5) Description of health product/service offering: Tuberculosis control programs in Africa loose grip on the emerging TB epidemic, especially because of the co-relationship with HIV/AIDS. Public Health community lacks a fast, cheap and reliable screening tool for early detection. However, if detected in an early stage - even in HIV positive people - patients can cure from the TB. In order to reach vulnerable African populations, we need a non-invasive and rapid diagnostic test, suitable for use in an active case finding strategy, that can be used at low cost by operators with a lower level of skills. The primary beneficiaries are vulnerable urban populations, crowded in poorer neighbourhoods of African cities. They have a higher risk to contract TB, seen their poor living conditions, and higher HIV prevalence. The suggested technologgy is suitable for use in an active case finding strategy, as a first line screening tool, to fast assess TB prevalence, and refer to second line TB control programs. Infected but undiagnosed TB patients spread the disease to an average of 15 persons/ year. Detecting especially these cases in an active case finding strategy may become key in curbing the TB/HIV epidemic. It has been proven that, once treatment has started, patients do not infect others anymore. With this method, which is already popular in Tanzania even before clinical tests have occured, a sustainable technology is proposed for the poorest and most vulnerable African populations.

6) Description of innovation: In general, rats are seen as a vernim. However true, rats have also less known characteristics: if well maintained and domesticated, rats are very social creatures, with an extremely keen nose. Based on this extreme olfactory sense, giant African pouched rats can be trained as cheap, reliable and fast biosensors for humanitarian detection purposes: detection of buried landmines and pulmonary tuberculosis. Rats as detectors have many logistic advantages: they are easy to train, cheap to maintain, they reproduce easily, they can be transported in big numbers at low cost, they are resistent to most tropical diseases, and they are very suitable for repetitive olfactory tasks in an automated setup. Detection rats pose an empowering and sustainable alternative to expensive technologies that require expertise from abroad. Training rats does not require a high level of skills in the operators, and the use of rats as a medical diagnostic tool in an African setting also poses many advantages: they can process big volumes of samples in a short time, produce almost immediate results, they don't require power nor refrigeration, they can be used in combination with a non-invasive sampling technique (currently used sputum is suitable - although APOPO plans to develop a simple breath sample) and they can be brought to the people, rather then passively wait for TB infected persons to be so ill that they finally report to a health center, while in the meantime infecting many others. This approach has been proven successful in a different thematic domain: the detection of buried landmines, which has now been unanimously adopted as a priority approach in humanitarian demining by the 11 Great Lakes Region countries.

7) Operational model: With a 1 year grant that was provided by the World Bank's Development Marketplace competition, APOPO has been able to provide proof of principle of the technique. However, more experiments are needed to further this promissing tool for use in the public health sector. APOPO focuses especially on this R&D aspect, while the relevant instittutions in Tanzania have already shown their keen interest to deploy the technique within the TB control program. If funding for this approach can be found, further planned experiments in the immediate future include: 1. Establishing the detection treshold M.TB for sniffer rats, 2. A specificity experiment in which rats will be exposed to a variety of Mycobacteria, prevalent in Tanzania (especially M.Bovis and M.Avium), and 3. investigation of what volatile compounds of Mycobacteria the animals are discriminating. In terms of product development, APOPO plans to develop a simple non-invasive breath sample, suitable for use in an active case finding strategy, and development of a mobile screening unit, to reach out to populations in slums and e.g. refugee camps to actively find TB cases among these especially vulnerable target groups. Beside the relevant government institutions that APOPO already works with, several NGO's have also shown an interest to deploy the technique.

8) Human resources: At this stage, there is just a small research group developing the tool. This group consists of a 2 researchers, a training supervisor, 4 animals trainers, 1 lab technician, and 2 logistic support personnel. Besides this staff, the project relies on the organizational capacity of SUA-APOPO, situated at Sokoine University. This involves co-ordination by SUA professors with the relevant health institutions, and technical support from the landmine detection staff (the landmine detection application is at this stage scaling up and already operational with 18 accredited teams in Mozambique). Furthermore, external reviewers from the co-operating institutions are monitoring and evaluating the project.

9) Key operational partnerships: APOPO is based at the Sokoine University of Agriculture (200 km from the capital Dar Es Salaam) and co-operates with the National Institute for Medical Research, and the National Tuberculosis and Leprosy Program within the Ministry of Health. Morevover, the project is externally monitored by the Royal Tropical Institute in Amsterdam, Netherlands, the Max Planck Institute in Berlin, and by the Antwerp University, Belgium. In Tanzania, APOPO is provided on a weekly base with 500-1000 sputum samples from 4 urban health centers in Dar Es Salaam. Already in this pre- operational stage, APOPO's HeroRATS indicate TB-patients that have been missed in the peripheral health centers by using standard sputum microscopy. APOPO relies on the Tuberculosis reference laboratory at Muhimbili hospital in Dar Es Salaam for preparation of cultures that serve as a gold standard.

10) Financial Sustainability

          • Fees charged to clients?: No

          • How do you assure affordability?: Later, when the project will be operational, it is imaginable, seen the high mediatic and sensational degree of the approach, that rats will be an attraction to slum dwellers that want to find out how their TB status is. If we observe how popular the mine detection rats are in the media, we can anticipate that urban populations will be ready to pay a very little sum (e.g. in the magnitude of 0,1 USD) to get their sample analysed, if they can watch the animals at work. In this way, the approach may have at once an educational aspect and a public health control aspect.

          • Earned incomes as a percentage of operating costs: 0

          • Other funding sources: At this stage the project has been provided a small sum by an anonymous donor, that allows to keep the animals in training, and to collect samples continuously. This is however insufficient to conduct the planned experiments. Neverhteless, several proposals are pending, and the project hopes that at least one of these proposals will be granted.

          • Strategy for long-term sustainability: If the project manages to secure the funding for the required additional R&D, it is assumed that the approach will be integrated in the national public health control program, seen its many advantages. If above mentioned strategy proves successful, the project may even be profitable, and generate resources for other humanitarian spin-off applications, like detection of arms and explosives or other contraband in cargo at border crossings, environmental detection of pollutants and toxins, etc.

11) Current and Future Impact

          • Total number of clients: n/a

          • Clients in the past year: n/a

          • Percentage of low-income clients: 100

          • Impact: impact N/A yet

          • Overall "market": All African countries with a functioning public health system may benefit from this approach, and may, once validated and accredited, adopt it. This is hard to quantify at this stage, but obviously the potential is huge. Moreover, the application of TB detection is only a starting point in the medical realm. Many other diseases may qualify for olfactory vapour detection. Some examples: diabetes, a variety of cancers, etc. APOPO has developed a breeding program for this specific African rat (that lives 6-8 years in captivity and thus gives a good return on the initial training investment) a simple evaluation setup, that can be manufactured anywhere, a standardised training protocol that is suitable for ANY target scent, a data management system, that allows permanent monitoring and evaluation of the performances of the animals, and standard operational procedures for the use of this technology, which can be easily assimilated. As menitoned earlier, many other spin-off applications are at the horizon. The potential is not limited to Africa alone. Recently, a landmine detection rats project has started in Colombia, a Latin American country facing a severe mine problem.

12) Scaling up strategy

          • Stage of the initiative: Start Up stage.

          • Expansion plan: If funding can be secured, in the coming three years the project should be able to do the necessary additional experiments, test and validate the technology in the real world, and be ready for deployment. In the first two years, we will not focus on quantity, but rather on quality: assuring all the necessary factors are in place to allow a smooth scaling up. This will include, besides above mentioned experiments, the development of a simplified breath sample, that is less cumbersome for a patient to produce than a sputum sample, that avoids cross contamination between samples (current standard WHO sputum containers do leak) and that contains much less infectious materials, and is thus safer to handle for the operators. We also want to devise a mobile unit, that will allow to bring the technology into the field, to make an active case finding strategy practically possible in an African setting. Such a mobile unit would also be useful for bringing the service to remote areas, where public health service have less coverage, or in refugee camps, where TB thrives in combination with HIV.

13) Policy change: Already Tanzania has one of the best TB control programs in Africa. The government is ready to integrate the approach in the strategic plan of the Ministry of Health, if APOPO manages to validate the technology. Seen the completely different approach, the technology would be used complementarily to the existing services, as a first line screening tool, while refering suspected patients to the standard DOTS programs for follow up. Acceptance with the public opinion is a crucial point in this. But APOPO has crossed that bridge before with its landmine detection rats, that are very well accepted by the general public.

14) Origin of the initiative: This project is my own initiative, as a spin-off to mine detection rats, and because of the omnipresent burden of HIV/AIDS in the environment where I live and work. I believe that the social impact of TB sniffer rats will exceed that of landmine detection rats by far. In 1997, I initiated the APOPO program in response to the global landmine problem. Now, 9 years later, landmine detection rats are an accredited technology that is replicating itself (see e.g. Colombia). I have been driving the idea of TB detection, because I thought it would be possible, seen the fact that people living with TB in an evolved stage spread a specific tar-like smell that even humans can smell. I graduated as an engineer in product development, with a special focus on appropriate technologies for low-income countries. As teenager I had a passion for all kinds of rodents.

Contact Information:
Bart  Weetjens
managing director
APOPO vzw
(NGO)
Belgium
Website: www.apopo.org