one-STOP TB-service Print

Mobile TB diagnostics in a 20 foot self-sufficient (solar powered) container facilitate a “one-Stop TB-service”. A smart integration of a dCXR room, CAD4TB, a mini-lab for LED Fluorescent microscopy, Xpert MTB/RIF and internet connectivity respond to the call for Active Case Finding in risk groups.

Example of a mobile TB screening unit lay-out with dCXR room and mini-lab

Example of a mobile TB screening unit lay-out with dCXR room and mini-lab

Current passive case detection strategies in low resource areas are often inadequate to control TB in the general population and even more so in risk groups. The “one-Stop TB-service” concept integrates new and existing diagnostic technologies into a new “platform” for use at the place where the patient or risk group is such as the Point Of Care (POC), the prisons or mines.

New TB diagnostic tools at (primary) health facilities should be:

 

  • Easy to operate; one of the biggest challenges public health care faces is the lack of skilled health care workers
  • Integrated in DOTS program, so linked to TB treatment services including proper registration and treatment follow-up
  • Possible to integrate in the existing Health Service System
  • Preference should be given to diagnostics which can be used for the detection of multiple diseases and contribute to Health System strengthening
  • “Economic”, not only calculated as the total cost of the test, but also taking into account the patient gain from faster, better and more integrated diagnosis
  • Integrate diagnostic imaging with microscopy and molecular tests
  • Act as a platform for new diagnostics for HIV/AIDS, Malaria and TB
  • Enable multi-functional X-ray use for detection of extra-pulmonary TB and for imaging of trauma and extremities

The container designed in Zambia with support from Zambart and the National TB programme consists of a standard size 20 foot container, to be placed at POC or at district hospitals using any local available truck able to transport a 20 foot container. With an integrated lifting device the unit can be placed and become operational in just 2 hours at (almost) any venue thinkable. The unit is self supporting in terms of electrical power (power generator or solar power with batteries and inverters) and water for a period of time allowing operation even when such utilities are - short term -not available. Integration of an (information) system and database for lab results, X-ray and other health services is beneficial for TB programs, for instance for TB prevalence survey, and screening programs.


Layout of the "One-STOP TB" Container

The container unit is internally divided into three parts and two folding screens provide additional external space

  • In the Chest X-ray room the digital X-ray unit is placed and patients are X-rayed in an upright position (PA/LAT)
  • In the Chest X-ray control area the radiographer will enter patient data, make the Chest image and will give an onsite diagnosis with support from the CAD4TB protocol. In case needed a hardcopy print-out can be given to the patient for further reference at a cost of Euro 0,03 per print.
  • In the well ventilated lab room the sputum samples are processed. The room can contain a LED Fluorescent microscope and/or a molecular test unit (GX); special foamed transport case for the GXIV system and a rubber mat on the table is required.
  • Fall-out screens provide shelter and a separate waiting and sputum collection area for the suspects and patients.
  • A special lifting device can be integrated at the four corners which allows for easy up and offload of the unit from a standard size truck without the need for a separate crane.

  • Direct digital X-ray unit (DR). Chest radiography (CXR) is becoming increasingly important in the detection of TB especially in high HIV prevalence areas. Not only is CXR important to detect TB in HIV cases it is also an indispensable tool to realise universal access to TB care by finding more patients earlier. However, less experienced readers have difficulties in interpreting signs on a CXR. To enhance accuracy in image reading, the latest dCXR concepts allow automated CXR reading by CAD4TB software and/or sending images over internet or mobile phone networks. CAD4TB automatically indicates the location and probability of abnormalities consistent with TB will significantly reduce over and under-reading.

  1. Optimized Smear Microscopy. Fluorescence staining and sputum processing can increase the sensitivity of smears. LED based microscopy is simple and available at access pricing for resource limited settings. Optimized Smear Microscopy is known to increase the sensitivity of TB smears but is currently not widely available at POC.
  2. Xpert (Cepheid). This is a rapid system for the detection of M. Tuberculosis and of Rifampcin resistance. The system works direct on sputum samples and provides a result in just two hours and combines sample preparation with amplification and detection in a cartridge based system. The same technique can be used for numerous other diagnostic tests and because it is a closed loop system can be performed in just one room. Availability of PMDT (programatic management of Drug Resistant TB) and access to MDR treatment is required.
  3. Integration of communication/database system: The unit will make use of the so called African Access Point (AAP’s), a combination of wireless and GSM techniques which allow users to communicate with the unit through standard mobile phones. This will be useful in gathering patient data and treatment follow up in the communities. Communication between the unit and a central database will go through GPRS/EDGE and if available UMTS techniques. The AAP system can also be used to facilitate access to e-learning modules for the operating staff.
  4. Health System Strengthening. By linking TB control activities to respiratory health, TB programs can improve the overall quality of healthcare. In this respect access to high quality CXR will be prove to be an invaluable tool in the year of the Lung and onwards. As mentioned before, access to TB treatment for registered patients is a critical success factor for effective use of the platform. External Quality Assessment is to be budgeted for.
  5. Human technology. Although sophisticated technology is used, the platform is designed with a low resource setting in mind. All diagnostic techniques and tests are easy to operate and require basic training. Use of mobile phones is already widely accepted and the information system is Windows based.
  6. Advocacy. The one-Stop TB-service when communicated under a more general Lung Health program and brought close to the community, can reduce barriers to TB care. Most people are willing to get their X-ray taken and are more likely to accept to undergo additional testing if the CXR is considered to be abnormal. Other screening services such as for instance hypertension can also be performed in the container to reduce risk of stigma.