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Transforming Pediatric TB Diagnosis in Uganda Using Simple One-Step Stool Processing.
In Uganda, an estimated 36 percent of children with tuberculosis (TB) remained undiagnosed and unreported as of 2021, risking severe complications and death. Contributing factors included varying skill levels among health workers, difficulties obtaining sputum for testing, and low bacillary load in specimens. Many health workers lack the skills to obtain recommended samples to test for TB in children under five with invasive procedures like gastric aspiration—used to bring a specimen from the stomach for diagnostic testing—that require specialized training. Nonetheless, improved diagnostic testing is crucial to achieving the United Nations’ goal of ending TB in children and adolescents by 2030.
In 2022, only 47 percent of patients worldwide were tested using a WHO-recommended rapid diagnostic test (WRD), and diagnosing TB in children remains especially challenging, with 1.3 million children under 15 developing TB and 214,000 dying from the disease in 2022. Given the challenges with procedures like gastric aspiration, the WHO recommends using stool as an alternative sample for TB diagnosis among children 0 to 14 years old. Stool sampling allows children under 15 to receive bacteriological TB testing using the GeneXpert platform, facilitating faster diagnosis and treatment.
Grant-Funded Training Module Development and Dissemination. In May 2023, the Uganda National Tuberculosis Leprosy Control Program (NTLP) and the WHOSupranational Reference Laboratory/National Tuberculosis Reference Laboratory (SRL/NTRL) received funding from USAID’s Tuberculosis Implementation Framework Agreement (TIFA) to improve pediatric TB case finding using the simple one-step (SOS) stool-based TB processing method to prepare stool for testing in the Xpert platform—the grant aimed to disseminate the SOS stool processing technique throughout Uganda. SRL-Uganda developed 13 training modules by adapting materials from the KNCV Tuberculosis Foundation SOS toolbox, WHO guidelines, Global Laboratory Initiative tools, Uganda NTLP guidelines, standard operating procedures, and job aids. SRL held stakeholder meetings to validate the SOS training course content and ensure uptake and ownership.
After creating training materials, SRL-Uganda conducted Training of Trainers (TOT) workshops for 44 personnel from national and regional referral hospitals. Each hospital selected one laboratory personnel and one pediatrician to attend the five-day training, covering all national (5) and regional (17) referral hospitals. Masaka Regional Referral Hospital (RRH) staff in central Uganda quickly adopted the SOS stool processing approach. An early success encouraged the team when they used SOS to diagnose and treat TB in a 7-month-old infant from whom they could not obtain a sputum sample for diagnostic testing. Masaka RRH staff became early champions and steadily increased the number of children tested for TB using stool. “As the Masaka RRH team, we are glad to acknowledge that the stool testing is effective in the diagnosis of TB in children who are unable to produce sputum, and we have incorporated this test among the routine investigations for suspected pulmonary TB in children from 0–14 years who present to Masaka RRH and its catchment area. By the end of January 2024, we had performed 40 stool tests and identified two positive patients using the SOS processing method. We appreciate the NTRL and NTLP for supporting and training the staff of Masaka RRH,” said Dr. Sheila Sherine Oyella. To disseminate the technique, SRL-Uganda provided onsite training at 34 health facilities in 17 regions, targeting those with high numbers of pediatric TB notifications. This included theory and practical training sessions for at least ten health workers per facility. The cascade training reached pediatric clinical and laboratory staff from 56 hospitals and health facilities, with ongoing support supervision and learning exchange to facilitate the rollout.
Figure 1. Use of Stool Processing to Test Children 0–14 for TB in Uganda (August 2023–January 2024); N = 59–81
SRL-Uganda tracks the number of children tested via stool and the percentage of positive cases using the SOS stool processing method at trained sites. Among facilities trained in August and September 2023, 2.9 percent of the children tested positive (Figure 1). As partners continue to train and provide support supervision to sites with SRL-Uganda, SRL-Uganda will continue to monitor the number of children tested and the percentage of positive cases using stool testing.
Ongoing Support and Future Plans SRL-Uganda and implementing partners expanded the use of SOS processing and stool testing at health facilities beyond referral hospitals. WHO Uganda and the USAID Program for Accelerated Control of Tuberculosis (PACT) in Karamoja supported the early rollout in Karamoja. Other partners, such as USAID
Local Partner Health Services (LPHS)-TB Activity, USAID LPHS-East Central Activity, and USAID LPHS-East Activity, trained staff at 64 additional GeneXpert facilities throughout Uganda by the end of February 2024. SRL-Uganda will continue engaging partners to ensure uptake of stool testing, including sites that refer samples to facilities with GeneXpert and provide supportive supervision and mentorship.
The rapid and effective rollout of stool testing with SOS processing in the initial phase of TIFA grantfunded work marks a significant step forward in pediatric TB diagnosis in Uganda. High-level facilities like Masaka RRH successfully adopted the SOS stool processing technique, and numerous partners helped to expand it to other health facilities. As a result, SRL-Uganda’s technical expertise and collaborative approach are accelerating the elimination of pediatric TB.
Project report