Strengthening the Tuberculosis Specimen Referral Network in Uganda: The Role of Public-Private Partnerships

Private practitioners' practices for tuberculosis management in a city largely served by the private health sector in Uganda

BACKGROUND

Globally, tuberculosis (TB) remains a significant cause of morbidity and mortality having caused 1.6 million deaths in 2021. Uganda is a high TB burden country with a large private sector that serves close to 60% of the urban population. However, private for-profit health facilities' involvement with the National TB and Leprosy Program (NTLP) activities remains poor. This study evaluated the practices of diagnosis and treatment of pulmonary tuberculosis (PTB) and associated factors among practitioners in private for-profit (PFP) healthcare facilities in Kampala, Uganda.

METHODS

We conducted a cross-sectional study among randomly selected private practitioners in Uganda's largest city, Kampala. A structured questionnaire was used for data collection. Descriptive statistics and generalized linear models with log Poisson link were used to analyze data. Practices were graded as standard or substandard.

RESULTS

Of the 630 private practitioners studied, 46.2% (95% confidence interval (CI): 26.6 to 67.1) had overall standard practices. Being a laboratory technician (prevalence ratio (PR) = 2.7, p< 0.001) or doctor (PR = 1.2, p< 0.001), a bachelor's degree level of qualification (PR = 1.1, p = 0.021), quarterly supervision by the national TB program (PR = 1.3, p = 0.023), and acceptable knowledge of the practitioner about TB (PR = 1.8, p<0.001) were significantly associated with standard practices.

CONCLUSIONS

The practices of TB management for practitioners from the PFP facilities in Kampala are suboptimal and this poses a challenge for the fight against TB given that these practitioners are a major source of primary health care in the city.

COVID-19 impact on health service- and TB-related practices among private providers in Indonesia

SETTING

The COVID-19 pandemic has caused disruptions to healthcare services worldwide, including in private healthcare facilities (HCFs), where TB patients mostly initiate their care-seeking journey.

OBJECTIVE

To identify adjustments to TB-related practices made by HCFs during the pandemic.

DESIGN

We identified, contacted and invited private HCFs across West Java, Indonesia, to fill an online questionnaire. The questionnaire explored participants' sociodemographic characteristics, adaptations and TB management practices implemented in their facilities during the pandemic. Data were analysed using descriptive statistics.

RESULTS

Of the 240 HCFs surveyed, 40.0% shortened their operational hours and 21.3% have ever closed their practices during the pandemic; 217 (90.4%) made adjustments to keep delivering services, 77.9% by requiring the use of personal protective equipment (PPE); 137 (57.1%) observed fewer patient visits; 140 (58.3%) used telemedicine, a few of which (7.9%) ever handled TB patients on that platform. Respectively 89.5%, 87.5% and 73.3% of HCFs referred patients for chest radiography, smear microscopy and Xpert testing. Only a median of 1 (IQR 1-3) TB patient per month was diagnosed by the HCFs.

CONCLUSION

Two major adaptations rolled out during COVID-19 were the use of telemedicine and PPE. Optimisation of the diagnostic referral system to increase TB case detection in private HCFs is warranted.

Losses along the tuberculosis sputum sample referral cascade for Mpongwe District, Zambia

BACKGROUND

In resource limited-settings, timely tuberculosis (TB) diagnosis depends upon referral of sputum samples from non-diagnostic to diagnostic facilities for examination. The TB programme data for 2018 suggested losses in Mpongwe District's sputum referral cascade.

AIM

This study aimed to identify the referral cascade stage where loss of sputum specimen occurred.

SETTING

Primary health care facilities in Mpongwe District, Copperbelt Province, Zambia.

METHODS

Data were retrospectively collected from one central laboratory and six referring health facilities between January and June 2019, using a paper-based tracking sheet. Descriptive statistics were generated in SPSS version 22.

RESULTS

Of the 328 presumptive pulmonary TB patients found in presumptive TB registers at referring facilities, 311 (94.8%) submitted sputum samples and were referred to the diagnostic facilities. Of these, 290 (93.2%) were received at the laboratory, and 275 (94.8%) were examined. The remaining 15 (5.2%) were rejected for reasons such as 'insufficient sample'. Results for all examined samples were sent back and received at referring facilities. Referral cascade completion rate was 88.4%. Median turnaround time was six days (IQR = 1.8).

CONCLUSION

Losses in the sputum referral cascade for Mpongwe District mainly occurred between dispatch of sputum samples and receipt at diagnostic facility. Mpongwe District Health Office needs to establish a system to monitor and evaluate the movement of sputum samples along the referral cascade to minimize losses and ensure timely TB diagnosis.Contribution: This study has highlighted, at primary health care level for resource limited settings, the stage in the sputum sample referral cascade where losses mainly occur.

Experiences with Tuberculosis Management among Community-Based Care Providers in Indonesia: A Qualitative Study

To explore experiences with TB management among community-based care providers. Descriptive qualitative study. A total of 25 care providers were selected using purposive sampling. Data were collected by semi-structured interviews and analyzed using content analysis. Six themes emerged from this study: "various dissemination channels," "compassionate religious volunteerism," "shortage of resources," "keeping TB cases hidden," "patient impediments to care," and "perceived economic burdens of patients." The findings can provide an understanding that the management of tuberculosis in the community requires collaboration between various institutions as well as patients. Building a sustainable TB system would be beneficial. A TB care model can be established between government and other institutions.

Impact of on-site Xpert on TB diagnosis and mortality trends in Uganda

SETTING

Since 2012, Uganda expanded the Xpert^® MTB/RIF network for diagnosis of TB.

OBJECTIVES

We compared TB care cascades at health facilities with on-site Xpert vs. facilities that accessed the assay through specimen referral.

DESIGN

We analysed secondary aggregate data of the National TB and Leprosy Program (NTLP) from 2016 to 2019. We computed the proportions of notified TB cases and mortality ratios in relation to the estimated TB burden.

RESULTS

TB case notifications per annum increased from 24,287 in 2016 to 30,739 in 2019, and the proportion of cases diagnosed at facilities with on-site Xpert testing increased from 62% (15,070/24,287) to 81% (24,829/30,739) (P < 0.001). TB mortality at facilities with on-site Xpert decreased from 8.6% (1,302/15,070) to 7.8% (1,938/24,829) (P = 0.41), while it increased at facilities without on-site Xpert from 6.9% (638/9,217) to 8.8% (521/5,910) (P = 0.23). Furthermore, mortality among TB-HIV co-infected patients at facilities with on-site Xpert dropped from 5.0% (760/15,070) in 2016 to 4.8% (1,187/24,826) in 2019 (P = 0.84) compared to 4.4% (407/9,217) in 2016 to 5.3% (315/5,910) in 2019 (P = 0.57).

CONCLUSION

Wider installation and decentralisation of Xpert leads to increased case-finding. However, the impact on reduction in mortality remains limited. Interventions to address TB-related mortality in addition to Xpert roll-out are required.

Molecular characterisation of second-line drug resistance among drug resistant tuberculosis patients tested in Uganda: a two and a half-year's review

BACKGROUND

Second-line drug resistance (SLD) among tuberculosis (TB) patients is a serious emerging challenge towards global control of the disease. We characterized SLD-resistance conferring-mutations among TB patients with rifampicin and/or isoniazid (RIF and/or INH) drug-resistance tested at the Uganda National TB Reference Laboratory (NTRL) between June 2017 and December 2019.

METHODS

This was a descriptive cross-sectional secondary data analysis of 20,508 M. tuberculosis isolates of new and previously treated patients' resistant to RIF and/or INH. DNA strips with valid results to characterise the SLD resistance using the commercial Line Probe Assay Genotype MTBDRsl Version 2.0 Assay (Hain Life Science, Nehren, Germany) were reviewed. Data were analysed with STATAv15 using cross-tabulation for frequency and proportions of known resistance-conferring mutations to injectable agents (IA) and fluoroquinolones (FQ).

RESULTS

Among the eligible participants, 12,993/20,508 (63.4%) were male and median (IQR) age 32 (24-43). A total of 576/20,508 (2.8%) of the M. tuberculosis isolates from participants had resistance to RIF and/or INH. These included; 102/576 (17.7%) single drug-resistant and 474/576 (82.3%) multidrug-resistant (MDR) strains. Only 102 patients had test results for FQ of whom 70/102 (68.6%) and 01/102 (0.98%) had resistance-conferring mutations in the gyrA locus and gyrB locus respectively. Among patients with FQ resistance, gyrAD94G 42.6% (30.0-55.9) and gyrA A90V 41.1% (28.6-54.3) mutations were most observed. Only one mutation, E540D was detected in the gyrB locus. A total of 26 patients had resistance-conferring mutations to IA in whom, 20/26 77.0% (56.4-91.0) had A1401G mutation in the rrs gene locus.

CONCLUSIONS

Our study reveals a high proportion of mutations known to confer high-level fluoroquinolone drug-resistance among patients with rifampicin and/or isoniazid drug resistance. Utilizing routinely generated laboratory data from existing molecular diagnostic methods may aid real-time surveillance of emerging tuberculosis drug-resistance in resource-limited settings.

Losses in the Sputum Specimen Referral Cascade in Mpulungu District, Zambia: A Cross-Sectional Study

Sputum specimen referral cascades in resource-limited settings are characterized by losses of specimens, resulting in delays in tuberculosis (TB) diagnosis. Mpulungu District Health Office in Zambia conducted a quantitative based cross-sectional study using both primary and secondary data to identify points at which loss of specimens occurred in the sputum referral cascade. Primary data were collected through observations and interviews with 22 TB service providers. Secondary data were collected through examination of patient files and presumptive TB and laboratory registers to retrospectively track sputum specimens referred by ten health centers from April to September 2018. Proportions of specimens/laboratory results at every stage of the referral cascade were calculated using Epi Info v7. Only 49 (23%) out of 209 sputum specimens completed the referral cascade. The remaining 160 (76%) were lost at various stages of the referral cascade. The largest loss (51%) occurred between the release of laboratory results by the diagnostic facility and their receipt at referring facilities. Barriers included an inadequate number of staff oriented in sputum specimen referral, negative staff attitudes, and lack of specimen packaging material and specimen transportation. The district health office should strengthen the sputum specimen referral system by providing transport and specimen packaging material and by training staff in sputum collection transportation and tracking.

Barriers and facilitators to accessing tuberculosis care in Nepal: a qualitative study to inform the design of a socioeconomic support intervention

OBJECTIVE

Psychosocial and economic (socioeconomic) barriers, including poverty, stigma and catastrophic costs, impede access to tuberculosis (TB) services in low-income countries. We aimed to characterise the socioeconomic barriers and facilitators of accessing TB services in Nepal to inform the design of a locally appropriate socioeconomic support intervention for TB-affected households.

DESIGN

From August 2018 to July 2019, we conducted an exploratory qualitative study consisting of semistructured focus group discussions (FGDs) with purposively selected multisectoral stakeholders. The data were managed in NVivo V.12, coded by consensus and analysed thematically.

SETTING

The study was conducted in four districts, Makwanpur, Chitwan, Dhanusha and Mahottari, which have a high prevalence of poverty and TB.

PARTICIPANTS

Seven FGDs were conducted with 54 in-country stakeholders, grouped by stakeholders, including people with TB (n=21), community stakeholders (n=13) and multidisciplinary TB healthcare professionals (n=20) from the National TB Programme.

RESULTS

The perceived socioeconomic barriers to accessing TB services were: inadequate TB knowledge and advocacy; high food and transportation costs; income loss and stigma. The perceived facilitators to accessing TB care and services were: enhanced championing and awareness-raising about TB and TB services; social protection including health insurance; cash, vouchers and/or nutritional allowance to cover food and travel costs; and psychosocial support and counselling integrated with existing adherence counselling from the National TB Programme.

CONCLUSION

These results suggest that support interventions that integrate TB education, psychosocial counselling and expand on existing cash transfer schemes would be locally appropriate and could address the socioeconomic barriers to accessing and engaging with TB services faced by TB-affected households in Nepal. The findings have been used to inform the design of a socioeconomic support intervention for TB-affected households. The acceptability, feasibility and impact of this intervention on TB-related costs, stigma and TB treatment outcomes, is now being evaluated in a pilot implementation study in Nepal.

Epidemiological profile of patients with rifampicin-resistant tuberculosis: an analysis of the Uganda National Tuberculosis Reference Laboratory Surveillance Data, 2014-2018

BACKGROUND

Drug-resistant tuberculosis (DR-TB), including rifampicin-resistant tuberculosis (RR-TB) and multidrug-resistant tuberculosis (MDR-TB, or RR-TB with additional isoniazid resistance), presents challenges to TB control. In Uganda, the GeneXpert test provides point-of-care testing for TB and rifampicin resistance. Patients identified with RR-TB receive culture-based drug susceptibility testing (DST) to identify additional resistance, if any. There are few data on the epidemiological profiles of current DR-TB patients in Uganda. We described patients with RR-TB in Uganda and assessed the trends of RR-TB to inform TB control interventions.

METHODS

We identified patients with RR-TB whose samples were referred for culture and DST during 2014-2018 from routinely-generated laboratory surveillance data at the Uganda National Tuberculosis Reference Laboratory. Data on patient demographics and drug sensitivity profile of Mycobacterium tuberculosis isolates were abstracted. Population data were obtained from the Uganda Bureau of Statistics to calculate incidence. Descriptive epidemiology was performed, and logistic regression used to assess trends.

RESULTS

We identified 1474 patients whose mean age was 36 ± 17 years. Overall incidence was 3.8/100,000 population. Males were more affected by RR-TB than females (4.9 vs. 2.7/100,000, p ≤ 0.01). Geographically, Northern Uganda was the most affected region (IR = 6.9/100,000) followed by the Central region (IR = 5.01/100,000). The overall population incidence of RR-TB increased by 20% over the evaluation period (OR = 1.2; 95% CI 1.15-1.23); RR-TB in new TB cases increased by 35% (OR = 1.35; 95% CI 1.3-1.4) and by 7% in previously-treated cases (OR = 1.07; 95% CI 1.0-1.1). Of the 1474 patients with RR-TB, 923 (63%) were culture-positive of whom 670 (72%) had full DST available. Based on the DST results, 522/670 (78%) had MDR-TB.

CONCLUSION

Between 2014 and 2018, the incidence of RR-TB increased especially among newly-diagnosed TB patients. We recommend intensified efforts and screening for early diagnosis especially among previously treated patients. Mechanisms should be in put to ensure that all patients with RR-TB obtain DST.

Public-private partnerships in primary health care: a scoping review

Background

The Astana Declaration on Primary Health Care reiterated that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals. It called for governments to give high priority to PHC in partnership with their public and private sector organisations and other stakeholders. Each country has a unique path towards UHC, and different models for public-private partnerships (PPPs) are possible. The goal of this paper is to examine evidence on the use of PPPs in the provision of PHC services, reported challenges and recommendations.

Methods

We systematically reviewed peer-reviewed studies in six databases (ScienceDirect, Ovid Medline, PubMed, Web of Science, Embase, and Scopus) and supplemented it by the search of grey literature. PRISMA reporting guidelines were followed.

Results

Sixty-one studies were included in the final review. Results showed that most PPPs projects were conducted to increase access and to facilitate the provision of prevention and treatment services (i.e., tuberculosis, education and health promotion, malaria, and HIV/AIDS services) for certain target groups. Most projects reported challenges of providing PHC via PPPs in the starting and implementation phases. The reported challenges and recommendations on how to overcome them related to education, management, human resources, financial resources, information, and technology systems aspects.

Conclusion

Despite various challenges, PPPs in PHC can facilitate access to health care services, especially in remote areas. Governments should consider long-term plans and sustainable policies to start PPPs in PHC and should not ignore local needs and context.

The potential of diagnostic point-of-care tests (POCTs) for infectious and zoonotic animal diseases in developing countries: Technical, regulatory and sociocultural considerations

Remote and rural communities in low‐ and middle‐income countries (LMICs) are disproportionately affected by infectious animal diseases due to their close contact with livestock and limited access to animal health personnel). However, animal disease surveillance and diagnosis in LMICs is often challenging, and turnaround times between sample submission and diagnosis can take days to weeks. This diagnostic gap and subsequent disease under‐reporting can allow emerging and transboundary animal pathogens to spread, with potentially serious and far‐reaching consequences. Point‐of‐care tests (POCTs), which allow for rapid diagnosis of infectious diseases in non‐laboratory settings, have the potential to significantly disrupt traditional animal health surveillance paradigms in LMICs. This literature review sought to identify POCTs currently available for diagnosing infectious animal diseases and to determine facilitators and barriers to their use and uptake in LMICs. Results indicated that some veterinary POCTs have been used for field‐based animal disease diagnosis in LMICs with good results. However, many POCTs target a small number of key agricultural and zoonotic animal diseases, while few exist for other important animal diseases. POCT evaluation is rarely taken beyond the laboratory and into the field where they are predicted to have the greatest impact, and where conditions can greatly affect test performance. A lack of mandated test validation regulations for veterinary POCTs has allowed tests of varying quality to enter the market, presenting challenges for potential customers. The use of substandard, improperly validated or unsuitable POCTs in LMICs can greatly undermine their true potential and can have far‐reaching negative impacts on disease control. To successfully implement novel rapid diagnostic pathways for animal disease in LMICs, technical, regulatory, socio‐political and economic challenges must be overcome, and further research is urgently needed before the potential of animal disease POCTs can be fully realized.

Sample Transport Optimization: Mali Pilot Study

In Mali, qualified laboratories for testing of dangerous pathogens are centralized in Bamako. Creating a specimen transport system respecting timeline, specimen quality, biosafety, and biosecurity standards is a challenge. The current ad hoc system that relies on untrained public transport companies carries risks of spoilage, accidental release of pathogens, and delays, which compromise specimen quality. This pilot study aimed to evaluate the effectiveness (ie, timeline, quality of specimen, and cost) of using the trained postal service for sample transportation from district to central level, compared with the current system. The postal service intervention ran from mid-2016 to mid-2017 and covered 3 districts. Data were collected in the same districts during the same period of the preceding year for comparison. In all, 41 specimens were shipped using public transportation and 51 were shipped using the postal service. These included suspected meningitis, measles, yellow fever, and polio samples. Only 46% of samples sent by public transportation were received in Bamako within 72 hours of collection, compared to 71% of samples shipped via the postal service (p < .05). Further, 93% of samples shipped by public transportation arrived in good condition at the receiving laboratory, compared to 98% by postal service. Although cost comparisons were difficult (flat fee vs per-specimen fare), the average cost per specimen was 8 times higher with the postal service. Shipment of specimens from districts to central level using the postal service was feasible and appeared to be faster than public transportation, thus allowing specimen quality to be preserved. Further analysis regarding the most efficient costing mechanism is needed.

Comparative performance of the laboratory assays used by a Diagnostic Laboratory Hub for opportunistic infections in people living with HIV

OBJECTIVES

We evaluated the comparative performance of different assays used in a Diagnostic Laboratory Hub that linked 13 HIV healthcare facilities for the diagnosis of tuberculosis (TB), histoplasmosis, and cryptococcosis, and describing its functions in Guatemala compared with other National Reference Laboratories.

METHODS

The following diagnostic techniques were analyzed in 24 months (2017-2018) in a cohort of patients with HIV: smear microscopy, mycobacterial and fungal cultures, isolator blood culture, PCR assays, and antigen detection tests.

RESULTS

A total of 4245 patients were included, 716 (16.2%) had an opportunistic infection: 249 (34.7%) TB, 40 (5.6%) nontuberculous mycobacteria, 227 (31.7%) histoplasmosis, 138 (19.3%) cryptococcosis, and 62 (8.6%) had multiple opportunistic infections. Two hundred sixty-three [92.6%; 95% confidence interval (CI), 89-95.1] of TB cases were diagnosed by PCR. Urine antigen assay detected 94% (95% CI, 89-96) of the disseminated histoplasmosis cases. A lateral flow assay to detect cryptococcal antigen diagnosed 97% (95% CI, 93.3-98.7%) of the cryptococcal cases. In 85 patients (51.5%) with a cerobrospinal fluid sample, cryptococcal meningitis was diagnosed in 55 (64.7%), of which 18 (32.7%) were only detected by cryptococcal antigen.

CONCLUSION

Validated commercial antigen tests, as used in this program, should be the new gold standard for histoplasmosis and cryptococcosis diagnosis. In their absence, 35% of disseminated histoplasmosis and 32.7% of cryptococcal meningitis cases would have been missed. Patients with multiple opportunistic infections were frequently diagnosed and strategies should be designed to screen patients irrespective of their clinical presentation. In low resource settings, Diagnostic Laboratory Hubs can deliver quality diagnostics services in record time at affordable prices.

Multidrug-resistant tuberculosis surveillance and cascade of care in Madagascar: a five-year (2012-2017) retrospective study

BACKGROUND

In Madagascar, the multidrug-resistant tuberculosis (MDR-TB) surveillance programme was launched in late 2012 wherein previously treated TB cases and symptomatic MDR-TB contacts (hereafter called presumptive MDR-TB cases) undergo drug susceptibility testing. This retrospective review had per aim to provide an update on the national MDR-TB epidemiology, assess and enhance programmatic performance and assess Madagascar's MDR-TB cascade of care.

METHODS

For 2012-2017, national TB control programme notification, clinical management data and reference laboratory data were gathered. The development and coverage of the surveillance programme, the MDR-TB epidemiology and programmatic performance indicators were assessed using descriptive, logistic and spatial statistical analyses. Data for 2017 was further used to map Madagascar's TB and MDR-TB cascade of care.

RESULTS

The geographical coverage and diagnostic and referral capacities of the MDR-TB surveillance programme were gradually expanded whereas regional variations persist with regard to coverage, referral rates and sample referral delays. Overall, the rate of MDR-TB among presumptive MDR-TB cases remained relatively stable, ranging between 3.9% in 2013 and 4.4% in 2017. Most MDR-TB patients were lost in the second gap of the cascade pertaining to MDR-TB cases reaching diagnostic centres but failing to be accurately diagnosed (59.0%). This poor success in diagnosis of MDR-TB is due to both the current use of low-sensitivity smear microscopy as a first-line diagnostic assay for TB and the limited access to any form of drug susceptibility testing. Presumptive MDR-TB patients' sample referral took a mean delay of 28 days before testing. Seventy-five percent of diagnosed MDR-TB patients were appropriately initiated on treatment, and 33% reached long-term recurrence-free survival.

CONCLUSIONS

An expansion of the coverage and strengthening of MDR-TB diagnostic and management capacities are indicated across all regions of Madagascar. With current limitations, the surveillance programme data is likely to underestimate the true MDR-TB burden in the country and an updated national MDR-TB prevalence survey is warranted. In absence of multiple drivers of an MDR-TB epidemic, including high MDR-TB rates, high HIV infection rates and inter-country migration, Madagascar is in a favourable starting position for MDR-TB control and elimination.

Designing and Piloting a Specimen Transport System in Burkina Faso

Efficient specimen transport systems are critical for early disease detection and reporting by laboratory networks. In Burkina Faso, centralized reference laboratories receive specimens from multiple surveillance sites for testing, but transport methods vary, resulting in potential delays and risk to specimen quality. The ministry of health and partners, under the Global Health Security Agenda implementation, piloted a specimen transport system for severe acute respiratory illness (SARI) surveillance in 4 Burkina Faso districts. A baseline assessment was conducted of the current specimen transport network structure and key stakeholders. Assessment results and guidelines for processing SARI specimens informed the pilot specimen transport system design and implementation. Monitoring and evaluation performance indicators included: proportion of packages delivered, timeliness, and quality of courier services (missed or damaged packages). Our baseline assessment found that laboratorians routinely carried specimens from the health center to reference laboratories, resulting in time away from laboratory duties and potential specimen delays or loss of quality. The pilot specimen transport system design engaged Sonapost, the national postal service, to transport specimens from SARI sites to the influenza national reference laboratory. From May 2017 to December 2018, the specimen transport system transported 557 packages containing 1,158 SARI specimens; 95% (529/557) were delivered within 24 hours of pick-up and 77% (892/1,158) within 48 hours of collection. No packages were lost. This article highlights lessons learned that may be useful for other countries considering establishment of a specimen transport system to strengthen laboratory system infrastructure in global health security implementation.

Informing decision-making for universal access to quality tuberculosis diagnosis in India: an economic-epidemiological model

BACKGROUND

India and many other high-burden countries have committed to providing universal access to high-quality diagnosis and drug susceptibility testing (DST) for tuberculosis (TB), but the most cost-effective approach to achieve this goal remains uncertain. Centralized testing at district-level hub facilities with a supporting sample transport network can generate economies of scale, but decentralization to the peripheral level may provide faster diagnosis and reduce losses to follow-up (LTFU).

METHODS

We generated functions to evaluate the costs of centralized and decentralized molecular testing for tuberculosis with Xpert MTB/RIF (Xpert), a WHO-endorsed test which can be performed at centralized and decentralized levels. We merged the cost estimates with an agent-based simulation of TB transmission in a hypothetical representative region in India to assess the impact and cost-effectiveness of each strategy.

RESULTS

Compared against centralized Xpert testing, decentralization was most favorable when testing volume at decentralized facilities and pre-treatment LTFU were high, and specimen transport network was exclusively established for TB. Assuming equal quality of centralized and decentralized testing, decentralization was cost-saving, saving a median $338,000 (interquartile simulation range [IQR] - $222,000; $889,000) per 20 million people over 10 years, in the most cost-favorable scenario. In the most cost-unfavorable scenario, decentralized testing would cost a median $3161 [IQR $2412; $4731] per disability-adjusted life year averted relative to centralized testing.

CONCLUSIONS

Decentralization of Xpert testing is likely to be cost-saving or cost-effective in most settings to which these simulation results might generalize. More decentralized testing is more cost-effective in settings with moderate-to-high peripheral testing volumes, high existing clinical LTFU, inability to share specimen transport costs with other disease entities, and ability to ensure high-quality peripheral Xpert testing. Decision-makers should assess these factors when deciding whether to decentralize molecular testing for tuberculosis.

Improving the diagnostics of tuberculosis and drug resistance with Xpert MTB/RIF in a district general hospital in Sierra Leone: a quality improvement project

Sierra Leone has a high tuberculosis (TB) burden with a prevalence of 441 cases per 100 000 population. As a result of the Global Fund, some facilities in the country have access to improved diagnostics, including Xpert MTB/RIF testing, of particular use in diagnosing those at risk of drug resistance, in the form of rifampicin-resistant (RR) TB. This quality improvement project describes how a small, rural district general hospital in Masanga village improved the diagnosis of TB and RR-TB by creating a formal link with the regional hospital in Makeni city. In an effort to improve diagnosis, all patients with a suspicion of TB and one of the following would have a sample sent for Xpert MTB/RIF testing: previous TB treatment (of any course length), HIV positive or known contact of a RR-TB case. The samples were transported by the logistics team, who already drove weekly from Masanga to Makeni for supplies, and the results were texted to the clinician in charge of the medical ward. Over the course of the first 4 months of this intervention, 34 samples had Xpert MTB/RIF testing performed compared with two samples in the previous 12 months since the machine had been installed. This yielded nine additional diagnoses of TB (in patients with negative or unavailable smear results) and five diagnoses of RR-TB with subsequent appropriate isolation and transfer to the central tertiary centre. This study shows that it is feasible to centralise Xpert MTB/RIF testing in low-resource settings using creative methods for sample transfer and results dissemination, leading to both improved diagnostics and infection control.

Role of public-private partnerships in achieving UNAIDS HIV treatment targets

Background

Despite progress towards achieving UNAIDS 90–90-90 goals, barriers persist in laboratory systems in sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships (PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated impact in the scale up of VL and EID.

Methods

We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved associated systems from the point of viral load test request to the use of the test result for patient management were deemed eligible.

Results

We identified six PPPs collaborations with multiple activities in select countries that are contributing to address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented 94% of specimens to reach national laboratory through improved sample referral network and enabled a cost savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as well as reduced turnaround time of reporting results by 50%.

Conclusions

Our review identified the benefits, enabling factors, and associated challenges for public and private sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90–90-90 treatment targets for HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely untapped.

Does pre-diagnostic loss to follow-up among presumptive TB patients differ by type of health facility? An operational research from Hwange, Zimbabwe in 2017

Introduction

While there are many studies assessing the pre-treatment loss to follow-up (LFU) among tuberculosis patients in public sector, there is no evidence from private-for-profit health sector and pre-diagnostic LFU from Zimbabwe. We aimed to assess the gaps in the cascade of care of presumptive TB patients registered during January-June 2017 in different types of health facilities in Hwange district, Zimbabwe.

Methods

This was a cohort study involving review of routine programme data. Pre-diagnostic LFU was defined as the proportion of presumptive TB patients not tested using sputum microscopy or Xpert MTB/RIF. A log binomial regression was done to assess factors associated with pre-diagnostic LFU.

Results

Of 1279 presumptive TB patients, 955(75%) were tested for TB and 102(8%) were diagnosed as having TB. All TB patients were started on treatment. Pre-diagnostic LFU (overall 25%) was significantly higher among patients visiting private-for-profit health facilities (36%), local self-government run council health facilities (35%) and church-run mission health facilities (25%) compared to government health facilities (14%). Pre-diagnostic LFU was significantly higher among patients in rural areas (30%) compared to urban areas (18%). Type of health facility was associated with pre-diagnostic LFU after adjusting for HIV status and area of residence.

Conclusion

While pre-diagnostic LFU was high, there was no pre-treatment LFU. Pre-diagnostic LFU was especially high in private-for-profit and council health facilities and rural areas. National TB Programme should take immediate steps to improve access in rural areas and support the private-for-profit and council health facilities by improving sputum collection and transport.

Improving pathology and laboratory medicine in low-income and middle-income countries: roadmap to solutions

Insufficient awareness of the centrality of pathology and laboratory medicine (PALM) to a functioning health-care system at policy and governmental level, with the resultant inadequate investment, has meant that efforts to enhance PALM in low-income and middle-income countries have been local, fragmented, and mostly unsustainable. Responding to the four major barriers in PALM service delivery that were identified in the first paper of this Series (workforce, infrastructure, education and training, and quality assurance), this second paper identifies potential solutions that can be applied in low-income and middle-income countries (LMICs). Increasing and retaining a quality PALM workforce requires access to mentorship and continuing professional development, task sharing, and the development of short-term visitor programmes. Opportunities to enhance the training of pathologists and allied PALM personnel by increasing and improving education provision must be explored and implemented. PALM infrastructure must be strengthened by addressing supply chain barriers, and ensuring laboratory information systems are in place. New technologies, including telepathology and point-of-care testing, can have a substantial role in PALM service delivery, if used appropriately. We emphasise the crucial importance of maintaining PALM quality and posit that all laboratories in LMICs should participate in quality assurance and accreditation programmes. A potential role for public-private partnerships in filling PALM services gaps should also be investigated. Finally, to deliver these solutions and ensure equitable access to essential services in LMICs, we propose a PALM package focused on these countries, integrated within a nationally tiered laboratory system, as part of an overarching national laboratory strategic plan.

Multidisease testing for HIV and TB using the GeneXpert platform: A feasibility study in rural Zimbabwe

BACKGROUND

HIV Viral Load and Early Infant Diagnosis technologies in many high burden settings are restricted to centralized laboratory testing, leading to long result turnaround times and patient attrition. GeneXpert (Cepheid, CA, USA) is a polyvalent near point-of-care platform and is widely implemented for Xpert MTB/RIF diagnosis. This study sought to evaluate the operational feasibility of integrated HIV VL, EID and MTB/RIF testing in new GeneXpert platforms.

METHODS

Whole blood samples were collected from consenting patients due for routine HIV VL testing and DBS samples from infants due for EID testing, at three rural health facilities in Zimbabwe. Sputum samples were collected from all individuals suspected of TB. GeneXpert testing was reserved for all EID, all TB suspects and priority HIV VL at each site. Blood samples were further sent to centralized laboratories for confirmatory testing. GeneXpert polyvalent testing results and patient outcomes, including infrastructural and logistical requirements are reported. The study was conducted over a 10-month period.

RESULTS

The fully automated GeneXpert testing device, required minimal training and biosafety considerations. A total of 1,302 HIV VL, 277 EID and 1,581 MTB/RIF samples were tested on a four module GeneXpert platform in each study site. Xpert HIV-1 VL testing was prioritized for patients who presented with advanced HIV disease, pregnant women, adolescents and suspected ART failures patients. On average, the study sites had a GeneXpert utilization rate of 50.4% (Gutu Mission Hospital), 63.5% (Murambinda Mission Hospital) and 17.5% (Chimombe Rural Health Centre) per month. GeneXpert polyvalent testing error rates remained lower than 4% in all sites. Decentralized EID and VL testing on Xpert had shorter overall median TAT (1 day [IQR: 0-4] and 1 day [IQR: 0-1] respectively) compared to centralized testing (17 days [IQR: 13-21] and 26 days [IQR: 23-32] respectively). Among patients with VL >1000 copies/ml (73/640; 11.4%) at GMH health facility, median time to enhanced adherence counselling was 8 days and majority of those with documented outcomes had re-suppressed VL (20/32; 62.5%). Median time to ART initiation among Xpert EID positive infants at GMH was 1 day [IQR: 0-1].

CONCLUSION

Implementation of near point-of-care GeneXpert platform for integrated multi-disease testing within district and sub-district healthcare settings is feasible and will increase access to VL, and EID testing to priority populations. Quality management systems including monitoring of performance indicators, together with regular on-site supervision are crucial, and near-POC test results must be promptly actioned-on by clinicians for patient management.

Integrating tuberculosis and antimicrobial resistance control programmes

Many low- and middle-income countries facing high levels of antimicrobial resistance, and the associated morbidity from ineffective treatment, also have a high burden of tuberculosis. Over recent decades many countries have developed effective laboratory and information systems for tuberculosis control. In this paper we describe how existing tuberculosis laboratory systems can be expanded to accommodate antimicrobial resistance functions. We show how such expansion in services may benefit tuberculosis case-finding and laboratory capacity through integration of laboratory services. We further summarize the synergies between high-level strategies on tuberculosis and antimicrobial resistance control. These provide a potential platform for the integration of programmes and illustrate how integration at the health-service delivery level for diagnostic services could occur in practice in a low- and middle-income setting. Many potential mutual benefits of integration exist, in terms of accelerated scale-up of diagnostic testing towards rational use of antimicrobial drugs as well as optimal use of resources and sharing of experience. Integration of vertical disease programmes with separate funding streams is not without challenges, however, and we also discuss barriers to integration and identify opportunities and incentives to overcome these.

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A 23-year-old indigenous Guatemalan man presented in 2016 to our clinic in Sololá, Guatemala, with 10 months of recurrent neck swelling, fevers, night sweats and weight loss. Previously, he had sought care in three different medical settings, including a private physician-run clinic, a tertiary private cancer treatment centre and, finally, a rural government health post. With assistance from our institution's accompaniment staff, the patient was admitted to a public tertiary care hospital for work-up. Rifampin-susceptible tuberculosis was diagnosed, and appropriate treatment was begun. The case illustrates how low tuberculosis recognition among community health workers and health system segmentation creates obstacles to appropriate care, especially for patients with limited means. As a result, significant diagnostic and treatment delays can occur, increasing the public health burden of tuberculosis.

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The recent Ebola virus outbreak in West Africa clearly demonstrated the critical role of laboratory systems and networks in responding to epidemics. Because of the huge challenges in establishing functional laboratories at all tiers of health systems in developing countries, strengthening specimen referral networks is critical. In this review article, we propose a platform strategy for developing specimen referral networks based on 2 models: centralized and decentralized laboratory specimen referral networks. These models have been shown to be effective in patient management in programs in resource-limited settings. Both models lead to reduced turnaround time and retain flexibility for integrating different specimen types. In Haiti, decentralized specimen referral systems resulted in a 182% increase in patients enrolling in human immunodeficiency virus treatment programs within 6 months. In Uganda, cost savings of up to 62% were observed with a centralized model. A platform strategy will create a network effect that will benefit multiple disease programs.