New Policies, New Technologies: Modelling the Potential for Improved Smear Microscopy Services in Malawi

Background To quantify the likely impact of recent WHO policy recommendations regarding smear microscopy and the introduction of appropriate low-cost fluorescence microscopy on a) case detection and b) laboratory workload.Methodology/Principal Findings An audit of the laboratory register in an urban hospital, Lilongwe, Malawi, and the application of a simple modelling framework. The adoption of the new definition of a smear-positive case could directly increase case detection by up to 28%. Examining Ziehl-Neelsen (ZN) sputum smears for up to 10 minutes before declaring them negative has previously been shown to increase case detection (over and above that gained by the adoption of the new case definition) by 70% compared with examination times in routine practice. Three times the number of staff would be required to adequately examine the current workload of smears using ZN microscopy. Through implementing new policy recommendations and LED-based fluorescence microscopy the current laboratory staff complement could investigate the same number of patients, examining auramine-stained smears to an extent that is equivalent to a 10 minutes ZN smear examination.Conclusions/Significance Combined implementation of the new WHO recommendations on smear microscopy and LED-based fluorescence microscopy could result in substantial increases in smear positive case-detection using existing human resources and minimal additional equipment

Acceptability and Effectiveness of the Storekeeper-Based TB Referral System for TB Suspects in Sub-Districts of Lilongwe in Malawi

Background Early access to tuberculosis diagnosis and treatment remains a challenge in developing countries. General use of informal providers such as storekeepers is common. The aim of this study was to determine the effectiveness and acceptability of a storekeeper-based referral system for TB suspects in urban settings of Lilongwe, Malawi. Methods The referral system intervention was implemented in two sub-districts. This was evaluated using a pre and post comparison as well as comparison with a third sub-district designated as the control. The intervention included training of storekeepers to detect and refer clients with chronic cough using predesigned referral letters along with monitoring and supervision. Data from a community based chronic cough survey and an audit of health centre records were used to measure its effectiveness. Focus group discussions and in-depth interviews were carried out to document acceptability of the intervention with the different stakeholders. Results Following the intervention, the mean patient delay appeared lower in the intervention than comparison areas (2.14 weeks (SD 5.8) vs 8.8 weeks (SD 15.1)). However, after adjusting for confounding variables this difference was not significant (p = 0.07). After the intervention the proportion of the population diagnosed with smear positive TB in the intervention sites (1.2 per 1000) was significantly higher than in the comparison area (0.6 per 1000, p<0.01) even after adjusting for sex and age. Qualitative findings suggested that (a) the referral letters triggered health workers to ask patients to submit sputum for TB diagnosis (b) the approach may be sustainable as the referral role was linked to the livelihood of the storekeepers. Conclusion The study suggests that the referral system with storekeepers is sustainable and effective in increasing smear positive TB case notification. Studies that assess this approach for control of other diseases along with collection of specimens by storekeepers or similar providers are needed

New policies, new technologies:modelling the potential for improved smear microscopy services in Malawi

BACKGROUND: To quantify the likely impact of recent WHO policy recommendations regarding smear microscopy and the introduction of appropriate low-cost fluorescence microscopy on a) case detection and b) laboratory workload.METHODOLOGY/PRINCIPAL FINDINGS: An audit of the laboratory register in an urban hospital, Lilongwe, Malawi, and the application of a simple modelling framework. The adoption of the new definition of a smear-positive case could directly increase case detection by up to 28%. Examining Ziehl-Neelsen (ZN) sputum smears for up to 10 minutes before declaring them negative has previously been shown to increase case detection (over and above that gained by the adoption of the new case definition) by 70% compared with examination times in routine practice. Three times the number of staff would be required to adequately examine the current workload of smears using ZN microscopy. Through implementing new policy recommendations and LED-based fluorescence microscopy the current laboratory staff complement could investigate the same number of patients, examining auramine-stained smears to an extent that is equivalent to a 10 minutes ZN smear examination.CONCLUSIONS/SIGNIFICANCE: Combined implementation of the new WHO recommendations on smear microscopy and LED-based fluorescence microscopy could result in substantial increases in smear positive case-detection using existing human resources and minimal additional equipment.</p

Chronic Cough Survey: Care seeking, Delay, Referral by storekeepers.

<p>Chronic Cough Survey: Care seeking, Delay, Referral by storekeepers.</p

Poverty Characteristics of the three studied areas.

<p>Source: Projections based on Malawi 1998 Census and indicators are from Malawi – An Atlas of Social Statistics (2002).</p

Intervention Package.

<p>Intervention Package.</p

Suspected TB patients registered and sputum results.

1<p>2007 population projection.</p>2<p>2007 population projection.</p

Characteristics of Participants in Chronic Cough Household Survey.

<p>Characteristics of Participants in Chronic Cough Household Survey.</p

Number of TB suspects (by sex) classified as smear-positive PTB cases using different thresholds for case definition.

*<p>P<0.05 and **p<0.01 when compared to the definition “At least 1 smear with ≥1 AFB/smear”; Chi square for trend, males, p<0.001; females p<0.05.</p>†<p>sex not known for one patient.</p

Current workload based on examination of three specimens from TB suspects; comparison of ZN and FM.

*<p>Time taken to find a ZN smear neg  = 10 mins; Scanty  = 5 mins; 1+  = 2.5 mins; 2+  = 1.0 min; 3+  = 0.5 min. FU pos  = 2.5 mins.</p>**<p>Time taken to find an FM smear neg  = 2.5 mins; Scanty  = 2.0 mins; 1+  = 1.5 mins; 2+  = 0.5; 3+  = 0.25 min. FU pos  = 1.5 mins.</p>#<p>No of negative smears and positive smears (at different grades) calculated based on proportions of smears that were negative and positive (at different grades) in laboratory register at Bwaila Hospital.</p>†<p>Staff Full Time (Hands-on) Equivalent based on real working hours reported by Mundy et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0007760#pone.0007760-Mundy2" target="_blank">[26]</a>.</p