Working towards a TB-Free Gambia

Dr Ifedayo Adetifa, Interim Principal Investigator, explains the terms and expectations of the Award The award The Global Fund changed the way countries could apply for grants for Round 9, calling for multiple partners within countries, preferably partners with different strengths that would come together to complement each other. So we were approached by our long-term collaborators – the National Leprosy & TB Control Programme – to apply as co-principal recipients on that round.

$4.6 million of the $15 million grant has been earmarked for MRC related activities that we will carry out in our capacity as principal co-recipients. The award has two phases: the first phase followed by a project performance evaluation exercise which will determine whether the Global Fund will continue to fund the projects in the second phase.

Phases

MRC is focusing on aspects related to our strengths: research that can better quantify the disease burden or interventions that will have signifi cant impact on the prevalence of the disease in the country.

In phase 1 we plan to do a nationwide survey where we will attempt for the fi rst time since the 1950s to accurately quantify the burden of TB in The Gambia. This survey will cover the equivalent of 10% of the country’s population -160,000 people. Targeting people aged 15 years and above, we will screen everyone who is eligible and we are anticipating over 70,000 chest X-rays. We will do our fi rst sputum examinations on everyone who has either abnormal X-ray pictures or who reports symptoms suggestive of TB such as chronic cough. All these will be done in the fi eld and pose a major logistical challenge.

An accurate value of the country’s TB burden will enable us to measure the impact of the National TB Programme’s activities. The fi gure will also allow us to get a better estimate of TB incidence: the number of new cases in the population per year.

Testing children

It is known that TB infection in children – the quiet form of TB – provides an insight into background transmission in the community.

We plan to conduct a survey using tuberculin skin tests to assess ongoing community transmission of TB on young children. If it’s high, this will be a pointer to the presence of a lot of undetected TB cases in the community.

Enhanced case finding

The study will encompass much more than just surveys. Currently TB cases are only detected if people present at a health centre. Then one hopes that the health care worker will correctly identify these people as suspects and that they will be equipped with the means to make a TB diagnosis. With the steps described, it is easy to imagine the number of instances where things can go wrong.

We will try out a new intervention: enhanced case fi nding. We will go into the community to give audio-visual TB messages for sensitisation, answer questions and distribute sputum cups. Enhanced case fi nding means that you actually go out into the community and identify TB cases instead of just waiting for them to present at the health centres. If the pilot is successful, we hope it will be implemented across the country.

What people think

In addition we will be looking at people’s knowledge, attitude and beliefs regarding TB. As part of the TB Case Contact Study we conducted limited knowledge and attitude surveys that actually described these aspects very well. Now we hope to expand that to provide a better measure of all the advocacy and social mobilization activities the TB programme has undertaken under previous rounds of the Global Fund. The main outcomes here are the proportion of the sampled population with the correct knowledge of TB transmission, symptoms and treatment.

Microscopy

For the fi rst time in the West African sub-region, we plan to roll out a new and improved method of sputum smear microscopy. Smear microscopy is currently done routinely using light microscopes. But we know that fl uorescent microscopes are able to identify TB better and are at least 10% more sensitive than light microscopes.

As part of Phase 1 we will be helping the National Health Reference Laboratory to roll out fl uorescent smear microscopy in the Greater Banjul area. If successful, this will be expanded to cover the entire country in Phase 2.

When this portable fl uorescent microscope was at the prototype stage, the MRC TB Diagnostic Lab was approached by the WHO and FIND to help in assessing it. MRC’s Dr Martin Antonio and Mr Jacob Otu were part of that and data from the MRC actually

contributed to the assessment of the fl uorescent microscope, which has now been validated by the WHO.

Outcomes

At the end of fi ve years, we hope to have seen a signifi cant drop in TB cases in the country. And in the course of doing this study we hope to get a reliable estimate of what it costs the government to identify and treat each TB case. This information will certainly assist managers of funds and policy makers elsewhere in making informed decisions about the detection and treatment of TB.

The Gambia might just be the fi rst country to test such an intervention aimed at increasing TB case detection alongside an improved diagnostic technique on such a large scale and actually deliver on it well. If all goes well, we would be part of another Gambian success story (along with HiB, , Hepatitis B and Pneumococcal vaccines; and other interventions successfully tested in The Gambia to the benefi t of the people)…In addition, this project fi ts well with MRC’s new strategic research direction particularly the vaccinology and disease elimination themes.

The Global Fund against AIDS, TB and Malaria is the world’s largest public/private partnership, providing funding to countries that need it the most to combat these diseases.

Previously MRC (UK) The Gambia has been involved in Global Fund activities in HIV care as a sub-recipient to the National AIDS Secretariat. The Unit also acted as a sub-recipient to the National Leprosy & TB Control Programme in Round 5. Awards are disbursed via the Country Coordinating Mechanism, as awards are given to a country and not an institution.

Global Fund money is disbursed in phases: A pass mark from Global Fund’s evaluation of project implementation in phase 1 is a prerequisite for progress to phase 2.