For several years, the Central African Republic has been reporting only about half of the tuberculosis (TB) cases estimated by WHO. Limited access to laboratory services is the main cause of this reporting gap. Since 2019, WHO has increased its support to the country to strengthen its laboratory network.
During the pandemic, and despite the humanitarian challenges the country was already facing, WHO mobilized resources to build laboratory capacity and help address the country’s under-reporting deficits. As a result, WHO purchased 11 GeneXpert machines during the period 2020 and 2021. The GeneXpert is an easy-to-deploy platform for peripheral laboratories which detects the presence of TB bacteria as well as resistance. The platform provides results within less than two hours. WHO also supported the country in developing a strategy for transporting sputum and other biological samples in 16 health districts. This strategy has been successfully implemented in two of these districts (Bangui II and Bimbo). As a result of pilot implementation of the sputum transport strategy and the installation of additional GeneXpert machines, the country has significantly increased the notification rate of susceptible TB cases in only two years, from 43% in 2018 to 48% in 2020 and up to 58% at the end of 2021.
How did Central African Republic do it, and how did the WHO Secretariat support?
The COVID-19 pandemic hit the Central African Republic with its first imported case on 14 March 2020. Prior to the pandemic, the country was already ravaged by decades of civil unrest, armed conflict and underdevelopment. Challenges to the health system include chronic shortages of trained health workers, medical equipment and basic medicines, and many Central Africans travel more than one hour to reach the nearest health facility. The costs of accessing health care are not affordable for many households. The situation is further exacerbated by thousands of internally displaced persons who often live in overcrowded shelters with limited access to water, sanitation and health services.
The COVID-19 pandemic continues to have a negative impact on the provision of essential services, including TB diagnosis and treatment, particularly in the laboratory area, which was already suffering from a chronic shortage of skilled human resources. Prior to the pandemic, there were only 13 GeneXpert machines in the country and no functional sample referral system. Recognizing the risk for both COVID-19 and TB and the importance of the laboratory, the country was provided with 23 new WHO-recommended molecular rapid diagnostic tests, namely GeneXpert machines, in 2020-2021 to strengthen its network of laboratories.
WHO contributed to the purchase of 11 of the 23 machines, including fan, battery, solar panel, inverter, and APC inverter, made available to the country by its various partners. WHO contributed to the installation of the GeneXpert machines and to the training of staff for machine installation, use and maintenance. The machines are used in an integrated manner for the diagnosis of TB, resistant TB, COVID-19, and for viral load testing of people living with HIV and early diagnosis of HIV in exposed children. The machines are also used for suspected cases of Ebola.
WHO also put in place an adapted and functional strategy for the transport of sputum samples and other biological samples (TB, HIV, COVID-19) in order to bring them from the collection site to the laboratory as quickly as possible. For the implementation of this strategy, WHO developed sample transport micro-plans for 16 health districts. Each micro-plan includes targets and reporting gaps; mapping of available and accessible health facilities and laboratories; inventory of transport and communication facilities; inventory of required human resources; inventory of potential support partners; identification of costed and non-costed specimen transport activities; and definition of a timeline for the implementation of specimen transport activities.
The additional GeneXpert machines and the implementation of the transport of the samples has helped the country to further decentralize TB diagnostic services. As a result, suspects have had improved access to laboratory services and limited travel time. WHO supported the country and developed tools (technical sheets for the preparation and transport of samples, sampling protocols and training modules for actors, including community members) and sample transport kits based on materials that can be found locally in order to constitute triple packaging (sampling tube, zip bag, plastic jar, ice-box).
The results have been encouraging during these two years of the pandemic. Despite the challenges faced by the Central African Republic, the Ministry of Health, thanks to the financial and technical support of partners and WHO, has been able to significantly improve patient access to TB diagnosis. Prior to 2019, there was only one laboratory that tested for TB in the country, which performed 1345 tests (337 positive for TB and 99 multidrug resistance). With the additional laboratories decentralized throughout the country now having GeneXpert machines, in 2021, there were commutatively 4690 tests performed, (with 1270 positive, and 127 multidrug resistant).
The pilot implementation of the sputum sample transport strategy for suspected TB patients has seen clear improvement in the results of notification of susceptible TB cases. By using the sputum specimen transport network for TB, the country has provided laboratory access to more people suspected of having TB and has thus demonstrated a successful practice in providing TB diagnosis to its population. Thanks to the efforts of the Ministry of Health and with the support of WHO, the laboratories were able to test and diagnose more people throughout 2021.
Photo Credit: © Mr Augustin Dibert / WHO Country Office in Central African Republic
Photo Caption: WHO delivery, to the Ministry of Health, of electrification kits for laboratories equipped with GeneXpert machines on 6 November 2020.
