Rana Samundra Trophy for IOM Nepal’s TB Reach Project

Reaching Higher Ground with Groundbreaking TB Detection Technology

GeneXpert molecular diagnostic technology has contributed to more efficient and specific TB diagnosis in Nepal

by Anthony Caingles

On World TB Day, 24 March 2014, the International Organization for Migration – Nepal (IOM) was awarded the Rana Samundra trophy by the National Tuberculosis Center (NTC) for having introduced the molecular diagnostic tool GeneXpert in Nepal.  

After receiving the award, Dr. Raz Mohammad Wali, IOM Nepal Chief Migration Health Physician said, “We are pleased to receive this prestigious award which motivates and encourages us to continue our effective collaboration with the National TB Programme (NTP) of Nepal.” Dr. Olga Gorbacheva, IOM Chief Medical Officer for Health Assessment Programmes and a pioneer of the TB Reach efforts in Nepal, emphasizes the key role of the NTP “who recognized the importance of using an innovative approach to TB detection and mobilized resources from the beginning of the project to this day.”

Hitting two birds with one stone, GeneXpert is a fully automated cartridge-based DNA test that is able to simultaneously detect TB as well as Rifampicin resistance. This highly sensitive instrument is able to contribute to early detection – not just of TB, but of multi-drug resistant TB (MDR TB) or that TB strain which has become resistant to routinely used anti-TB medicine.

IOM’s GeneXpert strategy is being implemented under TB REACH, with funding from the STOP TB Partnership. IOM collaborates with the National TB Program of Nepal (NTP) and has installed nine GeneXpert machines in nine strategically located NTP microscopic centres.

IOM Nepal received funding for Wave 4 of its TB REACH implementation in March 2014.

History of Involvement

As early as 2007, IOM has been involved in the anti-TB programs of Nepal – one of two countries on which the world’s highest mountain rests, characterized by highly diverse terrain – making many areas difficult to access.  IOM’s TB REACH Project has provided effective TB detection services to residents in the Eastern Development Region and two districts in the Central Development Region - which include areas in the hilly and mountainous districts. Among the special subsectors that were targeted within these communities are migrant workers and HIV-infected people. The target groups represent the most impoverished, vulnerable, and hard-to-reach populations. 

National Concern

Tuberculosis is nothing to take lightly in Nepal – where 40,000 individuals develop active TB every year; where 50% of this number represent infectious pulmonary TB; and where – of those infected – 5,000 to 7,000 die. Some factors unique to Nepal contribute to these numbers – such as the heavy influx of migrants from neighboring India – where TB cases are even more prevalent (India is #8 among countries with the highest TB burden1).  MDR TB is the major challenge to public health in Nepal. TB/HIV co-infection is the other major issue. TB is a top killer of people with HIV. In general, the uneven terrain, poor road systems, and the limited number of TB/health facilities across the country (and consequently, the long travel required to reach these) are major hindrances to people’s being able to access TB services. 

Challenges in the Project Area

The first step towards effective treatment is early detection. The national case finding rate has reached 73% while the national target would be 82% by2015. Within the project area itself, the case finding rate in the project area is only 67%.  There are several factors to which this can be attributed: 

•    The absence of health-seeking behavior
•    Inadequacy of diagnostic facilities
•    People’s poor socio-economic status
•    Lack of awareness
•    Difficult terrain
•    Open border for seeking treatment
•    Significant number of TB cases are handled by private sector

TB REACH’s Global Reach

TB REACH, an initiative of the Stop TB Partnership and funded by the Canadian International Development Agency (CIDA), provided an excellent opportunity to address the problem at its roots. The main objective of TB REACH is to increase case detection of TB, detect the disease as early as possible, and ensure timely and complete treatment while maintaining high TB cure rates. TB REACH focuses on reaching people with limited or no access to TB services and looking for innovative ways to do this. 

In the very first wave of TB REACH – which supported 28 projects worldwide, case detection improved by an average of 26% compared to the previous year – as validated by external agencies. In some exceptional projects, the rate was doubled within just a year. 
TB REACH was launched in 2010 and will run through 2016, backed by a CAD$ 120 million grant from the Canadian International Development Agency. It has supported 109 projects in 44 countries this far.  

IOM Nepal’s TB REACH Project

IOM Nepal has been awarded a Rana Samundra Trophy by the National Tuberculosis Center (NTC), Department of Health Service, the Ministry of Health and Population, for having introduced the molecular diagnostic tool “GeneXpert” in Nepal.

IOM Nepal’s participation in TB REACH began in Wave 2 of the Program.

In Wave 1, groundwork was done by another organization which was able to screen 115,000 people and detected 700 cases in the first nine months of operation. The group proactively reached out to the most vulnerable groups, including migrants and sex workers – particularly along the Nepal-Indian border. 

In the Wave 2 TB REACH implementation by IOM Nepal, the use of GeneXpert equipment played a key role in early detection and a higher detection rate.  IOM operates 9 out of the 21 GeneXpert diagnostic centres in Nepal. 

It’s notable that despite the fact that more screenings were conducted in Wave 1, there were more instances of detection during IOM’s Wave 2 implementation.

Wave 2, implemented by IOM in Nepal, became fully operational in January 2012. In the first year, the project was able to perform 9,723 tests sputum tests, which detected TB among 1,901 beneficiaries. Without GeneXpert technology, these would have gone unnoticed. Moreover, 123 Rif+ (Rifampicin-resistant) cases were identified. Based on this performance, the project was extended for another year.

The Year 2 project was operational from March 2013. By February 2014, a total of 10,445 tests were performed. This was able to identify TB among 2,029 persons. And out of these, 150 were found to be resistant to the drug Rifampicin. There is also increased referral from the private sector (which covers 30% of the persons tested using GeneXpert). This is another important achievement during Wave 2.

These improved detection statistics show the efficiency of the GeneXpert technology adopted by IOM. 

To raise awareness, the campaign made use of the most effective communications media for these inaccessible locations and widely dispersed communities: radio. Informational messages were broadcast regularly on seven local radio stations. Through the airwaves, IOM staff and volunteers are able to impart knowledge about the disease, relevant activities, and important dates – even to residents in hard-to-access areas. More conventionally, over 15,000 IEC materials were also distributed to the target population.

The work is far from over and for this reason, IOM has submitted a Letter of Intent and Proposal to proceed with the next wave in Nepal (Wave 4) that would build on the gains already made. Very recently, IOM has received information that it has been awarded funding for WAVE 4 so the good work can continue.  

Wave 4

In the next TB REACH wave to come, IOM wants to expand coverage of detection in Nepal to symptomatic suspected cases.  To do this, IOM will:

•    Continue to operate the GeneXpert centres and will upgrade instruments, as necessary, so as to ensure increased sensitivity of lab tests
•    Need to establish a referral network/system among the peripheral microscopy centres so that they can refer migrants in need of sputum testing to the GeneXpert Centres. This is already being done in five locations.
•    Strengthen partnerships with the private sector to enhance TB detection and link better with the National TB program for treatment
•    Need to strengthen the monitoring and reporting system (i.e. by being more aggressive in following-up and by using the automated Xpert SMS reporting system which sends findings to both patients and doctors)
•    Have to build capacity:  by hiring more staff and training more operators/volunteers; by installing a backup solar power system

IOM’s Wider Involvement

IOM’s TB Reach efforts are not limited to Nepal. For TB REACH Wave 1, IOM received funding for a project in Lao PDR. For Wave 2, aside from Nepal, IOM also launched anti-TB work in Ethiopia and Cambodia. For Wave 3, although IOM did not receive new funding for its TB REACH efforts in Nepal, it did receive funding for its project in Ghana.  For Wave 4, aside from the Nepal project, IOM also submitted Letters of Intent for projects in Bangladesh, Guinea and Zimbabwe.
 1WHO Global TB Control Report, 2012
2 For Wave 3,  TB REACH approved two anti-TB projects in Nepal other than IOM’s