Tuberculosis (TB) is one of the top 10 causes of death worldwide. In 2015, there were 10.4 million new cases of TB and 1.4 million died from the disease. These numbers are so stark partly because TB is one of the leading causes of death for those living with HIV. This is despite the fact that with a timely diagnosis and proper treatment, most people who develop TB disease can be cured. The increase in multi-drug resistant (MDR) TB, with an estimated 480,000 cases in 2015, is further cause for concern.
Lack of reliable diagnoses is the Achilles heel of the fight against TB; it is estimated that there is a global gap of 4.3 million cases of TB that were not diagnosed in 2015. This is in large part due to a dearth of reliable diagnostic capacity, including laboratory (and point-of-care testing) capacity, and the skilled workforce required for testing and reporting.
ASM supports this yearâ€™s World TB Day theme, â€śUnite to end TB.â€ť For the past 10 years, in partnership with CDC and the Presidentâ€™s Emergency Plan for AIDS Relief (PEPFAR), ASM has strengthened capacity in many resource-limited countries for quality assured TB diagnostics, in support of better healthcare outcomes, particularly for those living with HIV. Here are some of our recent success stories.
Botswana Transitions to LED Microscopy to Provide More Accurate TB Diagnoses
Globally, the most accessible and affordable diagnostic test to detect TB is microscopic examination of stained sputum. Several countries are transitioning from using the conventional Ziehl-Neelsen (ZN) technique to light-emitting diode (LED) microscopy as a faster, more accurate, and more cost-effective method in diagnosing cases of TB. Botswana has initiated a groundbreaking training-of-trainers program to build and strengthen laboratory workforce capacity to use LED microscopy to diagnose TB.
In 2016, ASM assisted Botswanaâ€™s public health laboratory network in its roll-out of LED microscopy to diagnose cases of TB. The workload per district laboratory is very high with more than 25 slides processed per day in the highest-burden regions. With ASM support, 13 new trainers were fully equipped with the knowledge and skills to return to their own district laboratories and impart their newly-acquired skills to their colleagues. Additionally, the newly-trained trainers have made several of their own site visits to high-burden areas and have worked with laboratory technicians on improving their LED microscopy diagnostic techniques. This train-the-trainers workshop is the first of many that will systematically build a strong and capable cadre of public health laboratorians who will be able to accurately and effectively diagnose TB.
Open-Source Toolkit Moves Labs Towards Accreditation
ASM, in collaboration with the CDCâ€™s International Laboratory Branch, Division of Global HIV/AIDS and TB, has developed an open-source toolkit, â€śMentor4TB: The Toolkitâ€ť for TB laboratory mentorship. The Mentor4TB program engages the entire laboratory system, marrying the technical aspects of TB testing and quality management system implementation as the laboratory advances towards accreditation. The easily customizable toolkit details the approach for conducting laboratory mentoring in national and regional laboratories in low- and middle-income countries. ASM has pioneered in laboratory mentoring in the resource-limited setting: a methodical approach to mentor laboratories towards ISO 15189 accreditation, ensuring high-quality testing and referral, utilizing best practices of biosafety.
ASM TB Mentoring Program in Mozambique
In Mozambique, almost 51% of TB cases are co-infected with HIV. To address this, the Ministry of Health of Mozambique has declared TB a national emergency and has committed to adopting new diagnostic standards to help prevent its spread in the country.
In late 2015, ASM, in partnership with CDC, started work with Mozambiqueâ€™s two regional tuberculosis reference laboratories (RTRL) to strengthen TB diagnostics, quality management systems (QMS), and biosafety practices to help them achieve international accreditation. The ASM TB mentoring program has yielded rapid and positive results at the Nampula RTRL, moving from one star to four stars in the Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) system in only 9 months. ASM mentoring at the Nampula RTRL also included support in the implementation of a diagnostic algorithm for TB testing; standardization of management and technical SOPs; development of technical assistance manuals addressing quality and safety; and publication of a client handbook. The Nampula RTRL is on track to receive international accreditation by the end of 2017.
Strengthening Quality Tuberculosis Laboratory Services in Zambia
ASM has been working with the Zambian Ministry of Health and the U.S. Centers for Disease Control and Preventionâ€”Zambia to ensure that the countryâ€™s TB laboratories have the infrastructure and capacity to provide quality diagnostic services for early diagnosis of TB. Through a targeted mentorship program using the Mentor4TB approach, ASM helped staff at three laboratories develop their technical skills and improve quality management systems (QMS), with the ultimate aim of achieving international laboratory accreditation.
Despite staff turnover city-wide electrical power outages and occasional supply shortages, significant progress was achieved at each TB laboratory, in line with the SLIPTA framework. While all three had started in 2014 at a baseline SLIPTA scores of zero stars, by 2016 a SLIPTA mock audit conducted showed that two of the laboratories had earned three stars, and one had achieved five stars. All partners anticipate that these laboratories will reach accreditation in 2017.
ASMâ€™s work in Zambia has shown that mentoring can be a powerful tool for personal and professional development. In the context of TB laboratory work, consistent mentorship can bring great advancements in the quality of laboratory servicesâ€”and can play a critical role in eliminating this deadly disease.
This publication features ASM activities supported by the Cooperative Agreement Number GH001116 funded by the U.S. Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Centers for Disease Control and Prevention or the U.S. Department of Health & Human Services.