services to patient pathways
The objective of the “Building Models for the Future” project was to improve health governance and access to affordable quality TB-HIV care through effective partnerships between government and the non-public sector. In 2017, in collaboration with the Philippine DOH’s National TB Control Program (NTP), the National AIDS/STI Prevention and Control Program (NASPCP), and the Mandaluyong City Health Office, the project provided technical assistance to LoveYourself to establish in their Mandaluyong City branch in Metro Manila a “one-stop shop” facility for quality TB and HIV care. The other two centers refer their presumptive patients to this center or other NTP facilities near the patient’s location.
Through the NTP a training on the program’s Manual of Procedure was conducted where an algorithm called for GeneXpert testing for TB for PLHIV. The project provided LoveYourself a GeneXpert machine to ensure that PLHIV with TB symptom(s), including findings on chest X-ray, are tested, diagnosed and initiated on treatment without delay, at the level of point of care. The clinic was provided and stocked with regular provisions of TB and HIV medications, including MTB/RIF cartridges for GeneXpert use. A direct link and access to the national Integrated TB Information System (ITIS) allowed ease of regular submission of reports. Aside from project technical assistance, the clinic is also part of the local NTP’s regular monitoring and supervision schedule.
From February 01, 2017 to June 30, 2018, LoveYourself had a total of 1,364 newly enrolled PLHIV, 100% of whom were symptom-screened for TB. Among these, 421 (31%) had symptoms of TB, and underwent GeneXpert testing. Of these, 148 (35%) were diagnosed TB patients, and 100% were started on anti-TB treatment. Of those without TB, 100% were started on Isoniazid Preventive Therapy (IPT). Among those who started TB treatment from February 1 until September 30, 2017, 54 (98%) have completed treatment. The cohort analysis of the 93 patients who commenced treatment after October 01, 2017 is not yet available.
Within seven months, LoveYourself has established a full-service TB clinic within the same location as its HIV clinic.
Active involvement of all levels of the government health program from national to local government unit is essential to achieve these successful outcomes such as 100% treatment initiation of diagnosed TB patients and 100% IPT initiation. This includes frequent and regular monitoring and supervision, and ensuring that key components to successful program implementation are fast-tracked and in place. This is critical for a solid foundation of ownership, trust and optimism among and between partners, and timely realization of rewards. The NTP being visible and actively involved renders legitimacy to project implementation. LoveYourself is now officially a part of the NTP and HIV Service Provider Network.
Within the year after engagement, the TB and HIV services of LoveYourself were duly certified by the DOH and accredited by the Philippine Health Insurance Corporation.
Realizing the good experience of having integrated care in one setting, LoveYourself Management made the decision to link its other HIV community center and its transgender clinic, both located in the City of Manila, to the main clinic in the City of Mandaluyong, through a strengthened referral system, recognized by the local City Health Offices.
The model is currently used as basis for establishing TB-HIV integrated care in other non-public sector facilities, within the project and beyond.
Screening health care workers for TB in Namibia
Contact person: Lisa Petersen, TB/HIV Technical Officer Namibia, KNCV TB Foundation, firstname.lastname@example.org
Other persons involved:
Dr Abbas Zezai1; Harriet Kagoya1, Monitoring & Evaluation Officer; Karin Husselmann1, TB/HIV Nurse Mentor; Mavis Mukamba1, TB/HIV Nurse Mentor; Modester Chiota1, TB/HIV Nurse Mentor, Selma Hedimbi1, TB/HIV Nurse Mentor, Rauha Nehale1, TB/HIV Nurse Mentor, Milton Mutanga1, TB/HIV Nurse Mentor, Edward Kakororo1, TB/HIV Nurse Mentor; Albertina Thomas2, Chief Health Program Officer; Helena Mungunda2, TB/HIV Focal person; Erwin Nakafingo3, -Lecturer; Max Meis, Senior TB Consultant1
Affiliations: 1. KNCV TB Foundation; 2. Namibia Ministry of Health and Social Services (MoHSS), National TB and Leprosy Programme (NTLP); 3. Namibia University of Science and Technology (NUST).
Namibia is one of the top 30 high burden countries for TB (WHO, 2017). The Namibian TB Infection Control Guidelines (2014) include annual training instructions and guidance on TB screening of health care workers (HCWs) to ensure that this high-risk population is protected against TB infection during their work and where applicable diagnosed early. The National TB and Leprosy Programme (NTLP) reported HCW screening to be as low as 23% in the districts where KNCV implemented the Challenge TB (CTB) project in 2017. In February and March of 2018, CTB worked in eight districts to accelerate and increase TB screening of HCWs in an attempt to Find and Treat all Missing Persons with TB (FTMP). In 2016 and 2017, TB screening among HCWs in the same districts was low.
FTMP implementation area: Triage and Screening
CTB staff, together with the District TB and Leprosy Coordinators (DTLCs) and TB focal persons, developed a simple Standard Operating Procedure (SOP), intended to guide staff on how to revisit HCW TB screening practices in the districts using the TB Infection Control Guidelines as leading. Meetings were held with district management to review the status of staff screening, identify gaps and discuss interventions to scale up HCW TB screening. The reviews identified two main gaps, namely the lack of importance attached to HCW TB screening and the preference of HCWs to use a private practitioner for screening.
Interventions included sharing information and evidence on HCW TB screening efforts in 2015 in the Engela district, intended to reiterate the importance of HCW TB screening. CTB staff used the World TB Day Theme: “Wanted: Leaders for a TB-free World” to develop local posters “Wanting Leaders for a TB-FREE Namibia – Taking Care of the Care Givers” to mobilize and motivate HCWs to undergo TB screening. Another crucial intervention included using role models who underwent annual TB screening and former TB patients among HCWs as “Leaders for a TB-free Namibia: “Taking care of self” to gain further momentum. The week prior to World TB Day was earmarked as “the week” to set up screening procedures facilities. Schedules were agreed that could accommodate all HCWs at any time of the day or night. Regular rounds were made in the facilities and more specifically in hospitals to remind staff of the importance of TB screening as well as when and where they could be screened. The screening was done in private, using the questionnaire.
Localized World Stop TB Day activities, combined with the introduction of the screening SOP plus structured discussions around screening gaps all contributed to the mobilization of HCWs and ultimately the impressive results. In mid-2018 a total of 823 (37%) from 2,251 HCWs in the CTB supported districts participated in screening over a period of two months, compared to a total of 523/2,234 (23%) HCWs in 2017, and 291 (12%) in 2016.
The number needed to screen (NNS) to diagnose one HCW with TB in 2016 was 18, 33 in 2017 and 206 in the first six months of 2018.
DTLCs and focal persons took ownership of the SOP, and implementation in the long term looks promising. There is immense potential for replication of this approach.
CTB plans to work together with NTLP to roll out this intervention from the current eight districts to all 35 districts in the country by June 2019 and thereby reach all HCWs. This will be achieved by sharing the SOP and the interventions and outcomes with all regions at review meetings. This forum will be used to learn from other districts and thereby further enhance the approach.
 CTB project districts: Rehoboth, Grootfontein, Tsumeb, Andara, Nyangana, Onandjokwe, Omuthiya, Oshikuku
Implementation of the FAST strategy in Lagos State
Contact person: Moses Onoh (Senior Regional Program Manager) email@example.com
Other persons involved: Adebukola Adegbola, Program Officer, Lagos State.
Lagos State with a population of over 24 million, accounts for 8.4% of the national TB burden (Lagos Bureau of Statistics). Lagos State is made up of 20 districts and over 3,450 health facilities, 953 of which are providing TB services. These include Primary Health Centers (PHCs), secondary/general hospitals and tertiary institutions.Poor knowledge of TB and infection control measures was evident in most facilities and though quite a number of them have an infection control committee, these were often non-functional. The FAST strategy was introduced in 2015, via the Challenge TB (CTB) project to stop the spread of TB in healthcare facilities. FAST stands for Finding patients with (presumptive) TB, Actively, Separating and Treating them effectively, and is implemented in seven general hospitals, one tertiary hospital, one military hospital and one comprehensive PHC.
FTMP implementation area: Triage and screening & Quality Prevention and Care
The FAST Strategy was deployed to increase knowledge of TB and infection control among general health care workers (HCWs) and to increase TB case finding in high burden health facilities in the CTB-supported districts in Lagos State. Finding unsuspected TB patients at the OPD can be done simply by enquiring about TB symptoms, for example coughing, fever, night sweats and weight loss.
As per national guidelines, nursing and auxiliary staff are assigned daily to, identify those patients with a cough, fast track them for screening for other TB related symptoms, and promptly collect sputum from those with presumptive TB for lab investigations, including rapid molecular testing. The intervention started with a 3-day on-site training for state, district and 15-20 key focal persons comprising of doctors, nurses, laboratory and information management personnel across all service delivery points. A representative from the health facility’s infection control committee also took part in order to understand what infection control measures were in place and agree on how to revive dormant infection control committees.. The training comprised classroom presentations and practical sessions, which included visits to the service delivery points. Participants could provide feedback to the hospital’s management and the key focal persons at the respective service delivery point.
Monthly follow-up review meetings were instituted. These review meetings addressed key issues including, comparisons of presumptive patients with hospital attendance, collecting participant feedback on referral activities in the month(s) under review, cross checking referrals’ time to diagnosis and time to treatment for diagnosed TB patients from the respective service delivery points in comparison with previous months. Also discussed were the challenges facing FAST implementation, e.g. missing presumptive and diagnosed patients, lab challenges and enrollment on treatment.
Training on FAST Strategy at General Hospital Badagry: didactical presentation (L) and practical session (R) (Courtesy of David Folivi)
There was an increase in the number of referrals (presumptive TB patients) across all facilities from 7,952 in the year before the intervention to 11,515 in the following year. There was also an increase in the number of notified TB patients from 1,486 to 2,275 in the same period. (see the figure below). The principal nursing officer of a general hospital, who identified a colleague as a presumptive TB patient, has now become a TB champion. The patient turned out to be the first reported HCW with drug-resistant TB in Lagos State.
Figure. TB case finding results through FAST strategy
Besides contributing to TB case notification in Lagos state, these facilities have potentially minimized the risk of nosocomial TB infection as time to diagnosis and treatment has been reduced from an average of 1-2 weeks pre-intervention to 1-3 days post-intervention. In addition to the staff trainings, regular review meetings, supportive supervision, advocacy supporting TB stigma and TB infection control have all contributed to the success of this intervention.
The successful implementation of the FAST Strategy has facilitated a scale up to other health facilities in Lagos and other CTB-supported states. It has been adopted by the National TB Program for implementation in all government health facilities nationwide. Other implementing partners are also encouraged to support this intervention.