The Nodding Syndrome in Uganda: Where we come from and

 1 EAST AFRICAN INTEGRATED DISEASE SURVEILLANCE NETWORK (EAIDSNet) OCT -­‐ DEC 2011 VOLUME 1 ISSUE 4 EAIDSNet is a member of Connecting Organizations for Regional Disease Surveillance (CORDS) CONTENTS The Nodding Syndrome in Uganda eIDSR Influenza Surveillance in Rwanda World Aids Day at EAC Secretariat Lab Accreditation Mnazi Mmoja Hospital, Zanzibar mTrac reporting system in Uganda Recall of HIV Testing Kits : Public Health Implications Announcements Editorial Committee The Nodding Syndrome in Uganda: Where we come from and where we are today Dr Issa Makumbi1, Malimbo Mugagga1 1 Uganda Ministry of Health First Reports A progressive neurological disorder characterized by head nodding, seizures, mental retardation and stunted growth had been noticed in Kitgum and Pader districts located in Northern Uganda for over five years before it was officially reported to the Ministry of Health (MOH) by Kitgum District Health Office in August 2009. The report indicated that over 300 children in Kitgum District had been affected by the strange condition, mostly those between the ages of 5 and 15. Subsequently, the districts of Pader and Lamwo reported Dr Stanley Sonoiya
EAC Secretariat
Dr Ope Maurice
EAC Secretariat
Tanzania
Dr Peter Mbuji
MOHSW
Dr. Leonard Mboera
NIMR
Mr Juma Rajab Juma
MOHSW
(Zanzibar)
Dr Fausta Mosha
National Reference Laboratory
Mrs Attye Juma Shaame
MOHSW (Zanzibar)
Rwanda
Dr Thiery Nyatanyi
Rwanda Biomedical Center
Isaac Ntahobakulira
School of Public Health (FELTP)
Dr Leon Mutesa
MOH
Uganda
Dr Alex Opio
MOH
Julius J. Lutwama
UVRI
Kenya
Dr. David Mutonga
Dr Jared Omollo
MOPHS
FELTP
Mr James Ngumo Kariuki
KEMRI
Burundi
Dr Dionis Nizigiyimana
DSNIS
Dr Jacque Ndikubagenzi
University of Burundi
Dr Twungubumwe Novat
l’Institut National de Sante Publique
District Map of Uganda, with Kitgum, Pader and Lamwo Districts in the North. 2 similar cases. Initial Diagnoses Before this condition got a distinct characterization, it had earlier been referred to in various ways. For example in 2008, it was reported as an abnormally high prevalence of epilepsy in Northern Uganda and in February 2009 as narcolepsy – a sleeping disorder. Furthermore, an investigation team from MOH in March 2009 attributed the problem to a post-­‐traumatic stress disorder ; while another team conducting onchocerciasis mapping in March Cysticercosis, Toxoplasmosis, Schistosomiasis and Trypanosomiasis; other infectious diseases such as Congenital Syphilis; Metabolic and Nutritional Disorders; Intoxicants (heavy metals, poisons, drugs); War Zone Exploded Munitions and Military Ordinance Materials contamination, Endocrine Anomalies, Neoplasia, and Autoimmune disorders. Despite the extensive investigations conducted thus far, no definite aetiology/diagnosis of Nodding Syndrome has been made, and the condition continues to be reported. Epidemiology To-­‐date, the estimated number of affected children by both Nodding Syndrome and epilepsy is reported to be approximately three thousand (3000). From the field investigations and clinical experience on the ground, it has been reported that most of the children respond well on anti-­‐epileptics, especially carbamazepine – episodes of nodding are reduced and progress of the disease is slowed or halted. Whereas this condition is relatively new in A child diagnosed with Nodding Syndrome 2009 found high levels of onchocerciasis microfilariae in 88% of the sample of 60 patients with this condition. Onchocerca volvulus is a parasite that causes onchocerciasis or river blindness. Further investigation by a multidisciplinary team from the Ministry of Health and partners in August 2009 noted that the disease had started in 2003 when most of the Northern Uganda population had moved to Internally Displaced People’s (IDP) camps. The team concluded that this crippling disease was a “Progressive Cerebro-­‐Musculo-­‐
Skeletal Epileptogenic Syndrome” whose etiology had not been established, although acknowledging its association with river blindness. The differential diagnoses suggested by the team included Parasitic infections particularly Onchocerciasis and the associated River Blindness Epilepsy Syndrome, but also O. Volvulus (microfilariae), found in high prevalence among patients with Nodding Syndrome Northern Uganda, similar disorders which are linked to epileptic seizures had been reported previously in distinct geographic locations of sub-­‐Saharan Africa.Within the last decade, there were reports in Tanzania (Winkler et al , 2008) and Southern Sudan (Lacey, 2003). Interestingly, both areas are known to be endemic for O. volvulus. The condition is also similar to the illness that was described in 1962 by L. Jilek-­‐Aall in Ulanga district of Tanzania, in which children 3 had attacks of ‘‘nodding head,’’ some of them preceding the development of ‘‘grand-­‐ mal’’ seizures. In 1983 Gerrits reported a condition of “dropping the head in the pan” among the Bassa and Kpelle in Liberia. The Nakalanga syndrome consisting of epilepsy, stunted growth, and mental retardation, reminiscent of the ‘‘nodding disease’’ was reported in parts of Western and Eastern Uganda (Kipp et al, 1996) and in Burundi (Newell et al, 1997). In Uganda, nodding syndrome cases were described for the first time in 2000 in Kabende Parish, Kabarole district, Western Uganda -­‐ an area that is endemic for onchocerciasis (Kaiser et al, 2000). The most common factor among places where the Nodding syndrome and other syndromes reminiscent of it have been reported, is high endemicity of O. volvulus. However the actual cause of the head Nodding Syndrome as observed in Tanzania and Sudan remains unclear and a relationship with onchocerciasis remain unconfirmed but highly suspected. Investigation and Response In investigations into Nodding Syndrome the Ministry of Health has collaborated with a number of partners who include the World Health Organization, the US Centres for Disease Control, Makerere University, Transcultural Psychosocial Organisation (TPO Uganda) and the African Field Epidemiologists Network (AFENET) among others. Whereas the investigations remain inconclusive, we now have a good description of the disease that can help us to identify the new cases as early as possible. Based on the information available, the Ministry of Health with support from partners developed a comprehensive response plan for Nodding Syndrome. The main objective of this plan is to provide an integrated response to Nodding Syndrome through coordinated implementation of interventions and measures that will ultimately identify the cause and control the disease syndrome to the level where it is no longer of public health importance. Components of the plan include: •
strengthening surveillance, •
case management including nutritional rehabilitation -­‐ a case management and rehabilitative protocol has been established that can greatly improve the lives of those affected by the conditions. Subsequent efforts have been made to train/sensitize health workers to be able to not only detect the disease but also manage patients well. •
psychosocial support, and •
further research into the cause and pathology of Nodding Syndrome. An interim response plan is also in place that requires actions from various actors. However, as the the cause of the illness and the mode of transmission remain unknown, no specific preventive interventions can be REFERENCES 1. Winkler AS, Friedrich K, Konig R, Meindl M, Helbok R, Unterberger I et.al . ‘’The head nodding syndrome—Clinical classification and possible causes”. Epilepsia. Dec 2008. Volume 49 (12); pp 2008-­‐2015. 2. Lacey M (2003). "Nodding disease: mystery of southern Sudan". Lancet Neurology 2 (12): 714. 3. Kipp W, Kasoro S, Burnham G. (1994) Onchocerciasis and epilepsy in Uganda. Lancet 343:183–184. 4. Newell ED, Vyungimana F, Bradley JE. (1997) Epilepsy, retarded growth and onchocerciasis in two areas of different endemicity of onchocerciasis in Burundi. Trans R Soc Trop Med Hyg 91:525–527. 5. Kaiser C, Benninger C, Asaba G, Mugisa C, Kabagambe G, Kipp W, Rating D. (2000) Clinical and electro-­‐clinical classification of epileptic seizures in West-­‐Uganda. Bull Soc Pathol Exot 93:255–259. 6. Gerrits C. (1983) Conceptions and explanation of sii, epilepsy. A medical-­‐anthropological study among the Bassa and Kpelle in Liberia. Curare 6:33–40. 7. Jilek WG, Jilek-­‐Aall LM. (1970) The Problem of epilepsy in a rural Tanzanian tribe. Afr J Med Sci 1:305–307.
4 The Integrated Disease Surveillance and Response system contributing to sustained influenza surveillance in Rwanda. M.A. Muhimpundu1, T. Nyatanyi1, E. Karuranga1, J.Rukelibuga2, A. Kabeja1 1 Other Epidemic Infectious Diseases Division-­‐ IHDPC/ RBC, Ministry of Health, Rwanda 2 CDC, Rwanda Introduction Surveillance is the ongoing systematic collection, analysis, and interpretation of health data. It includes the timely dissemination of the resulting information to those who need them for action.Surveillance is also essential for planning, implementation, and evaluation of public health practice (WHO 2002). The World Health Organization (WHO) proposed an Integrated Disease Surveillance and Response (IDSR) approach for improving public health surveillance and response in the African Region linking community, health facility, district and national levels (WHO and CDC, 2010). The IDSR was adopted by the WHO African Region member states since 1998 to coordinate and streamline all surveillance activities; rather than using scarce resources to maintain separate vertical activities. In a streamlined surveillance system resources are combined to collect information from a single focal point at each level . The objectives of this improved integrated surveillance system included: strengthening the capacity of countries to conduct effective surveillance activities; integrating multiple surveillance systems so that data collection tools, personnel and resources can be used more efficiently ; improving the use of information to detect changes in time in order to conduct a rapid response to suspect epidemics and outbreaks ; and monitoring the impact of public health interventions. (WHO and CDC, 2010). Integrated Disease Surveillance and Response in Rwanda and adoption of electronic Disease Surveillance and Response (e-­‐IDSR) In 2000, Rwanda implemented the IDSR strategy at all health system levels after assessment of national surveillance systems and development of a strategic plan based on the identified strengths, weaknesses, gaps and opportunities in disease surveillance and response (WHO, 2002). However this surveillance system has failed to capture some major outbreaks that occurred in the recent past years, partly due to late reporting and inefficient communication among the different actors of the surveillance system (TRAC Plus, 2010). Based on the experience with the TRACnet system that collects real-­‐time HIV AIDS data, The Ministry of Health through former TRAC Plus proposed to move from paper-­‐based system to an electronic reporting system, called “electronic Integrated Disease Surveillance and Response system” (e-­‐IDSR). Thus, the proposed electronic system should: • contribute to improved the completeness and timeliness of reports as well as quality of the data collected throughout the country • allow district and central level staff to easily analyze their data and to recognize suspected outbreaks • it should be a monitoring and alert tool on disease outbreaks to allow prompt and efficient responses to these suspected outbreaks throughout the country • The eIDSR should also permit to monitor the strategic activities implemented to contain and manage these outbreaks The database will also be used for operations research addressed to continuously improve public health programs in Rwanda, evidence-­‐
based planning and to contribute to set new priorities and policies. The surveillance data will be properly stored in a secure and reliable place and be continuously accessible only for authorized personnel. The e-­‐IDSR version should improve on the IDSR by quicker detection, higher sensitivity and lower burden on health workers (TRAC Plus, 2010). 5 The process of revitalization and reform of surveillance and response system started in 2011. Since adoption of electronic surveillance system; e-­‐IDSR was developed, technical documents were elaborated, trainings were conducted and now the electronic system is piloted in 77 Health Facilities, among them 5 district hospitals and 72 Health centres located in their catchment areas. (RBC/EID Division, 2011). Integration of Influenza surveillance in Integrated Disease Surveillance and Response From July 2008, Influenza Sentinel Surveillance (ISS) has been conducted at 6 health facilities (HF). The main objectives of the surveillance system are to describe the epidemiology and seasonality of influenza, to monitor emergence of novel influenza viruses, to describe the circulating influenza types and subtypes, and for early detection influenza outbreaks in the country. pneumonia in children <5 years of age on the list of weekly reportable diseases. Standard case definitions of ILI and severe pneumonia < 5 years were developed to be included in IDSR technical guideline and in training modules. An ILI case is defined as any outpatient with fever ≥38°C and cough or sore throat in the absence of another diagnosis, with symptom onset within 72 hours of presentation ; a severe pneumonia < 5 years is defined as any child 2 months to 5 years of age who is hospitalized with cough or difficulty breathing, and at least one danger sign, with symptom onset within 7 days of presentation. Health workers, among others Surveillance Focal Point, Data Manager and Laboratory technician from all district hospitals as well as health providers from seventy two Health Centers were trained on how to identify cases using standard case definitions ; report and analyze data of immediate and weekly reportable diseases using e-­‐IDSR. Posters of standard case definitions were distributed to Despite the fact that the established network health facilities to guide clinicians to identify for influenza surveillance is achieving its main cases. The epidemiological mission, data collected by the ISS weekly reports are are not population based, thus “The e-­‐IDSR version should prepared and sent by HF not sufficient to understand the improve on the IDSR by every Monday before 12:00 public health importance of quicker detection, higher am. If reports are not sent influenza in Rwanda. Hence sensitivity and lower burden on time, the electronic there is still a need of on health workers… “ system will automatically denominator data to estimate send a text reminder to the the burden of influenza. It is in concerned health facility these regards that in 2011, when data manager. We analyzed Rwanda started the process of data in Excel for completeness, timeliness and revitalizing its Integrated Disease Surveillance trends. and Response system (IDSR), an opportunity was taken to integrate influenza like illness Results (ILI) and severe pneumonia in children <5 years of age on the list of priority reportable From October to December 2011, a total of 43 diseases specially, weekly reportable diseases. 065 cases of ILI and 1361 cases of severe pneumonia< 5 years were reported through This article proposes to report preliminary eIDSR. The figure 1 presents the breakdown findings of integration of influenza like illness by District Hospital. Average of completeness (ILI) and severe pneumonia in children <5 of epidemiological weekly reports was 98% years of age in e-­‐IDSR. It shows how baseline whereas timeliness was 90%. data to detect and predict unusual increase in The figure 2 presents the breakdown results influenza is generated by piloted electronic by case classification per epidemiological diseases surveillance system. week. There is almost a constant number of Methods pneumonia cases though the weeks and there is a visible increase in ILI cases over time. Based on the 2nd edition of IDSR guideline issued by WHO in 2010, we reviewed the national IDSR technical guideline and included Influenza like illness (ILI) and severe 6 Figure1: Number of cases of Pneumonia and ILIper District Hospital in Rwanda, October-­‐ December 2011 Pneumonia and ILI cases per DH, 2011 Pneumonia Nyagatare Gisenyi Gihundwe ILI Byumba 3500 3000 2500 2000 1500 1000 500 0 Kibungo Cases DHs Figure 2. Number of ILI and Pneumonia<5 cases per week in 5 District Hospitals, October-­‐December 2011. Number of Cases ILI and Pneumonia per Week, 5 D.H, 2011 6000 5000 4000 3000 2000 1000 0 ILI Pneumonia W W W W W W W W W W W W 41 42 43 44 45 46 47 48 49 50 51 52 Weeks Limitations We have limited data to evaluate the usefulness of eIDSR to meet the established objectives and the data can not be extrapolated to the entire country to give information on other areas in the country. Conclusion The integration of ILI and severe pneumonia < 5 years surveillance into the IDSR in Rwanda improves the surveillance of influenza in sentinel sites. We obtained the preliminary baseline data from the five D.H. The timelines and completeness of the reports are satisfactory to help the surveillance system to predict and detect Influenza outbreaks. There is a need to roll out the surveillance of ILI and severe pneumonia at national level in order to have a weekly epidemiological 7 picture of influenza for the whole country, to determine influenza threshold in all regions and to establish denominator to calculate the burden of disease. Triangulation of data from sentinel sites and IDSR shall help to achieve easily the objectives of influenza surveillance. REFERENCES RBC/EID Division. (2011). Report of Training of trainers in integrated disease surveillance and response. Kigali. Rwanda TRAC Plus. (October 2010). Software requirements specification document. v0.5. Kigali. Rwanda RBC/EID Division. (2009). Standard Operational Procedures for Influenza Surveillance. Kigali. Rwanda World Health Organization.(2002). Technical Guidelines for Integrated Disease Surveillance and Response in the African Region, Brazzaville, Republic of Congo World Health Organization and Centers for Disease Control and Prevention.(2010). Technical Guidelines for Integrated Disease Surveillance and Response in the African Region, Brazzaville,Republic of Congo and Atlanta, USA Acknowledgements 1. The Rwanda Ministry of Health ; 2. Rwanda Biomedical Center ; 3. District Hospitals (Nyagatare, Byumba, Gihundwe, Gisenyi and Kibungo) ; 4. Rwanda FELTP ; 5. CDC Rwanda ; VOXIVA ; WHO The East Africa Community (EAC) celebrates World AIDS Day with a call to redouble efforts in the prevention of HIV transmission Alison Kaitesi1 1Health Department, East African Community Secretariat The East Africa Community (EAC) Secretariat Health Department, jointly with the United Nations International Criminal Tribunal for Rwanda (ICTR) and the Ministry of Health and Social Welfare of Tanzania, joined the rest of the country, and the world, in commemorating World AIDS Day (1 December) at the Arusha International Conference Centre (AICC) complex in Arusha, Tanzania. Other organisations that participated included World Vision and AAR Health Services. In a show of unity and concern for their staff and the surrounding local community the Health Team from the District, led by the District AIDS Coordinator Dr. Isir Ismail, spearheaded the HIV Testing and Counselling exercise that was part of the broader health services provided on that day. Other health services included weight checks, blood sugar and blood pressure measurements to screen for diseases like obesity, diabetes and hypertension. !
A participant undergoing HIV Testing and Counselling In line with this year’s theme namely “Getting to Zero: Zero new HIV infections, Zero discrimination, Zero AIDS-­‐related deaths,” the EAC Principal HIV & AIDS Officer , Dr. Michael Katende, rallied the staff and surrounding community to undertake HIV Testing and Counselling to know their HIV status, 8 practice safe behaviour and protect their loved ones in order to break the vicious cycle of HIV infection and re-­‐infection. “HIV prevalence in East Africa ranges between 3.6% and 6.4% in the 15-­‐49 age group, which comprises the most productive population. If the trend continues, our East African region socio-­‐economic progress will slow down significantly”, he said. While the availability of ARVs has prolonged lives, there still remains a big challenge in combating stigma and discrimination. “Stigma and discrimination hinder many people from accessing prevention services”, said Dr. Katende. He reiterated that criminalisation of HIV and harmful gender norms and activities are some of the structural problems that fuel the spread of HIV in the region; these also account for the majority of people who shun HIV Testing and Counselling for fear of repercussions should their families discover their positive HIV status. The fear of being ostracised by one’s family or community, including disinheritance, is one of the barriers to efforts to address the effects of HIV and the global targets to eliminate the virus. “We need to go beyond the statistics and appreciate the real impact that HIV and AIDS has on families and most especially the poorest of the poor,” said Dr. Muhammad Sohali Ali, the UNICTR Staff Counselor. The majority of those infected and affected by HIV live in developing countries. Most cannot afford life-­‐prolonging drugs and other associated expenditures. “The greatest number are in the prime of their lives and would be working, driving their economies and looking after their families”, Dr Ali added. Further, the impact of HIV is felt all round – by infected individuals, their children, family members and caregivers. “Sometimes families have to grapple with the decision [whether] to feed their children or buy medicine. Children become burdened by taking up more responsibilities as parents become more ill. Kids become upset and start blaming themselves and become afraid that when they come home from school one day, they may find their parents gone and so they start avoiding school. Some become orphans as a result of AIDS and may end up doing drugs and engaging in sex work’, added Dr. Ali. Dr. Ali talked of how care givers have no lives of their own as caring for their loved ones takes up more of their time and energy, often times feeling helpless as they deal with stigma and discrimination while facing uncertain futures, financial worries and interpersonal stress. He noted that the psychological and social impact of HIV and AIDS are profound and difficult to measure and implored all to remain faithful to their sex partners, have protected sex, get tested and treated for sexually transmitted diseases and overall, avoid risky behaviour and practices that may lead to HIV infection. The EAC Principal Health Officer, Dr. Stanley Sonoiya, in his remarks, called upon the EAC and UNICTR Staff to double their efforts to promote prevention by creating awareness among their colleagues in both institutions and the surrounding community, and most especially sex workers and their clients and provision of preventive measures. While acknowledging the importance of HIV testing, he pointed out the need to put emphasis on HIV and AIDS psychosocial impact mitigation. A participant having his blood pressure checked. Other checks included blood sugar and weight. 9 mTrac: Using e-­‐reporting technology to improve health service access for the Ugandan population Eddie Mukooyo1, Carol Mothupi Mamothena2 1Ministry of Health Uganda, 2School of Public Health, Moi University In an effort to deal with the challenges of drug supply chain management, delayed alert and response to disease outbreaks or drug stockouts, poor linkages at lower levels of the health system and lack of engagement with the community, the Ugandan Ministry of Health and partners are piloting an electronic surveillance and monitoring system, called mTrac. mTrac is a mobile phone and web based reporting system for health-­‐related data which, in its pilot phase, will enable better detection of outbreaks, monitoring of malaria morbidity and tracking use of Artemisinin Combination Therapies (ACTs). The objectives of the mTrac initiative are: • To adapt a proven software application for collecting routine Health Management Information Systems (HMIS) data through mobile phones to extend DHSI2. • To use disease outbreaks, malaria morbidity data, and tracking use of ACTs as an entry point to extending a comprehensive real-­‐time, health information package • To strengthen dissemination of information and feedback to stakeholders, and usage of the system for supply chain management. •
•
•
To generate greater accountability and involvement of all stakeholders in ensuring the provision of malaria-­‐related services. To achieve national coverage, with all 112 districts and at every health facility in Uganda, by October 2012. Based on evidence gathered during this initial roll-­‐out, extend support to other HMIS modules / essential drugs. Through the mTrac system, health related data is made available to district and national health authorities in a timely and accurate manner to allow for prompt feedback and response especially during disease outbreaks or stock-­‐outs of important medicines. Weekly epidemiological data on notifiable diseases and Malaria, as well as reports on drug stock outs are sent via SMS, USSD (Unstructured Supplementary Service Data) or web-­‐based dashboard (http://cvs.rapidsms.org) to a central database accessible to District Health Officers and authorities at the national level. The District Health Officers review, edit and validate data; summary data is sent back via mobile phone to health workers and village health teams and also relayed to Ministry of Health Resource Centre, from where it is distributed to other stakeholders. Figure 4. District Dashboard: Summary data and mapping of disease reports 10 Below are diagrams illustrating the information flow through mTRAC system: Figure 5. Flow of data through the mTrac system A) Data sent to central database VHT
Hospital
HC
Information
Flow
DHO
DHO
This information is made
immediately available to
be viewed, edited, and
validated by the
appropriate DHT Teams.
b) Summary data sent back via mobile phone VHT
Hospital
HC
Information
Flow
DHO
DHO
Once validated, summary
data is sent back to Health
Facilities and Community
Health workers…
11 c) Data also sent to Ministry of Health Resource Center and relevant partners. VHT
Hospital
HC
… and sent to the
Ministry of Health
and Partners
Information
Flow
DHO
DHO
MOH/RC
NMS
Tech. Prog
MHSDMU
The system incorporates automatic analysis and feedback mechanisms, and alerts triggered by the system are immediately sent to the proper office/unit to prompt action and follow-­‐up; outcomes of follow up are also noted on the customized web-­‐dashboard. Within the system there are clearly defined roles and responsibilities with the Ministry of Health and Partners such as UNICEF, WHO, Malaria Consortium, Foundation for Innovative New Diagnostics (FIND) and MUK providing technical support. Further, the Ministry of Health provides coordination at national level and ensures high level of reporting and compliance. The District Health Teams, besides dealing with data, also follow up on alerts and ensure compliance. The health facilities report data weekly, follow up on alerts, and assist and ensure Village Health Teams report their data weekly. In terms of sustainability, the system cost about $15 in recurring costs per district per month. Additionaly, leveraging existing in-­‐
country telecommunication infrastructure through toll-­‐free numbers, flexible software suitable for any phone, and using available phones ensured cost-­‐effectiveness and sustainability of the system. It was important to ensure that district health teams and national authorities were capacitated to handle this innovative health management systems. Therefore, through mTRAC, traditional and non-­‐traditional data sources will be triangulated to generate a robust health management information base. The automatic in-­‐built analysis & feedback mechanisms will improve Ministry of Health response time and efficiency and build confidence in the health system. Further, streamlined management, analysis and response will be generated through robust and diverse sources of information. And a strengthened “accountability chain” will provide real-­‐time management data to stakeholders, identifying bottlenecks and gaps as they occur. In conclusion, the greater transparency, and real-­‐time nature of data, will allow for better resource allocation at all levels, thereby improving health service access for the Ugandan population. 12 Towards Accreditation: Pathology Laboratory Mnazi Mmoja Hospital, Zanzibar (PLMMH) Salum Seif Salum1, Dr Mohamed Ally Mohamed2 and Dr Rugola Mtandu2 1Head of Laboratory Services, Mnazi Mmoja Hospital Ministry Of Health, 2Zanzibar, Ministry of Health and Social Welfare, Tanzania The Pathology Laboratory Mnazi Mmoja Hospital Zanzibar (PLMMH) is among the seven proposed satellite laboratories under the East Africa Public Health Laboratory Networking Project (EAPHLNP) in Tanzania. One of the roles of the EAPHLNP is to promote sharing of common standards between the participating laboratories and preparedness for the application of the WHO/AFRO stepwise accreditation process in order to achieve international accreditation. Some of the EAC Partner States have already adopted laboratory standards (ISO 15189) through the Strengthening Laboratory Accreditation Management Toward Accreditation (SLAMTA) programme and made significant progress toward accreditation. In Tanzania, the accreditation concept was first introduced in March 2007 by Tanzania Bureau of Standard (TBS) and later its road map was developed and began implementation in August 2007 by Clinical Laboratory Standard Institute (CLSI) in collaboration with the Ministry of Health and Social Welfare Tanzania through US Center for Disease Control (CDC) support. So far five mentorship programs with gap assessment in all twelve quality system essentials have been conducted (2007 – Oct 2011). In general, progress was impressive and two among the six laboratories including PLMMH are now ready to apply for accreditation through Southern African Development Community Accreditation Service (SADCAS), an international body. The figure below highlights the performance of PLMMH previously conducted by CLSI (Figure 3). In November 2011 the EAPHLNP, in collaboration with the Ministry of Health and Social Welfare Tanzania, conducted its first ever regional assessment (using WHO/AFRO Checklist) that was used as a preliminary to the upcoming SADCAS assessment. The Figure 3. Performance of Pathology Lab Mnazi Mmoja Hospital as assessed by CLSI 2007 -­‐ 2008 Note : Other bars on the graph represents other zonal laboratories 13 Students at PLMMH ‘ Poor quality lab results are worse than no tests at all ‘ EAPHLN assessment went in detail in comparison with the last CLSI gap assessment that used SADCAS checklist. Its finding was a score of three stars for PLMMH. At present, PLMMH is busy working on a number of suggestions /recommendations made by EAPHLNP accreditation team to strengthen the position of PLMMH to secure international accreditation from the SADCAS. The SADCAS assessment will be conducted in March 2012. The recommendations included availability of adequate human resources and basic laboratory equipments ; completion of renovation with standard requirements for safety and quality at PLMMH, together with collective effort done by laboratory staff on the implementation of a quality Defective HIV Test Kits: what are the potential public health impacts? Martin Matu1 ; Victor Mchunguzi2 1East African Public Health Laboratory Networking Project, 2East Central and Southern Africa Health Community, 1Ministry of Health and Social Welfare, Tanzania Several types of assays for HIV antibody detection have been developed, and promoted for HIV screening and diagnosis; the rapid HIV antibody test is the diagnostic tool of choice in low and middle-­‐income countries. However, some evidence suggests that rapid HIV diagnostic tests may underperform in the field, failing to detect a substantial number of infections. Reports emerged that a deal was made to
import and supply HIV Test Kits in East
Africa manufactured in South Korea which were found to be defective following quality assurance checks. In November 2011, the UN
World Health Organization removed the Standard Diagnostics Bioline® HIV 1/2 3.0 Rapid HIV Test Kit from its list of approved rapid test kits with immediate effect; the alert was issued after Bioline failed quality assurance tests. East Africa countries: Kenya and Uganda re-­‐called controversial HIV Rapid testing kits “Bioline® HIV 1/2 3.0” for poor quality. As of December 20, 2011, PEPFAR advised its country teams to quarantine all Standard Diagnostics (SD) Bioline 1/2 3.0 HIV rapid test kits. This problem may have serious public health impact although, in Tanzanina the health administration asked the public not to panic as “the malfunctioning of the kits was not on giving wrong results but rather giving no 14 results at all and, thus, there is no need for Tanzanians who went for HIV tests to panic” said a senior health official. Tanzanian health authorities on 9th January 2012 announced the withdrawal of a South Korean HIV test kit from circulation following warnings about its poor quality. The Tanzania re-­‐call was second in the East African countries after the alert by the Ministry of Public Health and Sanitation in Kenya, who had previously recalled over one million of the South Korea made HIV Bioline testing kits after the global alert by WHO. The World Health Organization had found an unacceptably high rate of invalid test results with devices of certain SD Bioline HIV-­‐1/2 3.0 (product code 03FK10). This blurs the visibility of the test lines and therefore makes correct interpretation of the test result impossible. At the time, WHO advised that there was no evidence to warrant the retesting of individuals for whom an unambiguous, valid positive or negative test result using this test had been obtained. A positive HIV test result given to an individual should always be confirmed with a second and/or third test different from the initial screening test. Defective kits could have some public health, economic and social implications. Poor testing procedure in the field can lead to exceedingly low levels of rapid HIV test sensitivity, making it imperative that stringent quality control measures are implemented where they do not already exist. Social Risks •
•
•
•
•
•
Psychological and psychiatric morbidities (depression, anxiety and panic attacks) to patients affected Bad implications to the individual, their partners and social contacts, as well as for the community Reiterating the importance of HIV testing among individuals Impacting Health seeking behavior Developement of acute stress reaction followed by mixed anxiety and depression. development of suicidal ideation among affected patients •
•
•
•
•
experiencing anger and regret for major life decisions and developing acute stress reaction and panic attacks among the affected. change of roles and expectations. Affecting relationships, occupation,future planning and carrying social stigma. Anger over predicament and anxiety of losing newfound social circle based around AIDS support groups. Engaging in risk-­‐taking behaviour (unprotected sex and harmful use of alcohol). Economic costs • medico-­‐legal implications for the health care provider testing for HIV. • There are also medico-­‐legal implications for the individual in terms of insurance and disclosure • rejection in relationship and discrimination in job • Demand in evaluation of new test kits and changing of testing Algorithm Public Health outcomes: • Public health and epidemiological implications • The risk of false positive results increases in low-­‐risk population screens requiring psychotherapy for continued adjustment difficulties related to misdiagnoses. • Affecting Integrity of some National programs like VCT, PMTCT and CTC What did Kenya do ? As a result of the recall of Bioline®, Unigold® the brand used in Kenya as a tie-­‐breaker, now replaces Bioline® as the confirmatory test, and the enxyme-­‐linked immunosorbent assay (ELISA) test-­‐which requires a blood sample to be collected and sent to a laboratory and takes significantly longer than the rapid tests-­‐
becomes the tie breaker. Determine® brand retains its place as the official screening test. REFERENCES WHO, 2012: Update information on the SD Bioline HIV-­‐1/2 v3.0: http://www.who.int/diagnostics_laboratory/proc
urement/120106_final_update_info_sd_bioline_hiv
_rtd.pdf. Accessed February 15, 2012 15 PEPFAR Field Advisory on Recall of Certain HIV Rapid Test Kits: http://www.pepfar.gov/press/releases/2012/180163.htm http://allafrica.com/stories/201201030858.html http://www.usaid.gov/our_work/global_health/aids/TechAreas/treatment/hiv_tests.pdf ANNOUNCEMENT I. 5th Conference on Peer Education, Sexuality and HIV&AIDS. 13-­‐15th June 2012. Kenya International Conference Centre (KICC), Nairobi, Kenya. The goal of the conference is to dialogue on policies, programs and current innovations by governments, civil society, PLWHIV and other stakeholders on reducing new HIV infections. For more info go to website: www.thenopeinstitute.org/conference or E-­‐mail your enquries to [email protected] QUARTELY PUBLICATION SCHEDULE ISSUE 1 : January – March ISSUE 2 : April – June ISSUE 3 : July – September ISSUE 4 : October – December Deadline: 20th Day of Each Quarter Month EDITORIAL ADDRESS EAC Secretariat, East African Community (EAC), AICC Bldg, Kilimanjaro Wing , P.O. BOX 1096, Arusha, Tanzania. Tel:+255 27 2504253/8 Fax: +255 27 2504255/2504481 E-­‐Mail: [email protected] and [email protected]