NIMR - Mbeya Medical Research Programme

Quick Information

NIMR - Mbeya Medical
Research Center

P.O Box 2410
Hospital Hill rd, Mbeya Tanzania

Tel    +255 25 250 3364
Fax   +255 25 250 3134
Working hours:
Mon   -  Fri
08:00 - 16:30 EAT (GMT + 3)

Interventions

ADAT study - Mobile Diagnostic and Training Centre (MDTC)

Investigators

Principal Investigators: Dr. Petra Clowes and Dr. Leonard Maboko

Background

NIMR – MMRC started the Mobile Diagnostic and Training Centre under a four (4) year EC funded Active Detection of Active Tuberculosis (ADAT) project since June 2007. Costs for purchasing the truck, laboratory and film show equipments, generator and generator trailer were approximately TANZANIAN SHILLINGS 390,000,000/=. Besides NIMR-MMRC which is the main implementer, other partners who are supporting the implementation of this MDTC include Walter Reed Army Institute of Research (USA), German Technical Cooperation – GTZ (Germany) and Mbeya Regional Medical Office (Tanzania). In close collaboration with the US PEPFAR funded Southern Highland AIDS and Care Programme, NIMR-MMRC is conducting several intervention activities mainly focused on the early detection of pulmonary tuberculosis of which the MDTC activities are part of.

To make the introduction of new diagnostic methods or treatments sustainable, intense training and thereafter constant utilisation of those new techniques is required. This can only be achieved through regular supervision but also through a high acceptance and strong demand from the communities served.

Coupled with a mobilization and awareness campaign, the well equipped mobile diagnostic and training centre (MDTC) can in relatively short time (24 hrs) diagnose and stage a number of TB and HIV cases. Newly diagnosed cases can then receive their treatment within the recently established collaborative TB and HIV services at sub-district level, resulting in quicker and easier access to diagnosis and treatment for the rural population. This support to the introduction of combined TB / HIV activities will provide the desired push and pull effect to increase acceptance and demand in the population and make it more sustainable.

This pilot study will explore the feasibility of a MDTC equipped with innovative rapid diagnostic methods for TB , HIV testing and immune status staging in terms of technical feasibility, acceptability in the population and health care staff, cost effectiveness, training effect for health facility staff, sustainability and rapid access to care and treatment.

Objectives

This centre has 3 main objectives which are:

i. To facilitate early diagnosis of HIV/AIDS and Tuberculosis in collaboration with the health facilities in the rural communities using modern laboratory equipments which are many times not available in these settings. Therefore, the diagnosis time is shortened to a great extent and early treatment of the diseases is facilitated. The diagnosed patients are therefore, immediately referred to the treatment centres.

ii. To train health workers in the health facilities within the communities served by the MDTC and ensure quality control of the laboratory services in the respective health facilities.

iii. To give health education to the community members using video/film shows in the evenings. The video/film shows focus on HIV/AIDS, Sexually Transmitted Infections and Tuberculosis - how to recognize them, prevention, importance of early diagnosis and treatment.

Methods

By combining the introduction of HIV/TB co-activities through the National Programmes with the services of the MDTC, the activities will be accelerated and boosted and made more sustainable. All clients are recruited through the health facility or the mobile VCT activities of PEPFAR and referred to the MDTC for TB and HIV testing and staging. Direct access to the MDTC is aimed to be avoided in order to prevent the creation of a parallel system. The intervention sites are 8 health facilities in the Mbeya Region which are visited on a regular basis by the MDTC, as well as 8 health facilities that will be supported regarding infrastructure of their laboratory and training of the laboratory staff, but will not be visited by the MDTC in the first year. In addition 8 health facilities without any additional interventions are evaluated as comparator. The site selection was done according to recommendations of regional and district authorities. Selection criteria were accessibility, available laboratory facilities, defined TB/HIV burden in the area and access to at least a mobile CTC.

The target population is all clients reporting to the respective health facilities for intensified TB and HIV diagnosis during the time of the MDTC visit at such facility, as well as all contacts of TB patients or TB suspects.

Equipped with innovative rapid diagnostic methods for TB/HIV testing and HIV staging and coupled with a mobilization and awareness campaign, the MDTC can in shorter than usual time diagnose and stage TB and HIV cases, who then have access to their treatment at sub-district level.

Intensified TB diagnostic includes the smear microscopy with a LED fluorescence microscope as well as the processing of the sputum samples with the new GenXpert® system. This system conducts a semi-quantitative nested real-time PCR in vitro diagnostic test (Xpert MTB/Rif) for the detection of Mycobacterium tuberculosis complex DNA in sputum samples or concentrated sediments, prepared from induced or expectorated sputa that are either acid-fast bacilli (AFB) smear positive or negative. Since the system does not require specialized skills to operate, the GenXpert® system can be used in any surrounding, e.g. in the field, thus making it a perfect solution for high tech approach in a resource limited setting.

Intensified HIV testing and staging enables the clients to access their results for HIV with the least possible delay and can therefore be started on treatment as soon as possible.

The proposed intervention will be entirely integrated into the health facility activities and is fully supported by the Regional and District authorities. The assessment of the intervention will be done utilizing data collected from three areas:

1.data that are routinely collected as part of a regular visit to a health facility

2.data generated through the investigations in the mobile diagnostic and training centre

3.data that have been previously generated at the health facility as well as at the corresponding CTCs and referral centres

Existing and newly generated data will be compared in order to assess the impact of the MDTC to support HIV/TB co-activities at dispensary and health centre level.

Preliminary findings

The Mobile Diagnostic and Training Centre have been operating in Tanzania since October 2009. The following data were collected in the one year period until October 2010.

• A total number of 6,632 clients were seen at the MDTC, either for VCT or for TB investigations, of which 63.3% were female and 36.7% were male

• A total of 866 TB suspects had a sputum smear with fluorescence microscopy. 23 suspects (2.65%) had positive smears. The majority was smear ++ (12 individuals), followed by +++ (6) and + (5)

• In a small subset of samples (100) the TB-detection rate could be doubled with the Cepheid GeneXpert® System

• Of the smear positive clients, all underwent HIV testing. 39% (9 individuals) were HIV positive with a median CD4 count of 262 (interquartile range = 211 to 305)

• In total, 5442 clients had an HIV test (3281 female and 2161 male clients), of which 14.4% were HIV positive (782). 61.9% (484) were female and 38.1% (298) of the clients were male

• The median CD4 count at time of HIV diagnosis was 378 (interquartile range = 220 to 579)

• So far, data for 2009 and 2010 for one HF of each stratum were compared. The facility from stratum 1 (regular MDTC) showed a clear increase in TB diagnosis during that period, compared with stratum 2 (infrastructural and training support). However, even the facility of stratum 3 (no support) showed a marked increase in case detection.

Conclusions:

• The MDTC is very well accepted and attended in the rural communities. It is an operationally feasible tool to implement combined HIV and TB activities

• Regarding the low smear positivity rate amongst TB suspects, it has to be kept in mind that screening was done upon the slightest suspicion of TB and clients were diagnosed at an early stage of their disease

• The median CD4 count at point of diagnosis was above 200 (for both TB suspects and non-suspects). This indicates that clients are identified early on in the disease, which could potentially reduce mortality of these clients

• Reasons for the increase of case detections in all 3 strata need further evaluation

Progress

The MDTC was piloted for 3 days between 3 – 6 July, 2009 during the Uhuru Torch Rally at Mbalizi (Mbeya District), Uyole (Mbeya City) and Rujewa (Mbarali District). Additionally, we piloted the MDTC services for 6 days (3 – 8 August, 2009) during the Farmers Days (Nanenane) in Mbeya Region. After this pilot phase, the actual planned MDTC services started on 12th October, 2009 in rural settings of Mbeya Region.

In addition to the normal day to day activities, the MDTC participated and provided services in 2 national events in 2010. From the 28th June to the 8th July 2010 the MDTC offered TB diagnosis and HIV testing and staging at the MoHSW/NIMR stand during the Trade Fair in Dar es Salaam. From 29th July to 8th August the MDTC provided similar services during Nane-Nane in Dodoma.

Future plans

The MDTC has recently entered a second round of activities, supported by the TB REACH project. Advocacy and community involvement has to be further strengthened. It is planned to apply a Health Seeing Behavior questionnaire to community members.

Sponsor

The MDTC activities are part of the ADAT (Active Detection of Active Tuberculosis) project, which is funded by the European Union as part of EuropAid, contract number SANTE/2006/129-931.

Pictures:
mobile_lab_kikwete2
Official opening of the MDTC by the president of Tanzania, his Excellency J. Kikwete

mobile_lab_training
Education session and discussions at night
mobile_lab_inside
Inside view of the MDTC

Pictures:
mobile_lab_kikwete2
Official opening of the MDTC by the president of Tanzania, his Excellency J. Kikwete

mobile_lab_training
Education session and discussions at night
mobile_lab_inside
Inside view of the MDTC