Amref Health Africa in Kenya (Amref), a non-state Principal Recipient (PR) for Global Fund Tuberculosis (TB) project, implemented TB activities through 29 Sub- recipients in the year 2016. Global Fund supported Amref in Kenya to implement TB activities in 33 counties with Case Notification Rate (CNR) of less 175/100,000 and Treatment Success Rate (TRS) of less than 88% as per the National strategic plan 2015-2018.(14) In 2015 the percentage of (TB) cases identified through tracing of contacts in these counties was 6% (3,365) of the 59,921 cases notified to the National TB Program while the percentage of notified TB cases, all forms contributed though community referrals was only 4% (2,228).
Study population
The study population included all the TB index cases and children under 5 years whose households were visited by CHVs for contact screening between January and December 2016 and reported to Amref. A total of 2,691 Community Health Volunteers (CHVs) in the 33 counties of implementation were taken through a three days training on community TB care management; some of the topics covered during this training included, introduction to TB basic information, drug resistance, TB/HIV association, Nutrition management of TB, Infection prevention and control of TB. The CHVs were also trained on the community based reporting tools with emphasis on data collection and recording from the households, contact screening as well as referral for persons with signs and symptoms of Tuberculosis.
In addition, a total of 2,398 Community Health Extension Workers (CHEWs) were trained on Tuberculosis and supervision of community based activities that included TB control with intensified focus on supervision of the Community Health volunteers. CHVs were then linked to 2,404 health facilities registering at least one TB patient within the 33 counties of intervention. CHEWs generated a list of the bacteriologically confirmed TB patients and children under five years with TB and allocated them to the CHVs who visited their households for health education, screening and referral for cases with TB signs and symptoms.
Study design and setting
This was a retrospective desk review of project reports submitted to Amref by the sub recipients implementing activities in the 33 counties with Case Notification Rate (CNR) of less 175/100,000 and Treatment Success Rate (TRS) of less than 88% as per the National strategic plan 2015-2018. Data for this study covered a time period between January and December 2016. Data on the notified TB patients was obtained from the National Tuberculosis Information Basic Unit (TIBU) a national platform for all Tuberculosis patients’ data.
Household contact screening was done for all contacts of bacteriologically confirmed TB patients and contact of all children under five years with TB regardless of the type of TB. Household TB screening for contacts of bacteriologically confirmed TB patients and contact of all children under five years included evaluation for possible TB disease with a symptoms questionnaire with six key questions that included: Cough of any duration, History of close contact with confirmed TB patient, body fever, noticeable weight loss, chest pain or breathlessness and finally night sweats. In case any of the six questions were answered “yes” then the person was considered presumptive for TB and referred to the health facility for further TB investigation. The clinician at the facility did physical examination of the contacts and symptomatic persons were sent for Gene Xpert test or examination by smear microscopy where there was no Gene Xpert machine.
The CHVs ensured that all children under five years who had close contact with the index cases were referred irrespective of the screening outcome for further investigations and possible Isoniazid preventive therapy (IPT) initiation. Community Health Volunteers were provided with transport and lunch allowance of USD 8.4 for every household visited and family members screened. The CHEWs were supported with airtime allowance for effective supervision and coordination of the CHVs activities.
The community health volunteers used the Ministry of Health (MOH) approved screening, referral and contact tracing forms, which they filled in during household visits. The forms were verified by the CHEWs for completeness and correctness. The CHVs then followed up the referred TB presumptive contacts through household visit or telephone calls and ensured they all arrived at the link health facility (TB clinic) for further investigations.
CHVs together with the Health Care Workers (HCW) at the TB clinic ensured that all contacts were registered in the contacts register and their outcomes updated appropriately. The contacts diagnosed with TB were recorded in the facility TB register and ‘referred by’ column updated appropriately to make sure the yield from the CHVs household contact screening was well captured and reported .
For each index case visited and contacts screened, the contact investigation form was attached together with the screening and referral forms. These forms were verified and certified by the sub county TB coordinators and then submitted to the sub recipients (SR) implementing the Global Fund TB project in the specific counties. Original copies of the forms were submitted to Amref the Principal Recipient (PR), second copy remained with the SR and the last copy was filled at the facility. Data from all the verified forms collected by the SR, were entered into the Grants Management Information System, a web based systems that works as the project database for all the implementation data.
Data Validation
The Sub-recipient held monthly meetings with the Community Health Volunteers to validate data collected and share any challenges. In addition the Sub-recipients held monthly facility meetings with the TB nurse, facility in charge and representatives from the community health volunteers to discuss the work done by the community health volunteers and validate data submitted every month. Amref carried out Quarterly Onsite Data Verification (OSDV) to assess the quality of reported programmatic results. The on-site checks were basically made to provide valuable information to the project team on where potential issues and gaps could be, and allow project to plan appropriate follow up actions to address these issues. Random sampling, which is important to minimize selection bias, combined with purposive selection, was used to select the counties, sub counties and facilities visited. Using the sampled forms submitted to Amref, the project team through the support of the county and subcounty TB coordinators verified the index cases visited for contact screening by checking their names from the TB register to confirm that they were true TB patients. The team worked with the TB nurses at the facility level to confirm that the households were visited for contact screening, the team also verified duplicate copies of the contact screening and referrals forms filed at the facility level.
Variables
The primary outcome variable was TB cases notified to the national TB program through referral by community health volunteers. When persons with TB signs and symptoms are referred for investigation by CHVs, they start from the laboratory where they provide sputum that is tested for TB using GeneXpert or TB microscopy. Those diagnosed with TB are enrolled and initiated on treatment. TB coordinators enter the facility data into a central electronic database, TIBU, using mobile computer tablets. Other covariates in this study include TB index cases visited for contact screening, number of contacts screened, number referred for further investigation and TB cases identified from referrals by CHVs. Demographic variables of the subjects such as gender and age were also included.
Ethical issues
Amref Health Africa was competitively selected as the Principal Recipient for Global Fund TB in Kenya for non-state actors with a mandate to implement community based TB control activities in partnership with the National TB program, Sub-Recipients and communities living with the disease. The data used in this study was purely from the project reports submitted to Amref by the sub-recipients. Approval to use national data on notified TB patients to be visited by CHVs was provided by the national TB program, the custodian of all TB patients’ data, as part of the grant implementation partnership. For purposes of confidentiality, the data received on cases notified to the National TB Program contributed though community referrals was an aggregate of case finding and referrals from the 33 counties generated from Tuberculosis Information Basic Unit (TIBU) without the patient names.
Data processing and analysis,
Data was obtained from the project monthly reports submitted to Amref by the sub-recipients. The project team verified all contact tracing, screening and referrals forms for completeness. The team also verified that all the index TB patients visited for contact screening were either bacteriologically confirmed or children under 5 years with any type of TB. Any forms with incomplete details were returned back for correction by CHVs under supervision and verification by the sub-recipients. Data for TB patients over 5 years who were not bacteriologically confirmed was excluded from this study. Data was recorded into excel spreadsheets where descriptive analysis was done, proportions calculated and summarized in a table. Simple frequencies and percentages described the number and proportion of household contacts identified, screened and referred.