t he Antenatal Care Setting in Malawi Symposium Exploring the intersection between TB and maternal and neonatal health from research to implementation Florence Kayambo Senior HIVTB Technical Advisor ID: 325010
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TB Screening in the Antenatal Care Setting in Malawi
Symposium: Exploring the intersection between TB and maternal and neonatal health: from research to implementationFlorence KayamboSenior HIV/TB Technical AdvisorTB Lung Conference Barcelona, Spain 28th October – 1st November 2014Slide2
Presentation OutlineBackground
Program ObjectivesProgram ActivitiesAchievementsChallengesRecommendationsConclusion
2Slide3
Background: Malawi
Indicator
Malawi
Population
13.1 million
HIV
prevalence in Adults (2010)
10.6%
TB incidence163 per 100,000MTCT rate17,000 infants infected yearlyMMR675 per 100,000TB/HIV co-infection63%TB case detection rate65%
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Program ObjectivesIncrease early TB case detection and management in pregnant women accessing ANC/FANC by 50%
Accelerate integration of TB screening in ANCAccelerate national scale-up of effective and comprehensive PMTCT services (Option B+)Improve the quality of PMTCT programContribute to the reduction of maternal and newborn mortality through strengthening linkages between maternal health and TB management
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ProcessDiscussion with National
TB Control Programme, HIV Directorate, RHD and TB Care II Procurement of 2 microscopes and IP suppliesDevelopment of job aids to standardize implementation (FANC/TB card and tape measure)Revised M&E data collection toolsOrientation of service providers
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Program Activities
One-day orientation for providers Training of HSAs in TB microscopyProcurement of microscopes and laboratory supplies Demand creation and awareness through community mobilization activitiesIntegration of TB screening into MCH platformClinical mentoring Supportive supervisionDocumentationOperational research
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Program Activities, Continued
Task shifting HSAs trained in TB microscopyHIV testing and counseling by HSAsProvider initiated testing and counselling in ANC settingsInitiation of ART in ANC by nursesEstablishment of sputum collection and microscopy sites Sputum sample collection and slide fixing Quarterly review meetings
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Monitoring and Evaluation
Expected Outcomes
Outcome Indicators
Target
Enhanced case finding among ANC attendees
Percentage increase in pregnant women screened for TB signs/symptoms in intervention sites
50%
Number/percentage of mothers screened have symptoms of TB
n/a
Percentage increase in reported TB cases referred from ANC in the district post-intervention100% Prompt diagnosis Percentage of ANC clients with symptoms of TB with at least one sputum sample tested for TB and results returned within 24–48 hours50%
Percentage increase in ANC clients with symptoms of TB with documented diagnosis and HIV ascertainment
100%
Prompt treatment
Time to initiation of TB treatment from initial symptom screening
< two weeks
Percentage improvement in time to initiation of ART in those women who do or do not have symptoms of TB
50%
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AchievementsModification of data collection tools to include TB case diagnosis and lead time to treatment initiation
PITC/HTC integrated within ANC settingART initiation within ANCTB screening, including referral sputum collection to those eligibleTB-positive clients treated according to guidelines and protocolsPMTCT is fully integrated into maternal and child health servicesVery high (93%) ANC attendance rate, providing an exceptional opportunity to identify and reach women in need of TB management
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AchievementsSupport from District Health Management Team
Oriented 300 providers in FANC/TB6 HSAs and 4 laboratory technicians trained in TB microscopy (3 weeks) Development of job aids: fundal height tape measure with key messages, routine TB screening in ANCFANC/TB guideDraft TB/HIV training manual for community
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Summary of Results
Total ANC Attendees
5,474
Women screened for signs/symptoms
of TB in ANC
3,920 (
71.6%)
Women with signs/symptoms of TB
68 (1.7%)Women with signs/symptoms of TB diagnosed with TB4 (5.9%)Women with signs/symptoms of TB diagnosed with HIV8 (11.8%)11Slide12
Challenges Human and financial resource
High workload in the ANC setting, average 45–60 on clinic dayNo laboratory facilities in 3 of the 5 facilitiesLong distance to treatment initiation centers 30–50 kmsInadequate documentation (data quality) Inadequate infrastructure at health centersNo courier system for transportation of sputum samples/slides Delays in lead time to access results range 1–3 weeks
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RecommendationsIntensify and regularize follow-up visits from all levels
Onsite orientation of all members of staffDefine roles and responsibilities of the health center staffConduct monthly onsite coordination and review meetings to assess progressDevelop ANC/TB screening implementation scheduleUse community mobilization and sensitization, key to the uptake of the programDecentralize TB initiation centers Develop courier system for transportation of sputum samples/fixed slides, including feedback of results
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Zambia ConclusionIntegration TB screening in ANC setting is feasible
Lifelong ART for all HIV-infected pregnant women will ensure virtual elimination of MTCT is achieved TB diagnosis and management will contribute to reduction of MMR, reduce number of orphans For sustainability, a concerted effort is needed from all funding and development partners for development and successful implementation of TB as part of the eMTCT strategy
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“
At first I was scared, but after being counselled by Mr.
Mbwagha
, I started taking the TB drugs. I did not have any problem or labor complication during birth to my twins up until I finished my regime and now I am fine. TB is curable in pregnancy
”, Elizabeth said jovially
.
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Lesotho PSETuberculosis Specific Tasks (Skills)
Tuberculosis (TB)
Screen
for TB based on patient symptoms
Contact tracing of
TB patient
family
members,
including sputum sample collection
Trace lost to follow-up within the communitiesCounsel TB patients and immediate contacts, e.g., family on adherenceTrain communities and community health workers on the administration to and supervision of patients on DOTSAdminister initial and follow-up DOTS TB treatment16