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Implementation of Thin Layer Agar for Mycobacterium culture in rural Kenya

Implementation of Thin Layer Agar for Mycobacterium culture in rural Kenya. Médecins Sans Frontières. MSF support in the Hospital Since 2000 TB program ART program Integrated TB/HIV care TB culture laboratory in 2007 MSF support in the periphery Mobile clinic to 3 health centres

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Implementation of Thin Layer Agar for Mycobacterium culture in rural Kenya

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  1. Implementation of Thin Layer Agar for Mycobacterium culture in rural Kenya Médecins Sans Frontières

  2. MSF support in the Hospital Since 2000 TB program ART program Integrated TB/HIV care TB culture laboratory in 2007 MSF support in the periphery Mobile clinic to 3 health centres Supply drugs 6 month regimen Context Homa Bay District • Rural area • 350,000 habitants • 30% HIV prevalence

  3. Context TB patients • 1,500 new TB cases/year in District • 400 new TB cases in Chest Clinic • 80% HIV/TB co-infected HIV patients • 13,000 active patients on care • 10,000 active patients on ART

  4. Methods • Mycobacterium culture laboratory • Techniques: Thin Layer Agar, Lowenstein-Jensen • Routine activity since November 2007 • Patients targeted • Patients with cough >2 weeks and at least 2 negative sputum smear microscopy • Retrospective study • Period of the study: 15th Nov 07 to 25th July 08

  5. Methods • TLA technique: • Solid culture (7H11) • Petri dish (2 parts: 1 normal media; 1 with PNB) • Incubator CO2 • Reading with microscope • Why this technique was chosen? • Less logistics, maintenance, technical problems • Lower cost • Solid culture – less contamination expected, bio-safety

  6. Comparison Mycobacterium culture techniques * Int J Tuberc Lung Dis 10 (6):613-619, 2006. Robledo et al

  7. Results • Culture result available in 365 patients: 50% negative, 31% positive, 19% contaminated • 56% of culture positive had not started treatment • Out of the 63 patients traced: • 46% found and started on treatment • 11% found and referred to the closest TB site • 16% had died • 13% could not be found • 14% were still being traced

  8. Results • Patients missed through clinical algorithm and started on treatment after culture: • 29 patients = 3.5 patients per month • Patients diagnosed through clinical algorithm: • 265 = 31.9 patients per month • Proportion of TB patients diagnosed through culture: 10.9% • Average time to get a positive result: 24 days

  9. Results Culture results on smear negative samples from Nov 07 to Jul 08

  10. Discussion - Achievements • Almost a third of the TB suspect patients with negative smear were found positive by culture • More than a half of them had been missed through clinical algorithm • Culture had allowed the diagnosis of 11% of the total TB patients • Time for positive results long but improving

  11. Discussion - Challenges • Cost of the laboratory • Contamination rate currently high • Electricity: back-up system required • Keeping the laboratory clean: change shoes, windows closed, dust coats, etc. • Training of the laboratory technicians is long • BSC maintenance: technician coming from SA

  12. Discussion - Challenges Expenses for TB culture laboratory (Jan 07-Sept 08) TOTAL expenses : 280 000 € 17% 48,5 K€ 28% 77,8 k€ 30% 83,6 k€ 25% 70 k€ Construction Equipment Consumable Staff

  13. Conclusions • Routine culture may have an important impact in the diagnosis of TB in a high HIV prevalence setting • Is it cost-effective to set up a culture laboratory in an African rural context? Other alternatives? • TLA has a potential in peripheral settings compared with others techniques (MGIT, LJ)

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