Submitted by: Svetlana Pak, KNCV Tuberculosis Foundation; Manuela Rehr, KNCV Tuberculosis Foundation/Programme Management Unit tuberculosis CARE I; Venera Bismilda, National Reference Laboratory/National TB Programme, Kazakhstan; Zaurech Murzakhmetova, Akmola Oblast tuberculosis Dispensary; Moldir Aubakirova, Almaty City Tuberculosis Dispensary; Lyazzat Begalieva, Eastern Kazakhstan Oblast Tuberculosis Dispensary
kazakhstan Implementation of GeneXpert
Background
GeneXpert implementation
Kazakhstan is one of the 27 high MDR-TB burden countries. According the WHO Global tuberculosis report 2012,1 Kazakhstan had 28 550 notified TB cases in 2010, 19 703 of which were new and relapsed cases. According to the NTP review 2011, the rate of MDR-TB among new TB cases was 21% and among re-treatment cases was 45%. HIV infection is a minor problem in Kazakhstan, as the prevalence of HIV among adults (aged 15–49) is very low (0.1%). Most TB patients (84%) know their HIV status, of which approximately 1% are HIV positive.
Since June 2012, United States Agency for International Development (USAID) TB CARE I in partnership with the KNCV Tuberculosis Foundation has provided support to the NTP for the phased implementation of GeneXpert in Kazakhstan.
Laboratory service The laboratory service in Kazakhstan comprises the National Reference Laboratory; 22 regional bacteriological laboratories, including one in the prison sector (Karaganda); and 466 district microscopy laboratories, including primary health care facilities. Diagnostic algorithm All individuals with presumptive TB are investigated by smear microscopy, culture and DST. Three samples are collected for smear microscopy and culture for all new presumptive TB cases and positive samples are automatically inoculated for first-line drug susceptibility testing (DST). If any resistance to first-line drugs is detected, second-line DST is carried out. Smear microscopy is conducted as a follow-up to treatment for drug-susceptible TB cases and smear microscopy and culture are used to follow up category IV treatment. Hain testing is available in 10 regional laboratories and is used for diagnosing MDR-TB in sputum smear-positive patients. Diagnostic coverage The diagnostic coverage in Kazakhstan is high: smear microscopy coverage is 100% and culture and DST coverage about 91–92%.
1 Global tuberculosis report 2012. Geneva, World Health Organization, 2012 (http://www.who.int/tb/publications/global_report/en/, accessed 20 August 2012).
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Based on the result of a country analysis, it was agreed that the main goal for implementation of GeneXpert in Kazakhstan is improvement of diagnosis and management of MDR-TB. Taking into account the high coverage of culture and DST in the country, the biggest impact of GeneXpert in Kazakhstan is in reducing the time for MDR-TB diagnosis, allowing earlier initiation of adequate treatment. At the same time, in settings where culture and DST coverage is lower, GeneXpert improves diagnosis of MDR-TB. The following risk groups were identified and prioritized by a GeneXpert coordination group: »» contacts of MDR-TB patients with presumptive TB and/ or with abnormalities in the X-ray film; »» all re-treatment cases with presumptive TB; »» category I, II and III TB patients with a sputum smearpositive result at the end of the intensive phase of treatment who do not have DST results; »» patients with presumptive TB who have been previously treated not in accordance with Kazakhstan’s guidelines (from Baikonur, Kyrgyzstan, the Russian Federation, etc.); »» people with presumptive TB in prisons or after release; »» medical and prison personnel with presumptive TB; »» pregnant or postpartum women with presumptive TB; »» severely sick TB patients, with caseous pneumonia or generalized forms of TB, including miliary tuberculosis; »» patients with TB/HIV coinfection without DST; »» people living with HIV with presumptive TB; and »» others. It was agreed that prioritization for GeneXpert will be given to the groups mentioned above, and depending on testing capacity could be expanded to other groups. Ideally, any person with presumptive TB should be considered as poten-