DRUG SUPPLY & MANAGEMENT TB CARE I in TB CARE I-supported integrated TB/HIV sites (96%) ... Seven times as many RR-TB cases were ... 81% jump). 7 i Ì Ì ...

Year 4 Highlights | February 2015CARE ITB

Welcome to the 4th edition of the TB CARE I summary report which brings you an overview of TB CARE I achievements,

results and successes in the fourth and final year of the program.

Above - Cured TB patient travelling to hospital for check-up - Indonesia (Photo: TB CARE I)Below - MDR-TB patient - Zimbabwe (Photo: Jeroen van Gorkom, KNCV)

DRUG SUPPLY & MANAGEMENTTOOLS

TB CARE

Medium Investment

Large Investment

Medium/Large Investment

Small Investment

GhanaThe proven TB CARE I intensified hospital-based TB case detection approach has been included in both the new national strategic plan and the Global Fund concept note.

60% more TB patients were diagnosed by private providers in TB CARE I areas in 2013 compared to 2012.

NigeriaEQA performance has been maintained (86%) in TB CARE I areas despite major instability.

South Sudan

TB CARE I supported the development of an epi analysis, the national strategic plan and the single TB/HIV concept note.

Botswana

92% of TB patients in 2013 had an HIV test results recorded in the TB register (76% in 2010).

Namibia

Cotrimoxazole preventive therapy coverage in TB CARE I-supported integrated TB/HIV sites (96%) was well above the national average (77%).

Zimbabwe

External Quality Assessment coverage increased from 39% (Year 3) to 60% (Year 4) in TB CARE I-supported areas.

Mozambique

Treatment success rate improved from 62% in 2009 to 86% in 2012.

Kazakhstan

Case dectection rate increased from 73% (2010) to 91% (2013).

Kyrgyzstan

TB CARE I supported the development of a national strategic plan on pyscho-social support for TB patients.

Uzbekistan

A study showed that migration out of country, moving within country, treatment side effects and being a retreatment patient were significantly associated with loss to follow-up.

Tajikistan

From 2009-2013 case notification increased by 84% in TB CARE I-supported Kabul City

Afghanistan

Seven times as many RR-TB cases were diagnosed with TB CARE I support in 2013 (1,472) than in 2010 (209).

Vietnam

85% of MDR-TB patients (2011) were successfully treated.

Cambodia

Three times as many MDR-TB patients were started on treatment in 2013 (587) than in 2010 (142).

Indonesia

Three times as many MDR-TB cases were diagnosed in 2013 (558) than in 2010 (140).

Ethiopia

TB CARE I-supported Xpert implementation began in Year 4 with 10,951 tests conducted.Zambia

In the fourth and final year of the cooperative agreement with USAID (2010-2015), TB CARE I continued to achieve important results at global, regional, national and local levels. The program implemented 34 new core projects, four regional projects, and 17 country projects. Through these many projects, TB CARE I contributed to three USAID target areas:

r� Sustain or exceed 84% case detection rate and 87% treatment success rate

r� Treat successfully 2.55 million new sputum-positive TB cases

r� Diagnose and treat 57,200 new cases of multi-drug resistant TB (MDR-TB)

CONTRIBUTION TO USAID TARGETS

Since the start of the program, nearly 3.3 million TB V>ÃiÃ�>��v�À�Ã®��>Ûi�Lii��Ì�wi`�>VÀ�ÃÃ�/�Ƃ, ��countries. In 2013, 1,105,653 TB cases (new and Ài�>«Ãi®�ÜiÀi��Ì�wi`��v�Ü��V��x£Î]ÓÓx�ÜiÀi��iÜ�L>VÌiÀ��}�V>��Þ�V��wÀ�i`�«Õ��>ÀÞ�/�V>ÃiÃ°�Case detection rates have improved in 13 TB CARE I countries since the program began, eight of which showed improvement in the last year alone. This year Ghana, Kyrgyzstan and Uzbekistan have surpassed the USAID target of 84%.

TREATMENT SUCCESS:

Treatment success rates remain strong in most TB CARE I countries, with ten countries exceeding the nx¯�-Ì�«�/�Ì>À}iÌ�>�`�wÛi��v�Ì��Ãi�>�Ã��ÃÕÀ«>ÃÃ��}�the 87% USAID target. Improvements between 2011 and 2012 were noted in seven countries. The successful treatment of 861,406 sputum smear positive (SS+) patients from 2010-2011 and 805,266 new and relapse patients in 2012 translates to 65% of the 2014 USAID target of 2.55 million SS+ patients ÃÕVViÃÃvÕ��Þ�ÌÀi>Ìi`��ÛiÀ�wÛi�Þi>ÀÃ°

��Óä£Î]�£Î]xÎÎ�V��wÀ�i`��,�/�«>Ì�i�ÌÃ�ÜiÀi�diagnosed across 19 TB CARE I countries a 29% increase from 2010, treatment initiation for MDR-TB >�Ã��«À�Ûi`�V��Ã�`iÀ>L�Þ�Ü�Ì��£Î]ä{£�V��wÀ�i`�MDR-TB patients started on second-line treatment (an 81% jump).

7�i��Ì�Ì>��}�L�Ì��V��wÀ�i`��,�/�V>ÃiÃ�and rifampicin-resistant TB (RR-TB) cases, 20,508 RR-/MDR-TB patients have been diagnosed, which is >�nä¯��VÀi>Ãi�V��«>Ài`�Ì��Óä£ä°�n�¯��v�V��wÀ�i`�>�`�Õ�V��wÀ�i`��,�/�«>Ì�i�ÌÃ�ÜiÀi�ÃÌ>ÀÌi`�on treatment in 2013 compared to 21% in 2010. Between 2011-2013, TB CARE I countries contributed a total of 32,392 patients (57%) to the USAID target �v�xÇ]Óää�Èx¯��v�Õ�V��wÀ�i`É,,�/�V>ÃiÃ�>Ài�>�Ã��included in the total).

Number of Cases Notified (All Forms and New Confirmed) in

TB CARE I Countries 2010-2013

Number of New MDR-TB Cases Diagnosed and Put on

Treatment in TB CARE I Countries 2010-2013

TB CARE I Indonesia Director Jan Voskens with woman cured of MDR-TB (Photo: KNCV)

USAID TARGETS

2010

2011

2012

2013*

1,104,344

1,122,687

1,123,638

1,105,653

Number of Cases Notifed (all forms)

New Confirmed (2013*: New Pulmonary Bacteriologically Confirmed)

490,898

511,708

517,783

513,225

Confirmed MDR Diagnosed

2010

2011

2012

2013

RR-/MDR-TB Diagnosed

Confirmed MDR-TB Started on Treatment

Confirmed & Unconfirmed MDR-TB Started on Treatment

20,508

15,405

13,041

13,533

16,788

12,721

10,952

13,281

13,270

8,804

8,152

12,458

11,380

8,141

7,206

10,514

CASE NOTIFICATION & CASE DETECTION:

NUMBER OF NEW MDR-TB CASES DIAGNOSED AND PUT ON TREATMENT:

32

Medium Investment

Large Investment


Small Investment




South Sudan


Botswana


Namibia


Zimbabwe


Mozambique


Kazakhstan


Kyrgyzstan


Uzbekistan


Tajikistan


Afghanistan


Vietnam


Cambodia


Indonesia


Ethiopia


TB CARE I COUNTRY HIGHLIGHTS

3

Medium Investment

Large Investment


Small Investment




South Sudan


Botswana


Namibia


Zimbabwe


Mozambique


Kazakhstan


Kyrgyzstan


Uzbekistan


Tajikistan


Afghanistan


Vietnam


Cambodia


Indonesia


Ethiopia


TB CARE I COUNTRY HIGHLIGHTS

4

Medium Investment

Large Investment


Small Investment




South Sudan


Botswana


Namibia


Zimbabwe


Mozambique


Kazakhstan


Kyrgyzstan


Uzbekistan


Tajikistan


Afghanistan


Vietnam


Cambodia


Indonesia


Ethiopia


International Standards for Tuberculosis Care 3rd Edition

TB CARE I funded the development of the third edition of the ‘International Standards for Tuberculosis Care’ (ISTC) which describes a widely accepted level of care that all practitioners, public and private, should seek to achieve in managing patients who have or are suspected of having TB. This edition brings updated standards that are in line with recent WHO guidelines, and is accompanied by a free mobile phone app that features clinical decision algorithms with step by step guidance for diagnosing and managing TB, along with the full text of the ISTC. The app is designed for use by TB practitioners, and provides all the essential information for diagnosing and managing TB.

Summary of TB CARE I supported Xpert testing activity over four years of implementation, including TB positivity rate and

RIF-resistance rates (RR)

UNIVERSAL & EARLY ACCESS:

Universal and Early Access is a priority for TB CARE I given the range of technical issues that it covers, from a patient-centered approach to service quality, whether in the public or private sector, in the community or in prisons.

Among the 11 countries where TB CARE I has made moderate to substantial investments in addressing TB in children, ÇÎ]xx��«i`�>ÌÀ�V�/�V>ÃiÃ�ÜiÀi��Ì�wi`�in 2013 to NTPs in TB CARE I countries, making up 8% of all new and relapse cases with age information known, which is within the target range of 5-15% of all TB cases.

LABORATORIES:

One of TB CARE I’s greatest undertakings has been the rollout, strategic implementation and expansion of GeneXpert MTB/RIF (Xpert) across all TB CARE I countries. Although the level of investment and TB CARE I project role varied from country to country, these efforts began with training and procurements, and then expanded to providing extensive mentoring, supervision, and monitoring activities. In Year 4 training, technical assistance and mentoring were provided to 14 out of 17 countries, and at the end of the year 101 Xpert instruments were operational due to TB CARE I support.

Since the start of TB CARE I, 114,699 TB CARE I -supported tests have been conducted with a TB positivity rate of 34% and RR-TB detection rate of 26%. Testing jumped by 153% from Year 3 to Year 4 alone, 88% more samples in Year 4 detected TB (MTB+) than in Year 3 and 50% more RR-TB was diagnosed.

All but two supported countries have laboratory strategic plans that will enable national TB programs Ì��ivwV�i�Ì�Þ�>�`�ivviVÌ�Ûi�Þ�V��À`��>Ìi]��«�i�i�Ì�and budget laboratory activities over the next round of Global Fund grants.

Year 1/Year 2 Year 3 Year 4

Num

ber

of S

ucce

ssfu

l Tes

ts

8,133

3,6051,005

30,188

12,431

3,623

76,378

23,362

31%

5,432

23%

41%

29%44%28%

Total Tests MTB+ RR

In addition to strategic planning for laboratories, new linkages have also been established between national reference laboratories in TB CARE I countries and supranational reference laboratories (SNRLs). At present, all countries have developed SNRL linkages and have had at least one on-site visit.

Child with MDR-TB - Zimbabwe (Photo - Jeroen van Gorkom, KNCV)

UNIVERSAL AND EARLY ACCESSLABORATORIES

5

http://www.tbcare1.org/publications/toolbox/tools/access/download.php?file=ISTC_3rdEd_final_inter.pdf

INFECTION CONTROL (TB-IC):

All TB CARE I countries have developed national TB-IC guidelines, compared to only 50% at 2010 baseline, and TB-IC is now incorporated in the overall national Infection Prevention and Control Policy of all TB CARE I countries.

Ethiopia, Nigeria, Zambia and Viet Nam piloted the FAST strategy (Finding cases Actively, Separating them safely and Treating them effectively). The FAST strategy assumes that getting TB patients on effective (Xpert or DST-based) treatment faster will reduce the transmission of TB, long before the conversion of sputum smear or culture to negative. Preliminary data from the pilots in Zambia and Nigeria show a reduction in the average time to diagnosis and time to treatment and an increased level of case detection.

PROGRAMMATIC MANAGEMENT OF DRUG RESISTANT TB (PMDT):

As the diagnosis and treatment initiation for MDR-TB are scaled up, it is also essential to ensure the quality and completion of appropriate treatment. As PMDT programs expand, many countries have seen treatment success rates decrease (or remain low) as the complexities of managing more patients À�Ãi°�ƂÃ�Ãii��Ì�i�w}ÕÀi��ivÌ®]��Ài�«>Ì�i�ÌÃ�ÜiÀi�successfully treated from the 2011 cohort (5,994) than the 2010 cohort (5,596), however the overall number of MDR-TB patients on treatment also grew, resulting in only 69% treatment success (compared to 68% in 2010). Although an improvement over 2009 levels (only 3,811 treated and 66% successfully treated), there is still major work to be done.

TB/HIV:

The program implements TB/HIV-related activities in 11 country projects, 10 of which have U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)-supported activities or workplans. The average percentage of co-infected patients on Antiretroviral Treatment (ART) rose from 39% to 71% between 2010 and 2013. In general, the use of cotrimoxazole preventive therapy (CPT) did not expand over this period (85% coverage), although improvements were seen in some countries.In Zimbabwe where TB CARE I has been implementing a TB/HIV integrated care approach in 23 sites, CPT coverage is at 96% which is well above the national average of 77%.

Percentage of reported HIV-Positive TB patients started or

continued on ART (2010-2013)

MDR-TB patients registered on treatment and number (percent) that

successfully completed treatment (2009-2011)

% of HIV-positive patients started or continued on ART

Number of HIV-positive patients started or continued on ART

Thou

sand

s of

TB

Pat

ient

s

2010 2011 20132012

30

60

90

120

150

39%

49%

65%

71%

75

91

121127

MDR-TB patient receiving treatment - Kyrgyzstan (Photo: Nurgulya Kulbekova, KNCV)

Number Confirmed Started on Treatment Number Treated Successfully

2000

4000

6000

8000

10000

Num

ber o

f MD

R-TB

Pat

ient

s

5,805

3,811

8,172

5,596

8,739

5,994

2009 2010 2011

66%

68%69%

INFECTION CONTROLPMDTTB/HIV

6

8

HEALTH SYSTEM STRENGTHENING:

Health system strengthening is a component of nearly every country workplan with activities ranging from supportive supervision of and technical assistance with Global Fund planning, to the implementation and development of sustainable funding mechanisms. In the most recent scoring of Global Fund grants, 50% of all grants in TB CARE I countries are rated as A1/A2, whereas only 39% of grants in non-TB CARE I countries ha the same rating.

In Year 4, TB CARE I trained 15,772 individuals (health care workers, community volunteers, consultants, NTP staff, laboratory technicians, etc.), across all technical areas (see above), compared to Year 1 when 4,354 people were trained.

MONITORING & EVALUATION, OPERATIONS RESEARCH AND SURVEILLANCE:

Electronic recording and reporting (ERR) is established in ten TB CARE I countries (Botswana, Cambodia, Indonesia, Kazakhstan, Kyrgyzstan (not fully functional), Namibia, Nigeria, Tajikistan, Uzbekistan and Viet Nam) and TB CARE I provided moderate to substantial support for ERR in Botswana, Cambodia, Indonesia, Nigeria and Viet Nam.

TB CARE I has worked in 14 (82%) project countries to improve the quality of data at various levels of the system. The measurement of data quality has consistently gained greater traction with 88% of active TB CARE I countries now measuring data quality on a regular basis, compared to 50% of countries at the start.

Over the course of TB CARE I, operations research studies have been conducted in 18 countries. In total, 114 studies have been initiated, with TB CARE I’s level of involvement varying from major or minor w�>�V�>�ÉÌiV��V>��ÃÕ««�ÀÌ�Ì��vÕ��«�i�i�Ì>Ì��v�the studies.

Percentage of TB CARE I-Trained

Individuals by Technical Area, Year 4

(15,772 Trained)

Overview of Topic Areas for Completed or Ongoing Operations Research Studies, Years 1-4

Comparison of Grant Performance in TB CARE I

and Non-TB CARE I Countries

Trainees conducting a health facility risk assessment - Ethiopia (Photo: Max Meis, KNCV)

Patient interview on the quality of care Indonesia (Photo: KNCV)

Universal Access 56%

Laboratories4%

Epidemiology/M&E 11%

PMDT15%

TB/HIV6%

HSS4%

Morbidity/Mortality 2%

Drugs2%


Laboratories 16%

TB IC 12%

PMDT9%

TB/HIV 7%

HSS6%

M&E 7%

Drug Supply & Management 3%

Other 7%

Region-funded 1%

Core-funded 1%

INFECTION CONTROLPMDTTB/HIV

M&E, OPERATIONS RESEARCH & SURVEILLANCEHEALTH SYSTEMS STRENGTHENING

7

8

The Global Health Bureau, Office of Health, Infectious Disease and Nutrition (HIDN), US Agency for International Development, financially supports this publication through TB CARE I under

the terms of Agreement No. AID-OAA-A-10-00020. This publication is made possible by the generous support of the American people through the United States Agency for International

Development (USAID). The contents are the responsibility of TB CARE I and do not necessarily reflect the views of USAID or the United States Government.

TB CARE contributed to three USAID

target areas:

p� Sustain or exceed 84% case detection rate

and 87% treatment success rate

p� Treat successfully 2.55 million new sputum-

positive TB cases

p� Diagnose and treat 57,200 new cases

of multi-drug resistant TB (MDR-TB)

By focusing on eight priority technical

areas:

r� Universal and Early Access

r� Laboratories

r� Infection Control (IC)

r� Programmatic Management of Drug

Resistant TB (PMDT)

r� TB/HIV

r� Health Systems Strengthening

r� Monitoring & Evaluation (M&E), Operations

Research (OR) and Surveillance

r� Drug Supply and Management

And four over-arching elements:

r� Collaboration and Coordination

r� Access to TB services for all people

r� Responsible and Responsive Management

Practices

r� Evidence based M&E

WHAT IS TB CARE I?

E-mail [email protected] +31-70-7508447Website www.tbcare1.orgTwitter @TBCARE1

CONTACT DETAILS:

TB CARE I is a USAID five year cooperative

agreement (2010-2015) that was awarded

to the Tuberculosis Coalition for Technical

Assistance (TBCTA) with KNCV Tuberculosis

Foundation as the lead partner.

TB CARE I is a unique coalition of the major

international organizations in TB control:

American Thoracic Society (ATS), FHI 360,

International Union Against Tuberculosis

and Lung Disease (The Union), Japan Anti-

Tuberculosis Association (JATA), KNCV

Tuberculosis Foundation, Management

Sciences for Health (MSH), World Health

Organization (WHO).

WANT TO FIND OUT MORE?

The full TB CARE I Year 4 Annual Report is available on the TB CARE I website, along with all the tools that have been published.

CARE ITBDRUG SUPPLY AND MANAGEMENT:

In six countries, TB CARE I helps to ensure there are nationwide systems for a sustainable supply of drugs, by providing technical assistance to NTPs. Compared to baseline and Year 1 (8 countries), drug management Standard Operating Procedures (SOPs) are now available in 76% of TB CARE I countries.

TOOLS:

TB CARE I strives to make its documents and tools available to as wide an audience as possible. In the final year, the project produced over 30 publications covering a wide range of technical areas, all of which can be found on the TB CARE I website (www.tbcare1.org/publications)

A fundamental aspect of introducing new TB drugs in countries is to ensure that national authorities establish the necessary conditions for optimal and responsible use of new TB drugs/regimens. These conditions include: development/update of national guidelines, inventory of minimal infrastructure and resources required (clinical, laboratory, recording & reporting, monitoring and evaluation, drug supply etc.) for proper case-management, efficient pharmacovigilance, and surveillance of drug resistance. In Year 4, TB CARE I developed a protocol for the rational and safe introduction of Bedaquiline, a new TB drug for MDR-TB treatment, and supported Indonesia and Kazakhstan to develop country-specific versions of the protocol.

Design + Layout - Tristan Bayly

DOT for MDR-TB - Viet Nam (Photo - Matthieu Zellweger, WHO)


Laboratories 16%

TB IC 12%

PMDT9%

TB/HIV 7%

HSS6%

M&E 7%

Drug Supply & Management 3%

Other 7%

Region-funded 1%

Core-funded 1%

M&E, OPERATIONS RESEARCH & SURVEILLANCEHEALTH SYSTEMS STRENGTHENING

DRUG SUPPLY & MANAGEMENTTOOLS

mailto:[email protected]

http://www.tbcare1.org

http://twitter.com/tbcare1

http://www.thoracic.org/

http://www.fhi360.org/

http://www.theunion.org/

http://www.theunion.org/

http://www.jata.or.jp/eindex/home.html

http://www.jata.or.jp/eindex/home.html

http://www.kncvtbc.org/

http://www.kncvtbc.org/

http://www.tbcare1.org/reports/reports/download.php?file=TB_CARE_I_Annual_Report_Year_4_Oct_2013-Sept_2014.pdf

http://www.tbcare1.org/

http://www.tbcare1.org/

http://www.tbcare1.org/publications

DRUG SUPPLY & MANAGEMENT TB CARE I in TB CARE I-supported integrated TB/HIV sites (96%) ... Seven times as many RR-TB cases were ... 81% jump). 7 i Ì Ì ...

Documents