Evaluation of the TB/HIV Surveillance System and PDA Pilot in Two Kenyan Provinces

1. Evaluation of the TB/HIV Surveillance System and PDA Pilot in Two Kenyan Provinces T. Oluoch, Global AIDS Program CDC Kenya Bangkok Surveillance Conference March 2-5, 2009

2. Tuberculosis (TB) in Kenya • HIV infection fuels TB incidence • From 1995 to 2006, TB case incidence increased > three-fold from 103 to 384 cases/100,000 persons. • TB leading cause of death among PLWHAs (5-7% in 2007) • Strong TB/HIV surveillance important to ensure control of both diseases

3. Kenya TB Case Incidence, 1995-2006

4. TB/HIV Surveillance in Kenya • In 2005, HIV indicators added to TB surveillance system • At TB treatment initiation, TB patient demographic and clinical data entered into paper TB facility registers • At patient follow-up visits, updated TB and HIV care data entered in the register • Monthly, district TB coordinators (DTLC) transcribe data from clinic to district registers for two quarterly reports: • TB case finding report documents case incidence and TB-HIV program indicators from the most recent quarter • TB cohort report documents treatment outcomes for patients initiating treatment 12-15 months before

5. Paper-based TB/HIV Surveillance in Kenya Manual Transcription Manual Aggregation CLINIC REGISTER DISTRICT REGISTER QUARTERLY REPORT

6. TB Surveillance System Challenges • Reliance on paper-based facility register • District TB coordinators manually transcribe facility register data into district registers for summary reports • Manual transcription prone to errors • Only district aggregate data available; surveillance system unable to assess facility-level data • Lack of an electronic database for data manipulation

7. Personal Digital Assistant (PDA) Pilot • July 2007, NLTP/CDC piloted PDA use in 31 districts in Nairobi and Nyanza provinces • KEMRI/CDC programmed PDAs to be compatible with new facility registers • DTLCs trained, entered individual clinic register data into PDAs while maintaining paper district registers • PDA data downloaded into an Access database • Data to be used for generation of district quarterly CF reports

8. PDA Pilot Data Entry into PDA Computerized report generation and data analysis CLINIC REGISTER PDA MS Access

9. Snap-shot of one entry screen

10. PDA Assessment (Sept 2007) • We evaluated whether PDAs: • Were accepted by TB coordinators. • Improved usefulness of data collected. • Improved quality of data reported from facilities to the district-level

11. Assessment Methods • Visited a convenience sample of 5 (16%) of 31 districts • Interviewed TB coordinators and care givers to determine strengths and weaknesses of PDAs • Analyzed PDA data to determine its usefulness. • To determine if PDA improved data quality, we compared district register with PDA data quality: • In 10 of 93 clinic registers randomly selected : • 112 of 298 new TB patients during Oct-Dec, 2006. • 97 of 304 new TB patients during April-June, 2007. • Compared rates of missing patient records • Compared rates of data fields not up to date, in district registers with electronic databases.

12. Data Fields Assessed

13. DTLC Interviews • In general, DTLCs liked PDA concept • Lack of ongoing technical support to DTLC • Some DTLCs didn’t consistently use PDAs • User issues • Security issues • Increased work burden as continued paper-based facility register • Unable to use system to generate reports

14. PDA Pilot Results • PDA data available from 6 (19%) of 31 pilot districts • High proportions of TB/HIV data were missing from CLINIC REGISTERS before and after introduction of PDAs (Before: 308/1120 (28%), After: 303/970 (31%)). • Missing data; no clinic had new facility registers • Data fields more frequently incomplete in PDAs compared with district registers(148/1,449 vs. 167/2,331, p=0.03) • > 30% clinic register TB/HIV data fields missing(date of HIV test - 74% missing, testing of an HIV-infected patient’s partner – 61% missing, CD4 count - 52% missing) • Lack of relevant software/hardware at district/ provincial level hampered report generation

15. Challenges • Difficulty maintaining PDA components • Equipment security in some facilities • Inability by some DTLCs to generate reports from the database • Frequent revision of the paper based data tools • Slow embracing of the new surveillance system by some DTLCs

16. Actions Following the Assessment • May 2008, assessment report submitted and debriefing held with national TB program • Late 2008, new facility surveillance registers distributed to all participating facilities • DTLCs from pilot districts retrained on recording/reporting with emphasis on PDA use • Hardware/software distributed to DTLCs • Ongoing technical assistance provided by KEMRI/CDC

17. Conclusions and Recommendations • High rates of missing data on registers that can be linked to under-reporting. • PDAs have a potential to improve quality of surveillance data by creating electronic databases and facilitating facility data analysis • Need to repeat assessment once training, software, hardware and distribution of MOH tools issues addressed • Need to develop quality assurance system as expansion occurs to additional facilities

18. Acknowledgements • Kenya Ministry of Health – Division of Leprosy, TB, and Lung Disease • KEMRI • CDC-Atlanta • CDC-Kenya • Participating clinic staff