Zero TB Cities Vietnam (ZTV)
The Zero TB Cities Viet Nam (ZTV) project was designed in alignment with the National Strategy for ending TB in Viet Nam. The search-treat-prevent principles of the Zero TB Initiative were locally adopted and integrated into the existing primary health and TB care infrastructure. The ZTV project sought to optimize a comprehensive TB patient care model through the following activities:
- Active case finding through household contact tracing, community and high-risk screening
- Active referral through strengthened partnerships with non-NTP providers (private hospitals, district general hospitals, pediatric hospitals)
- Novel diagnostic tools and algorithm for TB diagnosis and treatment
- Patient and social support for improved treatment adherence to care
- Post-exposure therapy for people with latent TB infection
ZTV was implemented from September 2017 to March 2019 with funding from TB REACH Wave 5.
To build local capacity, we trained over 300 members of local community-based organizations to serve as community healthcare workers (CHW) to screen and refer people for TB testing in 3 cities across Viet Nam: eight districts in Ho Chi Minh City (districts 6, 7, 8, 12, Binh Chanh, Go Vap , Hoc Mon and Tan Binh), four districts in Hai Phong (districts Hai An, Hong Bang, Le Chan and Ngo Quyen) and Hoi An. This cadre of health workers acted as the outreach arm of the existing National TB Program services by visiting the homes of TB patients to screen their household and neighborhood contacts for TB symptoms. In addition to contact tracing, the CHWs went door-to-door in high risk and vulnerable populations to screen these groups for TB symptoms.
To complement active case finding activities, we organized mobile chest X-ray (CXR) events in the community to reduce access barriers to CXR. These events were conducted during weekend days and located at convenient public locations in the community .
In addition to community screening, we engaged private and public hospitals in Ho Chi Minh City and Hai Phong to screen children (0-14 years of age) and adults (over 15 years of age) for TB. At each facility, individuals were screened for TB symptoms by project staff and referred for CXR at either the hospital or at the local district TB unit (DTU).
Across all locations and strategies, individuals were first screened with a TB symptom questionnaire and all household contacts and people reporting any single TB symptom were referred for further screening by CXR at their local DTU. The project promoted the “Double-X” algorithm: initial screening by CXR, followed by sputum testing with the Xpert MTB/RIF assay for persons with abnormalities in the lungs to reduce diagnostic delay and improve diagnostic accuracy. All symptomatic people with normal CXR were referred for sputum smear microscopy. If people with TB symptoms were unable or unwilling to get a CXR, healthcare workers collected sputum samples at the person’s home and transported them to the local laboratory for smear microscopy.
We provide a small transport stipend for people who had been screened and referred for CXR at the DTU or at a mobile CXR event. If a person was diagnosed with TB, our CHWs assisted each patient with TB treatment initiation at the local DTU. To support treatment adherence, the CHWs visited patient homes and provided psychosocial support and counselling. For the most impoverished patients, we also provided social support in the form of cash payments.
Lastly, we supported the integration of latent TB infection (LTBI) testing and treatment into routine TB screening activities following updates to WHO guidelines for LTBI management in 2018. For the first time at this scale, the project expanded latent TB infection testing and treatment for household contacts of all ages.
All activities were supported by a custom-built mHealth app and web-based portal named Access to Care Information System (ACIS) which was installed onto 4G-enabled mobile tablets. The app was bi-directionally linked to Viet Nam’s national TB notification system (VITIMES). Whenever a TB patient was entered into VITIMES, the data were automatically pushed into the project database and down to the tablet of the CHW who was stationed in the ward where that patient resided. Data were collected at every patient encounter, from symptoms screening to cure, via the mHealth app and webportal. This robust data system allowed for central monitoring of all project data and enabled the provision of performance-based incentives to the CHWs.
Throughout project implementation, ZTV engaged closely with the provincial, district and commune-level authorities, in addition to technical and international organizations. FIT partners included: the National TB Program, the Viet Nam Association Against TB and Lung Disease (VATLD), Clinton Health Access Initiative (CHAI), and the Ho Chi Minh City Public Health Association (HPHA).