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Dr. Ismail M. Aboshama ZidanSurveillance Coordinator of NTP-Egypt

ismailabushama@yahoo.com

Action PlanAction Plan to Strengthen Laboratory Diagnostic Centers to Strengthen Laboratory Diagnostic Centers

for Improving Case Detection Ratefor Improving Case Detection Rate In Egypt 2007 – 2009In Egypt 2007 – 2009

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Executive summary:

The Ministry of Health and Population (MOHP) in Egypt has established the National Tuberculosis Control Program NTP in 1979.

The targets for TB Control are to detect more than 70% of existing cases of sputum smear-positive tuberculosis and achieving at least 85% cure rate for newly discovered sputum positive cases.

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Tuberculosis control is carried out through 111 chest centers and 39 chest disease hospitals with a total 6,351 hospital beds.

The main challenge for the tuberculosis program today is how to achieve an increase in the case detection rate.

To have WHO target case detection rates, funding to support laboratory capacity strengthening must be top on the agenda of the TB control program.

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Background information :

Area1,001,450 sq/km

Total population69.330.433

Population growth rate 1.8

Birth rate (per 1000 popul)23.8

Death rate (per 1000 popul)5.3

Life expectancy at birth 70.7 %

GNI Per Capita3.810 US$

Physician per 1000 people1.6

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Health organization chart

The Minister

Preventive & Tropical

Diseases Sector

Minister Office Affair Sector

Health Regions Affair Sector

Health Care & Nursing Sector

Population & Family Planning

SectorTraining & Researches

SectorCurative Care

Sector

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Annual Risk of Infection: In 2003, ARI was calculated mathematically with the help of WHO and it was found to equal 28/100,000.

MDR-TB: The Egyptian NTP has the plan to establish four DOTS plus centers to manage MDR-TB in the whole country.

BCG coverage: The national policy in Egypt is to vaccinate all children at birth with BCG as compulsory vaccination

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0.32

3.5

0.7

0.28 0.28

0.1

1

10

1952 1982 1997 2003 2004

Trend in Annual Risk of Infection

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Case notification:

Treatment Outcome:

1998199920002001200220032004

%51%52%50%48%47%55%58%

2000200120022003

Cured75%75%77%77%

Complete treatment12%13%12%12%

Success rate87%88%89%89%

Treatment Failure2%3%2%2%

Defaulted5%4%3%3%

Transferred out3%2%2%3%

Death5%3%4%3%

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Case Detection Rate of Smear positive cases

1998-2004

58%55%

47%48%50%51% 52%

40%

50%

60%

70%

80%

1998 1999 2000 2001 2002 2003 2004

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Treatment success rate 1997 - 2003

78%

83%

85%

87%88% 88%

89%

72%

74%

76%

78%

80%

82%

84%

86%

88%

90%

1997 1998 1999 2000 2001 2002 2003

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0%

1%

2%

3%

4%

5%

2000 2001 2002 2003

Death Rate

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HIV and TB

TB cases are examined with HIV4306

TB cases are HIV positive3

HIV positive persons reported117

AIDS cases reported 63

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Laboratory:

Central Lab. = 1 ( sensitivity, Culture and smear ex.)

Intermediate Lab. = 14 (Culture and smear ex.)

Peripheral Lab. = 134 (smear ex.)

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Problems Identified : Low case detection rate

MDR-TB cases are increasing

Poor collaboration with Prisons , Universities and Health Insurance Organization (HIO)

Poor collaboration with Private sector

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Core Problem :

The case detection rate in Egypt is low

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The case detection rate is low

The MDR-TB case increasing

The morbidity and mortality rateincreasing

Number of estimated

cases larger than the true number of TB

cases

Inadequate

diagnostic centers

Some of TB cases not notified

Limited IEC and

community mobilization

Patients go first to private

providers and traditional

healers

The reports from

Prisons, Universe

and HIO not complete

A critical need exists for trained

researchers to develop new diagnostic

assays

The health staff do not suspect

or diagnose cases correctly

Some of NTP records are incomplete

Patient have faith in

traditional healers

Poor link between NTP and private

sector

NTP program is

not adequately

link with Prisons,

Universe and HIO

Utilization of available

IEC material

and mass media is

low

Shortage of skilled staff for

IEC developmen

t and participatory approache

sInadequate knowledge and

skills of health staff on TB control Problem Analysis

The patient not treated well Community continue to be

Infected with TB

Private providers do not have knowledge

and awareness of TB symptoms and treatment

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Inadequate Lab. Diagnostic centers

Shortage of Skilled

Lab. staff

Shortage of Equipment and

Maintenancesupply

Number of Diagnostic Centers

not coverAll population

Laboratories in Existing chest facilities Need

to berenovate

The SupervisionFor lab. centers

Is weak

Health centersDo not have Budget line

For Lab. staff

Lack of Training for

Lab. staff

No plan forMaintenance

Facilities

Non availability of Staff for supervision

and monitoring

The link between NTPAnd Lab. sector is

weak

No budget line forsupervision

Problem Analysis

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Objective Analysis :

Improving case detection rate

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Improving case detection rate

The MDR-TB case decreasing

The morbidity and mortality rate decreasing

Number of estimated

cases equal the true number of

TB cases

ImprovingDiagnostic centers

Improving notification of

TB cases

Improving IEC and

community mobilization

Reaching Patients who prefer private providers and

traditional healers

The reports from

Prisons, Universe and HIO

complete

Train adequate number of researchers to

respond effectively to TB research needs

The health staff suspect and diagnose

cases correctly

NTP records are

complete

Cooperate with

traditional healers

Improving link

between NTP and private sector

Improving cooperatio

n of the NTP with Prisons, Universe and HIO

Utilization of

available IEC

material and mass

media

Increase skills of staff for

IEC developmen

t and participatory approache

sImproving knowledge and skills of health staff on TB control

The patient treated well Infected Community

with TB decreased

Private providers have knowledge

and awareness of TB symptoms and treatmentObjective Analysis

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Improving Lab. Diagnostic centers

Adequate number of

SkilledLab. staff

Improving of Equipment and

Maintenancesupply

Number of Diagnostic Centers

coverAll population

Laboratories in Existing chest facilities be

renovate

Improving Supervision

For lab. centers

Health centershave

Budget line For Lab. staff

Provide TrainingAnd evaluation for

Lab. staff

plan forMaintenance

Facilities

Available Staff for supervision and monitoring

Improving link between NTP

And Lab. sector

NTP has budget line forsupervision

Objective Analysis

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Project Selection:

1- Adequate Diagnostic Centers Approach

2- Improving Community Mobilization Approach.

3- Intersectoral Collaboration Approach.

1

2

3

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Improving case detection rate

The MDR-TB case decreasing

The morbidity and mortality ratedecreasing

Number of estimated

cases equal the true number of

TB cases

diagnostic centers

are adequate

Improving notification of

TB cases

Improving IEC and

community mobilization

Reaching Patients who prefer private providers and

traditional healers

The reports from

Prisons, Universe and HIO

complete

Train adequate number of researchers to

respond effectively to TB research needs

The health staff

suspect and

diagnose cases

correctly

NTP records

are complete

Cooperate with

traditional healers

Private providers have knowledge and awareness of TB symptoms and treatment

NTP program is adequately

link with Prisons,

Universe and HIO

Utilization of available

IEC material

and mass media

Increase skills of staff for

IEC developmen

t and participatory approache

s

Adequate number

of skilled

lab. staff

improving equipment

and maintenance supply

Number of diagnostic

centers cover all

population

Provide training

and evaluation

for lab staff

Health center have budget line for lab

staff

Improving knowledge and

skills of health staff on TB control

Project Selection

1

23

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Project Selection:

ApproachAdequate diagnostic

centers

Improving community mobilization

Intersectoral collaboration

Input522

Cost-benefit523

Social Risk111

Feasibility532

Sustainability523

Total 211011

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Project Design Matrix ( PDM ) : Project Name : Strengthen Lab. Diagnostic Centers for Improving Case Detection Rate in Egypt

Duration :1 Jan 2007 – 31 Dec 2009 Target Area: All Egypt

Target Group: Public, Health worker, Lab. staff and suspect patients

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Narrative Summary

O.V. IndicatorsMeans of variations

Important Assumption

Overall Goal :Improving CDR in Egypt

CDR increases to 75% by the year 2009

Reports of NTPTB registersLab. registers

The policy of NTP remains unchanged regarding the laboratory

Project Purpose: Function of Lab. Diagnostic Centers is improved in Egypt

The rate of suspected cases increases 50% by the year 2008

Suspected registersLab. registers

The TB\HIV co infection not increase

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Out Puts: 1- The lab. Diagnostic centers cover all population

2- Improving equipment and maintenance supply

3- Human Recourse Development

4- Strengthen link bet. NTP and Lab. sector

5- Strengthen Monitoring & evaluation related to lab.

6- Improving Quality Assurance in lab.

7- Lab. follows Infection control guidelines.

- No. of lab. Diagnostic centers cover 1/300000 pop. By year 2009- No. of renovated lab. reach 80% by year 2008 - the operation rate of the lab. maintenance equip. reach 80% by year 2008 - 60% of the lab. staff undergo training by the end of year 2007- No. of lab. staff increase 5o% by year 2008 - No. of supervisory visits reach 2/year for each lab.- major error of sputum (false positive & negative) decreased 60% by year 2009 - No. of lab. follow inf. Control guidelines

- Project survey reports.- Project records of the final examination of lab. training program - Project survey reports on the operation rate of lab maintenance equipment

- The already lab. equipment not worsen - The No. of lab. staff not decrease

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Activities: 1.1- Conduct baseline survey on lab. digonstic 1.2- Increase No. of lab. diagnostic centers1.3- Renovation of lab. in existing chest facilities2.1- Draw up an improvement plan for maintenance facilities 2.2- Purchase necessary equipment2.3- Purchase reagents and materials3.1- Provide training and evaluation of lab. doctors 3.2- Provide training and evaluation of lab. techn.3.3- Provide training and evaluation of lab. workers 4.1- Strengthen referral system bet. Lab& NTP 5.1-Strength supervision6.1- implementation of Quality Assurance7.1- implementation of infection control

Inputs:

Personnel : - Project manager - Project coordinator- Lab. staff- Maintenance - Health workersEquipment:- microscopes - safety cabinet - stainsFacilities: - Training facilities - maintenance facilities Local cost:- Project implementation and management cost

- Trained lab. staff continue working .-The price of equipment not increase .

Preconditions:The undersecretary of laboratory does not oppose the project

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