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Innovative Expedited Results System (ERS) greatly improves quality of Mozambique Early Infant Diagnosis program
 

Issues

In Mozambique, limited sample referral logistics, insufficient laboratory capacity and minimal numbers of skilled health care workers led to undesirably long turn around times for critical Early Infant Diagnosis (EID) results, significantly delaying treatment initiation, and ultimately contributing to child mortality.

 

Description

From 2007 to 2009, Mozambique saw a rapid expansion of the National EID program to include over 235 health centers across the country2 (fig 1).  However, transportation of samples and results between remote districts and two central laboratories often takes many weeks. To accelerate the return of results, an innovative system was designed to allow laboratories to print test results directly in any health center with network coverage (fig 2).  The Expedited Results System (ERS) utilizes GPRS technology and simple, inexpensive printers3 to vastly reduce the time and cost of transporting results from the laboratory to clinics.  It is managed centrally by an administrative assistant, reducing the workload of skilled laboratory technicians.  Confidentiality and the delivery of results are guaranteed through automated monitoring and evaluation software (fig 3).

 

   

Fig 1: Distribution of health centers with EID benefiting from ERS in Mozambique.

Fig 2: MCEL GPRS network present at over 90% of health centers with EID.
   
 

 
Fig 3: Flow diagram of results through the ERS:  Patient data is entered into the lab database when samples are received.  Once results are ready, they are sent from the database to a server, which in turn sends them through the GPRS network to printers located at each health center.  If a printer is unreachable, the results are retained in queue on the server and only deleted once print confirmation is received from the printer.
 

Lessons Learned

Pilot implementation of the ERS in greater Maputo city showed 100% successful transmission and printing of results, validating the system and monitoring software (fig 4).  The impact on the return time of ready results to health centers, measured by comparing a group of test and control sites, was dramatic: a reduction from average 17-22 days to 1-3 days (fig 5).  After ERS implementation in Oct 2009 and with improved sample processing times between Oct 2009 and Mar 2010, secondary downstream effects included reducing the time in which patients received EID results and enrolled in ART from over 6 months to less than 2 months (fig 6), and an increasing the percentage of infants enrolling in ART by over 60% (fig 7).

 

 
Fig 4: Quality and reliability of the ERS during a pilot in Maputo City:  16 health centers across greater Maputo were selected for a pilot to test the system quality and reliability.  During the pilot period 323 results were sent from the lab, with 100% of these received and printed at their destined health center.
 

 
Fig 5: Impact of the ERS on delivery time of ready results:  To examine the impact of the ERS on the delivery time of ready results, 7 health centers were selected and divided into control and test sites. The chart clearly shows the dramatic effect of using the ERS in place of the standard paper results transport system.
 

Fig 6: Impact of the ERS on the EID cascade:  A review of 4 health centers evaluated the effects of the ERS on the entire EID process.  The use of the ERS in Oct 2009 coupled with faster sample processing in Mar 2009 not only improved result delivery to sites but also to patients who more rapidly enrolled in ART.
 

Fig 7: Impact of the ERS on Treatment Initiation: A review of 4 health centers established that the reduced time for results to return to the health center from Apr 2009 to Mar 2010 contributed to a 60% increase in HIV+ children enrolling in ART. 
 

 
Fig 8: Timeline of the ERS project development:  Strong government commitment and coordinated partner support, along with simple operation and minimal training required, allowed the ERS to expand to over 275 health centers in less than 8 months after piloting.
 

 
Fig 9: Government, Partner, and Private Sector Collaboration: Coordinated by CHAI, the ERS benefited from the support of public and private sector partners alike, providing the Ministry of Health with a turnkey program with committed financial support for 3 years.
 

Next Steps

The ERS has since been rolled out on a national basis in Mozambique (including over 275 health centers - fig 8) - less than 8 months after piloting - as the result of collaboration between government, partners, and the private sector (fig 9).  While initially created to accelerate EID results, other tests such as CD4 and tuberculosis are currently being integrated. This approach, developed and tested, can be easily and rapidly be adapted for use in other countries.

 

Acknowledgements

We would like to recognize the pro-bono technical support from Sequoia Technology and MCEL and the collaboration of CDC, EGPAF, MSF, ICAP, FHI, FGH, HAI, and APHL.   We also thank the staff of the PCR laboratories, INS, and CHAI whose dedication and hard work made this project a success.

 

References

1Newell et al. Lancet 2004: vol 364: 1236-43,  22009 UNGASS Progress Report Mozambique,  3Sequoia Technology:  www.sms2printer.co.uk

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