Laboratory Strengthening in High TB-Burden African Countries

Laboratory strengthening in high TB-burden African countries
Seminar jointly organized by the Ministry of Health Lesotho and FIND under the auspices of WHO
Maseru, 24 February 2010
MDR XDR TB in Tugela Ferry/KZN overview and response 2010 Claudio Marra
Philanjalo/TFCARES
Msinga Sub District







Msinga Sub district

Population 172 000 TB incidence 1054/100 000 DRTB incidence 141/100 000 30% HIV+ pregnant women 75% of TB patients co infected HIV

SINCE 2005 A TOTAL NUMBER OF 852 DRTB REPORTED
364 MDR TB
488 XDR TB

MDR + XDR cases diagnosed between January 2005 and December 2009
35 35 30 30 25 25 20 20 15 15 10 10 5 5 0 0
2005 2005 2006 2007
2008 2009
JAA J NN
M M AA YY
M M AA RR

NN O O VV
J JUU LL
SS EE PP
MDR XDR TB
2008 MDR 46 XDR 75 TOTAL 121
2009 MDR 78 XDR 59 TOTAL 137

HIV-Associated MDR & XDR TB in S Africa

Gandhi et al, AJRCCM 2010
1. 00
0. 75
XDR TB (n = 382) mortality 82% MDR TB (n = 272) mortality 67%
0. 50
0. 25
0. 00
29 days
0 50 100
150
60 days
S RT : T AA
200 250 Survival in days S R 1Y UV R
300
350
400
T P= D Y E MR T P= D YEXR
C ensor ed T P = D Y E MR C ensor ed T P = D YEXR

Distribution of MDR by district

600 500 400 300 200 100 0
2000 2001 2002 2003 2004 2005 2006 2007 2008
DC21
PMB (D22)
DC23
Cosh
DC25
DC26
DC27
DC28
DC29
DC43
DURBAN

Distribution of XDR by district

80 70 60 50 40 30 20 10 0
DC21 DC22 DC23 Cosh DC25 DC26 DC27 DC28 DC29 dc43 durban 2001 2003 2005 2007 2002 2004 2006 2008

TB cases diagnosed annually
2004: all TB 4.572 mortality: 15.2% Defaulters, transferred, not evaluated:19.7% 2005: all TB 4.741 mortality:13.2% Defaulters, transferred, not evaluated:14.8% 2006: all TB 5.537 mortality:12.1% Defaulters, transferred, not evaluated:12.4%

Transmission of MDR & XDR TB

Evidence for Nosocomial Transmission
No prior treatment in 55% 2/3 patients hospitalized in past 2 years Initial community contact tracing-few additional cases Health care workers died with XDR TB Genotyping showed similar strain in 83%
Response
Coordinated response under the leadership of the Provincial- District Managers was planned More Human and Economic resources made available Support by International Partners available

Sustained Response
Improvement of the program for TB More nurses and tracing team available Training and supervision strengthened Cure rate at 83% default rate ~1% Since 2006 Household investigation started Contacts screened 4492 Adults contacts diagnosed with MDR: 29 Adults contacts diagnosed with XDR: 40 Total 69 transmission 3.7

Sustained Response
Decentralized MDR TB hospital opened (32beds) in the district Home base care for MDR TB started ~100 are followed Policy changes toward HIV/TB integration
Increased VCT among TB patients Increased ARV initiation among TB patients TB screening among HIV patients
Infection control COSH TB ward with negative pressure extractor installed in 2006 Open window policy implemented Administrative rules introduced like triage for patients with cough Use of mask N95 introduced for all health workers operating in TB wards and other areas Intensive case find started in the hospital and the community

Response challenges
Laboratory service at COSH with one microscopist processing an average of 75 sample a day TAT 48 h 78% 5.5% smear+ on TB suspects Cultures and DST sent to Durban (200KM) - ?cost? In 2009 COSH requested 5020 cultures and DST

Conclusion
MDR XDR TB remains a major and growing challenge in KZN Weve made progress with treatment (first 6 patients cured for MDR TB in the decentralized MDR TB centre in the district)
More than 100 patients with MDR TB on home base care in the district
Infection control is being addressed (still challenges linked to the old hospital infrastructures) Laboratory is the remaining challenge: needs strengthening at the district level

Acknowledgement
DOH District and Province COSH Philanjalo TFCARES (Yale University, Albert Einstein College of Medicine) Italian Cooperation Italian National Health institute University of KwaZulu Natal


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Laboratory Strengthening in High TB-Burden African Countries

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Laboratory strengthening in high TB-burden African countries

Maseru, 24 February 2010

Msinga Sub District