The hidden costs of installing xpert machines in a tuberculosis high-burden country: experiences from Nigeria

Introduction Since the endorsement of GeneXpert MTB/RIF by the WHO, many countries have embarked on implementing this technology. Objective: We outline the cost of installing GeneXpert in district hospitals in Abuja, Nigeria. Methods We prospectively documented costs related to the installation of GeneXpert at five sites. Costs were collected from receipts received from suppliers and normalized to USD 2012 values. Results Costs were often identified after initiating installation for many reasons. Installation varied widely between sites with sufficient space and power supply; sites with insufficient space or power supply and costs not directly associated with site installation. The basic cost for installation was USD 2,621.98 per machine. Sites that required additional space cost close to USD 7,000.00. Conclusion Space and power requirements have a significant effect on installation costs. Countries need to carefully consider the placement of Xpert machines based on the quality and size of the available infrastructure

The hidden costs of installing xpert machines in a tuberculosis high-burden country: experiences from Nigeria

Introduction: Since the endorsement of GeneXpert MTB/RIF by the WHO, many countries have embarked on implementing this technology.Objective: We outline the cost of installing GeneXpert in district hospitals in Abuja, Nigeria.Methods: We prospectively documented costs related to the installation of GeneXpert at five sites. Costs were collected from receipts received from suppliers and normalized to USD 2012 values.Results: Costs were often identified after initiating installation for many reasons. Installation varied  widely between sites with sufficient space and power supply; sites with insufficient space or power supply and costs not directly associated with site installation. The basic cost for installation was USD 2,621.98 per machine. Sites that required additional space cost close to USD 7,000.00.Conclusion: Space and power requirements have a significant effect on installation costs. Countries need to carefully consider the placement of Xpert machines based on the quality and size of the available infrastructure.Key words: Tuberculosis, Xpert-Installation, low resource –settings, hidden cost, operational researc

A Molecular Epidemiological and Genetic Diversity Study of Tuberculosis in Ibadan, Nnewi and Abuja, Nigeria

Background Nigeria has the tenth highest burden of tuberculosis (TB) among the 22 TB high-burden countries in the world. This study describes the biodiversity and epidemiology of drug-susceptible and drug-resistant TB in Ibadan, Nnewi and Abuja, using 409 DNAs extracted from culture positive TB isolates. Methodology/Principal Findings DNAs extracted from clinical isolates of Mycobacterium tuberculosis complex were studied by spoligotyping and 24 VNTR typing. The Cameroon clade (CAM) was predominant followed by the M. africanum (West African 1) and T (mainly T2) clades. By using a smooth definition of clusters, 32 likely epi-linked clusters related to the Cameroon genotype family and 15 likely epi-linked clusters related to other “modern” genotypes were detected. Eight clusters concerned M. africanum West African 1. The recent transmission rate of TB was 38%. This large study shows that the recent transmission of TB in Nigeria is high, without major regional differences, with MDR-TB clusters. Improvement in the TB control programme is imperative to address the TB control problem in Nigeria

Isoprenoids and Fatty Acids Derivatives from the Chloroform Fraction of the Antimycobacterial Methanol Extract Ximeniaamericana Lam. (Olacaceae) Stem Bark

This study investigated the triterpenoids and fatty acid derivatives, and the in vitro growth inhibitory effect against clinical strains of Mycobacteria tuberculosis of the stem bark of Ximenia Americanaa plant widely used in ethno-medicine for the treatment of bacterial and skin infections, poison, post-partum hemorrhage, anaemia, and dysentery. The macerated methanol extract (XAM) of the stem bark was evaluated for anti-tuberculosis activity using the Lowensten Jensen method against de-contaminated clinical strains of Mycobacterium tuberculosis. The XAM was fractionated by open column chromatography on a normal phase silica gel column with a 25 % stepwise gradient of chloroform-methanol as mobile phase. The constituents of the non-polar column fractions eluted with 100% chloroform were characterized using Gas Chromatography-Mass spectroscopic (GC-MS) techniques and by comparison with reference NIST library compound. The XAM (5 mg/mL) inhibited the growth of the Mycobacterium tuberculosis. GC-MS analysis of the non-polar column fractions afforded Two lupane-type triterpenoids: Lup-20-(29)-en-3-one (15) and lupeol (16), three phytosteroids: campesterol (11), stigmasterol (12) and gamma-sitosterol (14), one fridelane-type triterpenoid: Friedelan-3-one (8), one oleanane-type triterpenoid: 12-oleanen-3-one (13), and the fatty acids: Palmitic acid methyl ester (1), Palmitic acid (2), 11-octadecenoic acid methyl ester (3), Octadecanoic acid methyl ester (4), Cis-13-Octadecenoic acid (5), 10,13-octadecadiynoic acid methyl ester (6), Docosanoic acid (7), Tetracosanoic acid (9), and Hexacosanoic acid methyl ester (10). The presence of these bioactive triterpenoids and fatty acids could offer an explanation for the ethno-medicinal uses of this plant. Further work is on-going to isolate in pure form, and characterized the bioactive constituents in the XAM with the view of discovery lead compounds for the treatment of tuberculosis and associated opportunistic bacterial infections. &nbsp

Improved sensitivity, safety and laboratory turnaround time in the diagnosis of pulmonary tuberculosis by use of bleach sedimentation

Background: Inadequate diagnostic processes and human resources in laboratories contribute to a high burden of tuberculosis (TB) in low- and middle-income countries. Direct smear microscopy is relied on for TB diagnosis; however, sensitivity rates vary. To improve sensitivity of direct microscopy, the researchers employed several approaches, including sputum digestion and concentration of acid-fast bacilli (AFB), a technique which uses commercial bleach. Objectives: This study compared methods used to diagnose active Mycobacterium tuberculosis infections. Methods: Three sputum specimens were collected from each of 340 participants in Abuja, Nigeria, over two consecutive days. Direct microscopy was performed on all specimens; following microscopy, one specimen from each patient was selected randomly for bleach sedimentation and one for Lowenstein-Jensen culture. Results: Direct microscopy produced 28.8% AFB-positive results, whilst bleach sedimentation resulted in 30.3%. When compared with the cultures, 26.5% were AFB true positive using direct microscopy and 27.1% using bleach sedimentation. Whilst the specificity rate between these two methods was not statistically significant (P = 0.548), the sensitivity rate was significant (P = 0.004). Conclusion: Based on these results, bleach increases the sensitivity of microscopy compared with direct smear and has similar specificity. When diagnosing new cases of pulmonary TB, one bleach-digested smear is as sensitive as three direct smears, reducing waiting times for patients and ensuring the safety of laboratory technicians

Patients direct costs to undergo TB diagnosis

Background A major impediment to the treatment of TB is a diagnostic process that requires multiple visits. Descriptions of patient costs associated with diagnosis use different protocols and are not comparable. Methods We aimed to describe the direct costs incurred by adults attending TB diagnostic centres in four countries and factors associated with expenditure for diagnosis. Surveys of 2225 adults attending smear-microscopy centres in Nigeria, Nepal, Ethiopia and Yemen. Adults >18 years with cough >2 weeks were enrolled prospectively. Direct costs were quantified using structured questionnaires. Patients with costs >75th quartile were considered to have high expenditure (cases) and compared with patients with costs <75th quartile to identify factors associated with high expenditure. Results The most significant expenses were due to clinic fees and transport. Most participants attended the centres with companions. High expenditure was associated with attending with company, residing in rural areas/other towns and illiteracy. Conclusions The costs incurred by patients are substantial and share common patterns across countries. Removing user fees, transparent charging policies and reimbursing clinic expenses would reduce the poverty-inducing effects of direct diagnostic costs. In locations with limited resources, support could be prioritised for those most at risk of high expenditure; those who are illiterate, attend the service with company and rural residents

LED Fluorescence Microscopy for the Diagnosis of Pulmonary Tuberculosis: A Multi-Country Cross-Sectional Evaluation

Background The diagnosis of tuberculosis (TB) in resource-limited settings relies on Ziehl-Neelsen (ZN) smear microscopy. LED fluorescence microscopy (LED-FM) has many potential advantages over ZN smear microscopy, but requires evaluation in the field. The aim of this study was to assess the sensitivity/specificity of LED-FM for the diagnosis of pulmonary TB and whether its performance varies with the timing of specimen collection. Methods and Findings Adults with cough ≥2 wk were enrolled consecutively in Ethiopia, Nepal, Nigeria, and Yemen. Sputum specimens were examined by ZN smear microscopy and LED-FM and compared with culture as the reference standard. Specimens were collected using a spot-morning-spot (SMS) or spot-spot-morning (SSM) scheme to explore whether the collection of the first two smears at the health care facility (i.e., “on the spot”) the first day of consultation followed by a morning sample the next day (SSM) would identify similar numbers of smear-positive patients as smears collected via the SMS scheme (i.e., one on-the-spot-smear the first day, followed by a morning specimen collected at home and a second on-the-spot sample the second day). In total, 529 (21.6%) culture-positive and 1,826 (74.6%) culture-negative patients were enrolled, of which 1,156 (49%) submitted SSM specimens and 1,199 (51%) submitted SMS specimens. Single LED-FM smears had higher sensitivity but lower specificity than single ZN smears. Using two LED-FM or two ZN smears per patient was 72.8% (385/529, 95% CI 68.8%–76.5%) and 65.8% (348/529, 95% CI 61.6%–69.8%) sensitive (p<0.001) and 90.9% (1,660/1,826, 95% CI 89.5%–92.2%) and 98% (1,790/1,826, 95% CI 97.3%–98.6%) specific (p<0.001). Using three LED-FM or three ZN smears per patient was 77% (408/529, 95% CI 73.3%–80.6%) and 70.5% (373/529, 95% CI 66.4%–74.4%, p<0.001) sensitive and 88.1% (95% CI 86.5%–89.6%) and 96.5% (95% CI 96.8%–98.2%, p<0.001) specific. The sensitivity/specificity of ZN smear microscopy and LED-FM did not vary between SMS and SSM. Conclusions LED-FM had higher sensitivity but, in this study, lower specificity than ZN smear microscopy for diagnosis of pulmonary TB. Performance was independent of the scheme used for collecting specimens. The introduction of LED-FM needs to be accompanied by appropriate training, quality management, and monitoring of performance in the field

Unweighted Pair Group Method using Mathematical Averages (UPGMA) dendrogram (first column) built with Bionumerics® on a composite data set (24 VNTR-largest column)-Spoligotyping (coloured column) on the clinical isolates from Nnewi patients. (identification number : last column) Main Clades are also annotated right to identification number.

<p>Unweighted Pair Group Method using Mathematical Averages (UPGMA) dendrogram (first column) built with Bionumerics® on a composite data set (24 VNTR-largest column)-Spoligotyping (coloured column) on the clinical isolates from Nnewi patients. (identification number : last column) Main Clades are also annotated right to identification number.</p

Main spoligotyping clusters, orphan isolates and new variants within the Cameroon (CAM) (A) <i>M. bovis</i> (B), and <i>M.</i><i>africanum</i> (C) genotype families found in this study.

<p>In column B, a star (*) appears next to the « NEW » label when no Spoligo-International-Type (SIT) number was available within the international database SpolDB4. SIT1037 is also designated as SB0944 in the M. bovis.org database (SB nomenclature), new-h is identical to SB1026, new-d is identical to SB1099, whereas new-b has no SB number.</p