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TB Notes 1, 2001

International Activities Update

Image 1: Peter Ciegielski, MD, of DTBE's International Activities, showed his dedication to the cause on Friday, March 23, by adorning his car and himself with the "STOP TB!" logo. We hope he was able to raise a bit of awareness about TB on his way to and from work that day.

Latvian Center of Excellence Established

The International Activities branch of DTBE is involved in an ongoing project with the National TB Program (NTP) of Latvia to establish a Center of Excellence for the diagnosis, treatment, and management of multidrug-resistant TB (MDR TB). Latvia, a former republic of the Soviet Union, is being challenged with a substantial epidemic of MDR TB. After the disintegration of the Soviet Union in 1991, Latvia faced substantially depleted resources for TB control, resulting in erratic and unreliable supplies of anti-TB drugs. Additionally, treatment regimens were inadequate and treatment completion rates, as a rule, were very low. Furthermore, institutional infection control was inadequate, resulting in high levels of transmission of M. tuberculosis in prisons and hospitals and high numbers of staff developing TB and MDR TB. There were major delays in the diagnosis of drug resistance due to poor laboratory proficiency.

In 1996, Latvia participated in the first global anti-TB drug resistance survey, which was conducted jointly by the World Health Organization (WHO) and the International Union Against TB and Lung Disease (IUATLD). Latvia had the highest level of MDR TB of any of the participating 35 countries; 14.4% of its new TB cases were MDR, or roughly 1 out of 7. Latvia's neighbor, Estonia, also had high levels, at 10%, reflecting the regional impact of the disintegration of the Soviet Union.

The Latvian NTP responded as quickly and effectively as possible with the very limited resources available and with some limited financial and technical assistance from donor countries. Modeled on the United States' response to the MDR TB epidemic in New York City in the early 1990s, the initial steps taken by Latvia included fully implementing the WHO-defined DOTS strategy, improving the national laboratory proficiency and capacity, and addressing infection control issues in hospitals. The Latvian national surveillance system was also improved by adopting WHO reporting standards. By 1998, the Latvian NTP started a civilian and prison DOTS-plus program to treat the roughly 200 MDR TB patients diagnosed each year, which resulted in a 30% reduction in the level of MDR TB in Latvia.

Given the facts that the Latvians had made great strides and developed much expertise in mobilizing against MDR TB, yet also needed continued support to advance their progress in reducing MDR, an idea evolved to establish the Latvian National TB and Lung Disease Center as a regional Center of Excellence for the treatment and management of MDR TB. This collaborative project between CDC and the Latvian NTP began in late 1999 and is funded by the U.S. Department of State and the U.S. Agency for International Development (USAID). The specific objectives of the project are to assist the Latvian NTP in further reducing the country's MDR TB burden, to establish a sustainable model of MDR TB management in a resource-limited country, and to use the Center to train clinicians from other former Soviet republics that are facing similar issues with MDR TB.

The project consists of several components. The initial component is centered on continuing to build Latvian clinical expertise for MDR TB. First, a comprehensive training course taught by U.S. experts was held in March 2000 for the 22 Latvian physicians who treat MDR TB. Subsequently, a "telemedicine" (or videoconferencing) project was launched at the Center in June 2000 for monthly clinical case review with CDC MDR TB clinical experts. At the most recent conference, MDR TB experts from Partners in Health at Harvard University also participated. Additional laboratory upgrades for more rapid diagnosis of MDR TB are being made. The cost-effectiveness of using new technologies will be carefully studied. Moreover, continued improvements are being made regarding infection control. In August 2000, a TB infection control expert from the National Institute for Occupational Safety and Health (NIOSH) was sent to the Center to perform a full assessment and develop a comprehensive strategy and plan for improving infection control throughout the 500-bed facility. It is hoped that the measures being taken will serve as an infection control model for TB facilities throughout the region.

Another component of the project involves the development of a computerized data management and information system for MDR TB patients. Lorna Thorpe, PhD, International Activities' EIS Officer, began developing this system in August 2000. The system will be used for case management, better MDR TB surveillance, and outcome studies. It will also be exportable for use by other NTPs in the region that are implementing DOTS-plus programs for MDR TB. Building epidemiologic capacity is also a component of establishing the Center. This has involved working with the NTP staff on the design and implementation of a risk-factors study for MDR TB and also includes staging a basic epidemiology training course for the staff scheduled for May 2001. Finally, the first of three 3-week MDR TB training courses planned for 2001 for physicians from other countries in the region, including Russia, was held in late January.

Future plans for continued development of the Center as a sustainable resource for MDR TB training in the region include further expansion of training capabilities, to meet the growing demand of TB programs in the region for education of clinicians and program managers. A study of additional rapid-diagnostic technologies is also slated for the Center. The analysis of the cost-effectiveness of these technologies will be critical to determining their feasibility for use in resource-limited countries such as Latvia. Broadening infection control efforts to include smaller regional TB facilities, clinics, and prison facilities within the country is planned. It is hoped that the measures taken will serve as a model of TB infection control for the region. Also, given the high level of alcoholism and its role in the interruption of patient treatment in Latvia, effective approaches and strategies will be pursued for managing these patients to increase treatment adherence. This is a great need throughout the region, where alcoholism is a common problem.

-Reported by Charles D. Wells, MD
Division of TB Elimination

Use of a Computerized TB Register for Automated Generation of Case Finding, Sputum Conversion, and Treatment Outcome Reports

Background

During the 1990s, sub-Saharan Africa experienced an explosive increase in TB. Public health workers needed tools to strengthen TB surveillance activities and TB program management in the region. These tools had to be tailored to and compatible with local circumstances. For example, many countries follow the International Union Against TB and Lung Disease/World Health Organization (IUATLD/WHO) guidelines for TB recording and reporting. These guidelines recommend the generation of quarterly reports on the incidence of new cases and on treatment outcomes for cohorts enrolled 9 to 12 months previously. These reports serve as an important management tool to assess program performance and to determine future needs and direction. They also form the basis of ongoing TB surveillance. Manual generation of such reports is often extremely time-consuming, which may lead to failure to complete the reports in a timely fashion. Furthermore, the manual analysis of data, particularly for the cohort analysis, can be subject to error.

Development of the Electronic TB Register

In response to these issues, a user-friendly, menu-driven computer program based on EpiInfo version 6.04c was developed1. The Electronic TB Register, initially known as BOTUSA, was created in 1995 as part of a collaboration between the Ministry of Health of Botswana and CDC. The program was designed with three important principles in mind: 1) it should be capable of generating the standard case-finding and cohort analysis reports recommended by IUATLD/WHO guidelines; 2) it should include additional tools for TB program management and support at the district level (e.g., lists of patients for whom 2-month sputum specimens had not yet been obtained); and 3) it should be simple and highly user-friendly.

Implementation

The software was implemented in Botswana in 1995 after training was provided to the 22 District TB Coordinators, none of whom had previously had any computer experience. The software was installed on existing computers in each of the district health offices and, by 1996, was completely operational in all districts. Use of the software completely replaced manual compilation at the district level, with each District TB Coordinator entering the data, maintaining an ongoing electronic database, and producing district case-finding and cohort analysis reports. By 1997, data from the districts were being merged at national level to create a national database and produce national reports; the software was considered an integral part of the Botswana National TB Program. Subsequently, the software has been implemented in two of the nine provinces of South Africa, Lesotho, and three of the 12 districts of Namibia, with plans to extend to an additional two South African provinces and to Malawi, Tanzania, and Swaziland in the near future.

Botswana's TB register

In Botswana, the TB register is maintained on paper in a log book at the facility level, with manual data entry. The TB coordinators visit all health facilities in their district at regular intervals to provide program support and supervision, ideally monthly but, at a minimum, quarterly. During these visits, they review the registers for accuracy and completeness and hand-copy the information into their own district registers. Records for patients under treatment are updated with any new information.

At the district level, the TB coordinators enter information into the computer as it becomes available from the health facility visits. At this point, they are expected to have completed and validated the quality of the data at the end of each quarter so that the quarterly report and cohort analyses can be performed. In addition to generating paper reports for district-level management purposes, they send the data to the national level. The data are expected to arrive within 1 month of the closing of the quarter, although in reality, substantial delays may occur.

At national level, the data from the district level are merged into the national data base as they become available. The data for each district are examined for quality and completeness. Feedback is given to the districts, and corrections are requested. Only when the data from all the districts are available and considered to be of adequate quality is the final analysis performed. An annual report is published using the cumulative data for all four cohorts in the calendar year.

South Africa's TB register

In South Africa, the system functions at the provincial level. The TB register at the health facility level is based on a four-page form with autocarbons, with each page a different color. At the end of the first quarter, the first sheet is detached and sent to the District TB Coordinator, who enters the data. At the end of the second quarter, the second page, which contains information on sputum conversion, is detached and sent to the coordinator for ongoing data entry. The third page is sent in 9 to 12 months after the beginning of treatment and contains the treatment outcome data. The fourth sheet remains in the facility as part of its permanent register. This recently implemented system differs from the previous one, in which each facility was responsible for producing aggregate quarterly and cohort reports. As in Botswana, data are examined for completeness, entered, and analyzed at district level. They are then sent to the provincial level, where the combined data are examined and analyzed. The aggregate hard-copy reports at the provincial level are then sent to the national level for inclusion in the national report.

Image 2: Training class for TB Coordinators in South Africa in the use of the Electronic TB Register.

Program management

The Electronic TB Register has a number of patient management and supervision functions. These include the ability to generate facility-specific lists of patients who are active or sputum-smear positive and those who have died, defaulted, transferred out, or not converted their sputum. In addition, it can provide lists of potential duplicate patient entries and also permits the TB coordinators to identify whether patients who have transferred out were followed up in their new location.

Lessons learned

As a result of the Botswana experience, a number of important lessons were learned. Some of these lessons have resulted in further software enhancements, improved initial orientation for district medical staff, and modifications in training methods. The process of implementation, however, also highlighted underlying problems in the paper-based TB data collection system, which were subsequently addressed.

In Botswana, acceptance by the District TB Coordinators was generally high, though considerable support was required early in the implementation process to prevent frustration. Acceptance by the Senior District Medical Officers was initially more variable, with some reluctant to allow the District TB Coordinators, who are under their direct supervision, to use the district computer. This was remedied by providing demonstrations of the software to the Senior District Medical Officers, who readily acknowledged and accepted its value as a management tool in their jobs. In other countries where the software has been implemented, great efforts are now made to provide orientation to the supervisory medical officers as well as to health information systems staff at both district and central levels.

A second important problem was lack of uniformity in the computer equipment in the various districts, making it highly difficult for the central TB unit to provide adequate technical guidance and support. In 1997, an international donor provided all the district health offices in Botswana with updated computers and printers, which has greatly improved the performance of the system.

The need for ongoing training emerged as an important issue in the effective implementation of the software. Although the system was highly user-friendly, a single training session was insufficient. Three training sessions, held several months apart, were conducted, allowing the users to learn from their experience and ask additional questions.

Although the accuracy and completeness of the register improved after implementation of the software, timeliness of reporting to the central TB unit did not improve. The delay appears to be due largely to the inability of the District TB Coordinators to visit the individual health facilities on a regular basis to collect information from the facility-based registers.

Another important lesson has been the need for specifically dedicated central-level staff to provide training and support for the District TB Coordinators, validate the data coming in from the districts, and make minor modifications in the software to serve local needs.

A final but extremely important lesson has been that the software is only a tool for the compilation and analysis of data at the district level. Improper recording of data in the paper-based register and failure to transmit information to the district level result in poor reporting. For example, in Botswana a validation study of data on diagnostic sputum smears showed that 60% of patients recorded as having missing smear results actually had sputum collected and analyzed in the laboratory2. The vast majority of missing results had simply not been transcribed onto the patients' treatment card and thus were not in the register. Computerization can only succeed when adequate paper-based recording systems are in place at the facility level and where data are routinely compiled and evaluated for completeness and accuracy at the district level.

The Electronic TB Register has proven to be an acceptable and powerful tool for TB surveillance and program management in the five sites where it has been implemented. It functions well at the national level in Botswana, a country with 1.6 million people and 8000 TB cases annually; to date it is functioning well in two provinces of South Africa, the largest of which has more than 16,000 cases annually. Its feasibility in countries with several hundred thousand TB cases annually has not been evaluated, although theoretically it should be able to handle very large numbers of cases if computer memory is adequate.

-Reported by Peter Vranken
The BOTUSA Project
Gaborone, Botswana

References

  1. Dean AG, Dean JA, Coulombier D, Brendel KA, Smith DC, Burton AH, Dicker RC, Sullivan K, Fagan RF, Arner TG. Epi Info, Version 6: A Word Processing, Database, and Statistics Program for Epidemiology on Microcomputers. Centers for Disease Control and Prevention, Atlanta, Georgia, 1994.
  2. Alpers A, Chrouser K, Halabi S. et al. Validation of the surveillance system for tuberculosis in Botswana. Int J Tuberc Lung Dis 2000; 4(8):737-743

 


Released October 2008
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