Remote monitoring of XpertW MTB/RIF testing in Mozambique: results of programmatic implementation of GxAlert

INT J TUBERC LUNG DIS 20(3):335–341
Q 2016 The Union
http://dx.doi.org/10.5588/ijtld.15.0535
Remote monitoring of XpertW MTB/RIF testing in Mozambique:
results of programmatic implementation of GxAlert
J. Cowan,* C. Michel,* I. Manhi¸ca,† C. Mutaquiha,† C. Monivo,* D. Saize,* J. Beste,* J. Creswell,‡
A. J. Codlin,‡ S. Gloyd*
*Health Alliance International, Seattle, Washington, USA; †
Mozambican National Tuberculosis Control Programme,
Maputo, Mozambique; ‡
Stop TB Partnership, Geneva, Switzerland
S U M M A R Y
S E T T I N G : Electronic diagnostic tests, such as the
Xpertw MTB/RIF assay, are being implemented in
low- and middle-income countries (LMICs). However,
timely information from these tests available via remote
monitoring is underutilized. The failure to transmit real-
time, actionable data to key individuals such as
clinicians, patients, and national monitoring and evalu-
ation teams may negatively impact patient care.
O B J E C T I V E : To describe recently developed applica-
tions that allow for real-time, remote monitoring of
Xpert results, and initial implementation of one of these
products in central Mozambique.
D E S I G N : In partnership with the Mozambican National
Tuberculosis Program, we compared three different
remote monitoring tools for Xpert and selected one,
GxAlert, to pilot and evaluate at five public health
centers in Mozambique.
R E S U LT S : GxAlert software was successfully installed
on all five Xpert computers, and test results are now
uploaded daily via a USB internet modem to a secure
online database. A password-protected web-based inter-
face allows real-time analysis of test results, and 1200
positive tests for tuberculosis generated 8000 SMS result
notifications to key individuals.
C O N C L U S I O N : Remote monitoring of diagnostic plat-
forms is feasible in LMICs. While promising, this effort
needs to address issues around patient data ownership,
confidentiality, interoperability, unique patient identifi-
ers, and data security.
K E Y W O R D S : tuberculosis; monitoring and evaluation;
linkage to care; mHealth; eHealth; Xpert
OVER THE LAST DECADE, two major information
and communication revolutions have begun that have
the potential to transform how we deliver health care,
particularly in low- and middle-income countries
(LMICs). The first is the rapid spread of cell phone
and data transmission networks around the world,
and especially in LMICs.1 The second revolution is
the advent of affordable server- or Cloud-based
databases and sophisticated big data analysis. These
developments have spurred a growing interest in
mHealth, which is defined as using mobile devices,
such as mobile phones, personal digital assistants and
other wireless devices to improve health care deliv-
ery.2 Several studies have shown that specific
mHealth technologies are able to improve health
programs and outcomes in LMICs.3–6 For example,
mHealth programs have shown modest effects in
improving tuberculosis (TB) screening, linkage to
care, treatment initiation, medication adherence, and
follow-up clinic appointments.7–13 Although TB is a
priority disease, as prompt treatment of pulmonary
cases is necessary to prevent transmission, in most
LMICs laboratory and treatment results are recorded
in a paper registry and compiled on a monthly or
quarterly basis.
TB disease management is one of the many health
care delivery lines that could benefit from improved
Information and Communication Technologies
(ICTs). One of the most promising advances in TB
care is the recent advent of molecular diagnostic tools
for Mycobacterium tuberculosis and for drug resis-
tance. The Xpertw MTB/RIF assay (Cepheid, Sunny-
vale, CA, USA) is a highly sensitive, rapid, fully
automated molecular test that uses real-time poly-
merase chain reaction on sputum specimens to
simultaneously detect M. tuberculosis and to screen
for rifampin (RMP) resistance, a strong marker for
multidrug-resistant TB (MDR-TB).14,15 Xpert was
first recommended by the World Health Organization
(WHO) in 2010, and has been widely deployed in
LMICs.16–18
The WHO, the Foundation for Innovative New
Correspondence to: James Cowan, Health Alliance International, Suite 350, 1107 NE 45th
Street, Seattle, WA 98105, USA.
e-mail: jcowan22@uw.edu
Jason Beste, Health Alliance International, 1959 NE Pacific St, Seattle, WA 98195, USA. e-mail: bestej@uw.edu
Article submitted 16 June 2015. Final version accepted 29 September 2015.

Diagnostics, TB REACH and several for-profit
diagnostic companies are investing in mHealth
connectivity solutions for Xpert in LMICs that lack
well-developed Laboratory Information Systems
(LIS) or Electronic Medical Records (EMR). Within
the past 3 years, three new remote monitoring
solutions have been developed that use Cloud-based
technologies to disseminate real-time Xpert test
results. These innovative solutions include Remote-
Xpert (Cepheid), GxAlert (SystemOne, Boston, MA,
USA), and XpertSMS (Interactive Health Solutions,
Karachi, Pakistan). These technologies have the
potential to improve patient treatment, such as
linkage to care in the TB care cascade, programmatic
monitoring and evaluation of test results and key
indicators, and logistics management of Xpert
cartridges and machine performance/maintenance.
This paper compares these three remote monitoring
platforms and describes in detail our experience
implementing GxAlert in Mozambique.
SETTING
Disease context
In 2013, an estimated 9 million people developed
active TB and 1.5 million died; however, only 6.1
million received a diagnosis, started appropriate
treatment and were reported to National TB Pro-
grams (NTPs).19 Of the new TB cases diagnosed each
year, a growing number, approximately 480 000, are
thought to have MDR-TB, which is a much more
challenging disease to diagnose, treat, and cure. In
2013, 137 000 patients were diagnosed with MDR-
TB, yet only 87 000 started treatment and just 40 000
were cured.19 These statistics highlight the major
leakage points within the TB and MDR-TB care
cascade.
Country context
Mozambique is one of the world’s 22 high TB burden
countries. The WHO estimated the TB incidence rate
in Mozambique at 552 per 100 000 population in
2013, i.e., about 140 000 cases.20 However, only
37% of these estimated cases are diagnosed and
notified; 56% of TB patients in Mozambique are co-
infected with the human immunodeficiency virus
(HIV).20 In 2013, an estimated 3.5% (n ¼ 4900) of
the 140 000 new TB cases in Mozambique had MDR-
TB; however, only 313 patients (~6.4%) with MDR-
TB started treatment.21 Given the increasing preva-
lence of MDR-TB and the global threat of this
disease, improved MDR-TB diagnostics and access to
treatment are a priority for the Mozambican NTP
and the global health community. Xpert testing pilot
projects began in 2011 in Mozambique, and currently
an estimated 35 Xpert machines have been imple-
mented throughout the country, including five in
central Mozambique.21
Mozambique has a well-established NTP. Labora-
tory results for TB testing are kept in handwritten
registries at each health center, compiled by hand and
reported on a quarterly basis to provincial and
national level. Mozambique does not currently have
an electronic register for cough, laboratory results
(for smear microscopy or Xpert), or patient records.
As a result, the first GeneXpert machines installed in
Sofala and Manica did not have internet connections,
and were not networked. Despite being on a
computer, Xpert results were extracted manually
from each site, compiled, and reported quarterly. This
impeded real-time, effective oversight of the Xpert
testing program on a national level, and hindered
effective management of the expensive cartridge
inventory. Furthermore, MDR-TB provincial leaders
were frequently not notified about RMP-resistant
patients in a timely manner, and almost half of these
patients were not started on appropriate treatment
for MDR-TB.21
MATERIALS AND METHODS
The NTP sought to develop a remote monitoring
system for the growing GeneXpert network in
Mozambique, much like the online system used by
the Mozambican HIV program to monitor testing
with the Alere PIMAe CD4 machines (Waltham,
MA, USA). The NTP, with support from Health
Alliance International (HAI; Seattle, WA, USA), an
implementing partner, deployed five Xpert machines,
each with four modules, at the principal district (n ¼
2) and urban (n ¼ 3) public hospitals in Sofala and
Manica Provinces, beginning in February 2012.
Details of this process, the testing algorithm, and
monitoring are described elsewhere.21 The NTP
worked with HAI to develop a target product profile
in late 2013 for a remote monitoring platform and to
research and evaluate three connectivity solutions to
pilot for the growing GeneXpert network in Mozam-
bique with support from a TB REACH grant.
We evaluated three remote monitoring platforms
for GeneXpert: Cepheid RemoteXpert, XpertSMS,
and GxAlert (Table 1). Cepheid plans to release
RemoteXpert in 2015.22 Overall, we determined that
GxAlert was the best fit for Mozambique. GxAlert
was originally designed to create an Xpert network in
countries where EMR or LIS are not widely available.
Unlike XpertSMS, GxAlert incorporates a user-
friendly interface that does not require EMRs or an
LIS to analyze data. The GxAlert platform extracts
information from Xpert and sends it to a secure
Cloud-based or in-country server. We also wanted a
product that would allow for the transmission of
patient health information, which is particularly
important for local ministries so that they can
generate reports and ensure that patients who test
positive for M. tuberculosis, and especially for RMP
336 The International Journal of Tuberculosis and Lung Disease

resistance, are treated appropriately—this was re-
portedly not going to be possible using Cepheid’s
RemoteXpert system. As a third party platform,
GxAlert was attractive because it offered the possi-
bility of uploading results from other diagnostic
platforms not made by Cepheid, such as Alere PIMA,
M. tuberculosis culture, etc.
The Mozambican Ministry of Health (MOH)
approved Xpert for general use and the NTP
approved this pilot and subsequent expanded imple-
mentation of GxAlert. As this implementation project
was not a formal research study, the University of
Washington (Seattle, WA, USA) institutional review
board (IRB) declined to provide a full review of the
proposal.
RESULTS
GxAlert installation on Xpert computers
We first used commercially available USB internet
modems to confirm that each GeneXpert computer
could connect to the internet. We then performed a
one-time installation of OpenVPN (OpenVPN Tech-
nologies, Pleasanton, CA, USA) on each GeneXpert
computer, and entered a unique data encryption key.
This process allows Xpert results to be encrypted
during transmission via Cepheid’s LIS connector to a
secure, HIPAA (Health Insurance Portability and
Accountability Act) compliant, Cloud-based data-
base.23 Xpert software ‘Host Communication’ set-
tings were then changed to make sure that the Xpert
results were directed to the appropriate internet
protocol address associated with the secure GxAlert
database and to automatically upload all recent test
results every time the Xpert diagnostic software
detected a viable internet connection.23
Establishing the GxAlert web-based interface
We worked with SystemOne to develop a unique,
password protected, web-based portal for the Mo-
zambique GxAlert pilot project. In partnership with
the NTP, we identified a list of users —the Mozambi-
can provincial and national level MOH laboratory
and NTP staff— who were given a secure login and
password to review summary and individual Xpert
results, and defined the scope of their access —
district, provincial or national level data —and if they
could see patient-identifying information. We also
created a database of ‘contacts’, primarily laboratory
technicians and TB treatment nurses at each facility,
Table 1 Comparison of three remote monitoring tools for XpertW MTB/RIF
Features
Cepheid remote Xpert
monitoring tool* XpertSMS GxAlert
Secure data transmission and
storage
Yes Yes Yes
Location of data server Cepheid secure Cloud Secure Cloud or in-country
server
Secure Cloud or in-country
server
Ability to transmit patient
identifying data†
No Yes Yes
Uploads data automatically once
connected to the internet
Yes Yes Yes
Compatible with OpenMRSW EMR No Yes Easily connectible‡
Supports automated SMS to health
care providers
No Yes, used with OpenMRSW or
other EMR
Yes
Allows uploading of data from
different diagnostic companies
No Yes Yes
Can be configured to generate
automatic reports
Yes Yes if used with OpenMRS,
GxAlert or other EMR
Yes
Availability March 2015 Now Now
Estimated cost Free to low-income countries
but only for GeneXpert
machines that have an active
service and warranty package
Software is open source and
free, additional fees for
formal technical support if
desired
Software is open-source and
free, additional fees for
formal technical support if
desired
Developed by a third party relative
to Cepheid
No Yes Yes
Requires internet connection Yes, may require wired ethernet No§
Yes
Xpert cartridge inventory
management tool
Possibly¶
No¶
Yes
Allows downloading of all patient
and test results into Excel or csv
file
No Yes Yes
* Not available at time of submission. Data regarding Cepheid remote monitoring tool based on e-mails and personal communication with platform developer and
Cepheid data management team.
†
Allows for upload of data from Patient ID, Sample ID or Notes field. Patient ID could be entered in this field, but not always (one can use a unique patient
identifying number).
‡
One can develop a system for GxAlert to communicate with electronic medical records with existing or easily modifiable APIs. An API was recently released to
create interoperability between XpertSMS, GxAlert, and GenXChange.
§
XpertSMS allows results to be sent to the server either from SMS or internet.
¶
But inventory management could also be done outside the system, or in GxAlert.
SMS ¼ short message service; EMR ¼ Electronic Medical Records; API ¼ application programming interface.
Implementing GxAlert in Mozambique 337

and entered their cellphone and e-mail addresses, but
did not provide them with access to the online
database. Finally, we developed key tabs within
GxAlert so that users could 1) review a summary
page; 2) review the performance of each device (error
rates, kinds of errors, numbers of tests run per time
period, summary of positive and negative test results);
3) access individual test results; 4) access the cartridge
management tool; 5) develop and edit automated
SMS and e-mail notifications; and 6) add, delete or
edit contacts and users (see Results for examples).
Development of automated SMS and e-mail messages
We developed four specific automatic SMS messages
(without patient identifying information) with the
Mozambican NTP and SystemOne, which were
triggered by the following events: 1) an SMS message
to local laboratory technicians and TB nurses when
an M. tuberculosis-positive, RMP-susceptible patient
result was uploaded to GxAlert; 2) an SMS message
to local laboratory technicians and TB nurses when
an M. tuberculosis-positive, RMP-indeterminate pa-
tient result was uploaded; 3) an SMS message to local
laboratory technicians, local TB nurses, the provin-
cial MDR-TB point person, and the national MDR-
TB point person when an M. tuberculosis-positive,
RMP-resistant patient result was uploaded; 4) and
finally, an SMS message to local laboratory techni-
cians when they had not connected the GeneXpert
machine to the internet and sent results to GxAlert for
more than 3 days. Examples of these messages can be
seen in Appendix Figure A.1.*
We also created a monthly and quarterly summary
Excel file with the following indicators: 1) the total
number of Xpert tests performed at each site; 2) the
average number of tests run per day; 3) the total
number and percentage of M. tuberculosis-positive
Xpert tests by RMP resistance status at each site; 4)
the total number and percentage of failed tests at each
site; 5) the types of error results at each site; 6) the
estimated number of Xpert cartridges remaining at
each site; and 7) based on actual Xpert usage rates,
the predicted date at which each site will run out of
cartridges to aid in replenishing stock and to avoid
expiry of unused cartridges.
GxAlert results
GxAlert software was successfully installed on all five
GeneXpert machines in June 2014. To date, more
than 29 000 Xpert test results have been uploaded to
GxAlert (see Table 2), including five additional Xpert
testing sites recently connected in Southern Mozam-
bique and linked to GxAlert. Since July 2014, 13 000
new test results have been uploaded in GxAlert, more
than 2000 of which were M. tuberculosis-positive.
These have resulted in more than 8000 SMS
notifications to key personnel, including laboratory
staff, TB nurses, and NTP managers, notifying them
about patients who tested positive for M. tuberculo-
sis, and the results of RMP resistance testing
(Appendix Figure A.2): 44 individuals were entered
as users, and 45 as contacts, 35 of whom have logged
into GxAlert and 15 of whom logged in during the 30
days before 18 March 2015. Several important
challenges noted during this process are described in
Table 3.
GxAlert interface
Overall, the preliminary anecdotal reports of the
GxAlert online interface were positive, but have not
been systematically collected or analyzed. Initially,
GxAlert was only available in English, but it has
recently been translated into Portuguese, the official
language of Mozambique. It was relatively simple to
work with the product developers to change the
online interface, modify SMS alerts, manage users/
contacts, and to generate automated monthly and
quarterly e-mail reports. Appendix Figures A.3 and
A.4 provide representative images from the online
GxAlert platform.
Table 2 Xpert results by health facility
Xpert site
Total
tests
n
M. tuberculosis
n (%)
MTBþ/
RIFÀ
n
MTBþ/
RIFÀ
%
MTBþ/RIFÀ
indeterminate
n (%)
MTBþ/RIFþ
n, % of all
TB tests
Invalid
n
Errors
n
Test invalid/
error
%
Gaza: Xai Xai 454 310 (68) 99 22 1 (0.2) 18 (15) 6 20 6
Gaza: Chokwe 239 189 (79) 28 12 0 (0) 4 (13) 10 8 8
Gaza: Manjacaze 533 407 (76) 84 16 3 (0.5) 13 (13) 19 7 5
Manica: Ed Mondlane 4729 3820 (80) 556 12 45 (0.1) 34 (6) 104 170 6
Manica: Gondola 3404 2646 (78) 384 11 27 (0.7) 23 (6) 53 271 10
P Maputo: Boane 389 282 (72) 56 14 10 (3) 17 (23) 1 23 6
P Maputo: Machava 2 662 435 (66) 162 24 10 (1.5) 34 (17) 5 16 3
Sofala: Ponta Gea 4574 3464 (76) 688 15 33 (0.7) 39 (5) 85 265 8
Sofala: HC Beira 9078 7065 (78) 1281 14 76 (0.8) 141 (10) 150 365 6
Sofala: Nhamantanda 5185 4221 (81) 501 10 28 (0.5) 75 (13) 127 233 7
Total 2947 22 839 3839 233 398 560 1378 7
MTB ¼ M. tuberculosis; RIFþ¼ rifampin resistance; RIFÀ¼ rifampin-susceptible.
* The appendix is available in the online version of this article, at
http://www.ingentaconnect.com/content/iuatld/ijtld/2016/
00000020/00000003/art00012.

DISCUSSION
Overall, the installation of GxAlert was moderately
complex, but ultimately successful at all of our sites.
To simplify the installation process and to ensure that
‘incomplete’ test results (those that were terminated
due to electrical outages, but which Cepheid does not
currently allow to be sent via the LIS) were
transmitted, SystemOne recently created a simpler
one-click installation package. This product over-
comes the Cepheid LIS connector limitation and
transmits all results (including those that are incom-
plete), and uses a secure application programming
interface to encrypt transmission of data to the on-
line server, eliminating the need to install Open VPN.
This new product requires additional testing, but
should further improve the reliability and security of
the Xpert network in Mozambique.
As noted in Table 3, we experienced a variety of
internet connectivity challenges that our team and
internet providers need to address to take full
advantage of this platform. Furthermore, we would
like to create a system where GeneXpert computers
are constantly connected to the internet and the
results are uploaded immediately and automatically,
thereby removing the need for laboratory technicians
to actively connect each day. We are currently in the
process of developing and piloting several solutions to
these issues in Mozambique. With the exception of
HIV patients, Mozambique does not currently have
unique patient identifiers, which makes trying to
reconcile TB testing data to TB treatment data
challenging, especially if the patients are diagnosed
at one site and treated at another.
In 2015, Cepheid released version 4.6a of the
Table 3 Responses to technical and logistical challenges encountered when implementing GxAlert for remote monitoring of XpertW
MTB/RIF in Mozambique
Challenge Reason Response
Software installation Complex, multistep process requiring moderate to
sophisticated computer skills
Provide additional training to HAI and NTP staff, step-
by-step job aids
SystemOne has developed a simplified one-click
installation software package called GxConnect
(Itec, Gauteng, South Africa) that transmits results
to GxAlert with a secure API, eliminating the need
to install and use the OpenVPN software
Internet connectivity One site did not have adequate USB modem signal
strength
We were able to utilize a local cable modem internet
connection used by another project
Variable internet signal strength with different cell
phone companies
Trial USB modems with different cell phone
companies and use the one with the best and most
consistent signal
GxAlert online access
and utilization
Some MOH staff lost the website address, login and
password
Continue to send reminders to review Xpert data
We are developing a tracking tool within GxAlert to
see which MOH staff are logging into the system
and how frequently, and will provide targeted
feedback and outreach to those that are
underutilizing the program
Lusophone staff struggling
with English software
Software was initially only available in English We created automatically generated SMS and e-mail
reports in Portuguese
We worked with GxAlert to translate the web-based
interface into Portuguese
GxAlert only uploads results
from Xpert
Other diagnostic platforms are not currently designed
for remote monitoring
We are exploring the ability of other platforms such
as the Alere PIMAE system, MIDGET TB culture
and others to upload results into GxAlert
Paying for internet
connectivity
Commercial modems allow laboratory technicians
not only to upload Xpert results to GxAlert, but
also to access the internet
We are exploring ways to lock the modems, uninstall
web browsers, and to effectively monitor
appropriate utilization of Xpert computers and
internet connections
Daily internet connection Internet cell phone networks are frequently
overwhelmed during business hours, or
inaccessible
Connect to the internet early or late in the day when
there is less traffic, allowing for rapid result uploads
Develop systems that will allow Xpert to be
connected constantly to the internet via a USB
modem, allowing for real-time transmission of
results instead of requiring an individual to connect
to a modem each day
Underreporting of failed
Xpert tests
It appears that Cepheid does not currently allow the
transmission of ‘incomplete’ Xpert tests via the
LIS—this category of results appears to primarily
include those tests that were not completed due to
electrical outages, a not infrequent problem at our
sites
Further study this problem, and work with Cepheid
to allow for the transmission of these ‘incomplete’
test results via the LIS
SystemOne’s new software package, GxConnect,
overcomes the Cepheid LIS software obstacle and
allows the transmission of these ‘incomplete’ test
results
Managing digital database Limited resources of MOH to manage and oversee
digital information
Provide training and resources for MOH officials to
manage this system and digital information
HAI¼Health Alliance International; NTP¼National Tuberculosis Program; API¼application programming interface; MOH¼Mozambican Ministry of Health; LIS¼
Laboratory Information Systems.

GeneXpert DX software that is used on GeneXpert
machines. While this software update included many
improvements, it blocked a few important data fields
utilized by GxAlert and other LIS connectors. Some
programmatic monitoring and evaluation (M&E)
efforts were therefore interrupted. After receiving
feedback from programs and partners, Cepheid
pledged to reinstate the blocked fields with their next
software release.24 This episode highlights the im-
portance of having new diagnostics that are increas-
ingly connected, but that are designed in partnership
with the programs to align with public health
standards of data publication/transmission and best
practice. If done well, it can foster a closer
relationship between device makers and users both
to drive consumption and to best serve patients.
This project helped to highlight the need for LMICs
to develop comprehensive patient data management
strategies, and to determine how they want to
consume mHealth data. In particular, LMICs need
to address issues such as data security, data transmis-
sion, data storage, data ownership, interoperability
between different databases and systems, the need for
unique patient identifiers, and the growing need to
provide internet access at health care facilities to
facilitate real-time communication of test results.
Failure to address these challenges may lead to
significant fragmentation and may impede efficient
patient care and hinder effective M&E.
As products offer different advantages and disad-
vantages, it may be useful to use two or more
products in parallel instead of one. For example,
GxAlert is easier to use for monitoring and evaluating
patient information, MOH supply chain and logis-
tics, and external quality assurance programs, while
RemoteXpert provides better technical support, as
the GeneXpert machines can be monitored by their
manufacturer. This field continues to change rapidly,
and it is also possible that Cepheid may decide to
allow the transmission of patient health information,
which would make their product more attractive.
While this was not a formal research project, there
is a need to evaluate the impact of these remote
monitoring tools on patient care (appropriate treat-
ment initiation rates, time to treatment initiation),
and M&E efforts, and to understand how front-line
and national TB health care workers currently use
and want to use this platform. We are in the process
of undertaking a formal IRB-approved evaluation of
GxAlert in Mozambique to see if it has any impact on
patient care.
In conclusion, remote monitoring of electronic
diagnostic platforms is feasible in LMICs and has the
potential to be part of the ICT backbone for the next
generation of TB control strategies.
Acknowledgements
The authors would like to thank TB REACH, the Stop TB
Partnership, UNITAID, and the Canadian Department of Foreign
Affairs, Trade and Development (Ottawa, ON, Canada) for their
financial support; and Health Alliance International (centre within
the Department of Global Health University of Washington,
Seattle, USA); A Mondlane, C Mutaquiha, T dos Santos, M A
Cumba (Mozambique National TB Control Program); I Pinto
(National), Z Gondar (Sofala), R A Cebola (Manica) (Mozambique
Laboratory Program); S Viegas, I Filimone (Mozambique National
Reference Laboratory); and ABT Associates (Cambridge, MA,
USA) and SystemsOne for designing and developing GxAlert.
Conflicts of interest: none declared.
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non-communicable diseases in sputum producing adult
inpatients. PLoS One 2012; 7: e40774.
16 World Health Organization. Rapid implementation of the
Xpert MTB/RIF diagnostic test: technical and operational
‘how-to’ practical considerations. WHO/HTM/TB/2011.2.
Geneva, Switzerland: WHO, 2011.

17 Global Laboratory Initiative. Advances in TB diagnostic
services: transforming TB care and control. Geneva,
Switzerland: World Health Organization, 2013: pp 1–2.
18 UNITAID. Tuberculosis diagnostic technology and market
landscape. 3rd
ed. UNITAID, 2014.
19 World Health Organization. Global tuberculosis report, 2014.
WHO/HTM/TB/2014.08. Geneva, Switzerland: WHO, 2014.
20 World Health Organization. Mozambique TB Report, 2013.
Geneva, Switzerland: WHO, 2013.
21 Cowan J, Michel C, Manhi¸ca I, et al. Implementing rapid
testing for tuberculosis in Mozambique. Bull World Health
Organ 2015; 93: 125–130.
22 Interactive Health Solutions. Xpert SMS automated reporting
of GeneXpert results. Karachi, Pakistan: IHS, http://www.
ihsinformatics.com/xpert-sms. Accessed November 2015.
23 Abt Associates. The GxAlert Initiative: connecting rapid TB
diagnosis with a faster health system response for better health
outcomes. Cambridge, MA, USA: http://www.abtassociates.
com/AbtAssociates/files/be/be800553-1a76-4d3b-aa9b-
13ce2b86babb.pdf Accessed November 2015.
24 Foundation for Innovative New Diagnostics. Memo:
Information regarding restrict data in GeneXpert device
software 4.6. Geneva, Switzerland: FIND, 2015.

APPENDIX
Figure A.2 SMS alert trends for GxAlert in Mozambique. SMS ¼ short message service.
Figure A.1 GxAlert SMS notifications. NIMR¼National Institute for Medical Research; NTP¼National Tuberculosis Program; ASAP¼
as soon as possible; SMS ¼ short message service.
Implementing GxAlert in Mozambique i

Figure A.3 GxAlert dashboard for all Xpert testing.
Figure A.4 Dashboard for individual Xpert machine.
ii The International Journal of Tuberculosis and Lung Disease

R E S U M E
C O N T E X T E : Les tests de diagnostic électronique,
comme Xpertw MTB/RIF, sont en cours de mis en
œuvre dans les pays à revenu faible et moyen (LMIC).
Cependant, les résultats rapides qui pourraient être
obtenus par un suivi à distance sont sous-utilisés. Le fait
de ne pas transmettre en temps réel des données
décisionnelles aux personnes clés comme les cliniciens,
les patients et les équipes nationales de suivi et
d’évaluation peut avoir un impact négatif sur la prise
en charge des patients.
O B J E C T I F : Décrire les applications récemment
développées qui permettent un suivi en temps réel à
distance des résultats de l’Xpert et la mise en œuvre
initiale de l’un de ces produits au centre du
Mozambique.
S C H E´ M A : En partenariat avec le Programme National
de lutte contre la Tuberculose du Mozambique, nous
avons comparé trois outils différents de suivi à distance
de l’Xpert et nous en avons sélectionné un, le GxAlert,
pour le piloter et l’évaluer dans cinq centres de santé
publics du Mozambique.
R E´ S U LTAT S : Le logiciel GxAlert a été installé avec
succès dans les cinq ordinateurs Xpert et les résultats des
tests sont maintenant téléchargés tous les jours grâce à
un modem USB vers une base de données sûre en ligne.
Une interface web protégée par un mot de passe permet
une analyse en temps réel des résultats des tests et 1200
tests positifs pour la tuberculose ont généré 8000
notifications de résultats par SMS aux personnes
concernées.
C O N C L U S I O N : Le suivi à distance des plateformes de
diagnostic est faisable dans les LMIC. Même s’il est
prometteur, cet effort doit aborder les questions relatives
à la propriété des données par le patient, à la
confidentialité, à l’interopérabilité, aux identifiants
uniques pour chaque patient et à la sécurité des données.
R E S U M E N
M A R C O D E R E F E R E N C I A: Las técnicas informatizadas
de diagnóstico de la tuberculosis (TB), como la prueba
Xpertw MTB/RIF, se han introducido en los pa´ıses con
bajos y medianos recursos (LMIC). Sin embargo, aún se
subutiliza la información oportuna que podr´ıan aportar
gracias a la supervisi ón a distancia. El omitir la
trasmisión inmediata de la información con utilidad
cl´ınica a los principales interesados como los médicos,
los pacientes y los equipos nacionales de evaluación y
seguimiento puede tener consecuencias negativas en la
atención a los pacientes.
O B J E T I V O: Describir las aplicaciones desarrolladas
recientemente que hacen posible un seguimiento
inmediato y a distancia de los resultados de la prueba
Xpert y evaluar la introducci ón de uno de estos
dispositivos en la zona central de Mozambique.
M E´ T O D O S: En colaboración con el Programa Nacional
contra la Tuberculosis de Mozambique, se compararon
tres dispositivos diferentes de seguimiento a distancia de
la prueba Xpert y se escogió el programa GxAlert, con el
fin de realizar un estudio preliminar y evaluar cinco
establecimientos públicos en el pa´ıs.
R E S U LT A D O S: El programa GxAlert se instal ó
adecuadamente en los cinco computadores dedicados a
la prueba Xpert y ahora es posible colgar los resultados
de la prueba a una base de datos segura en l´ınea, por
conducto de un módem USB. En la web, una interfaz
protegida por contraseña permitió analizar de manera
inmediata los resultados de la prueba y los 1200
resultados positivos para TB generaron 8000 SMS de
notificaci ón de los resultados a los principales
interesados.
C O N C L U S I O´ N: El seguimiento a distancia de las
plataformas diagnósticas es factible en los LMIC. Esta
iniciativa es promisoria, pero quedan por solucionar
aspectos relacionados con la propiedad de los datos del
paciente, la confidencialidad, la interoperabilidad, los
identificadores únicos de los pacientes y la seguridad de
los datos.
Implementing GxAlert in Mozambique iii

Remote monitoring of XpertW MTB/RIF testing in Mozambique: results of programmatic implementation of GxAlert

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