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AUGUST 2020TB CARE II is funded by United States Agency for
International Development (USAID) under Cooperative Agreement
Number AID-OAA-A-10-0021. The project team includes prime
recipient, University Research Co., LLC (URC), and sub-recipient
organizations Jhpiego, Partners In Health, Project HOPE along with
BEA Enterprises; Brigham and Women’s Hospital; the Canadian Lung
Association; Clinical and Laboratory Standards Institute; Dartmouth
Medical School: The Section of Infectious Disease and International
Health; Euro Health Group; McGill University; and The New Jersey
Medical School Global Tuberculosis Institute.
ContextOne of the most serious threats to global tuberculosis
(TB) control efforts is drug-resistant TB (DR-TB). It includes
multi-drug resistant TB (MDR-TB), resistant to two of the most
powerful TB drugs, isoniazid and rifampicin, and the even more
severe extensively drug-resistant TB (XDR-TB). DR-TB develops when
TB drugs are used inappropriately or incorrectly, if ineffective
formulations are used, or if the treatment isn’t completed. It can
also be spread through person-to-person transmission.
Several gaps in the DR-TB care continuum undermine success.
According to the World Health Organization, there were an estimated
484,000 cases of MDR-TB in 2018. However, only 51% of people with
bacteriologically confirmed TB were tested for rifampicin
resistance – the first gap in the TB care continuum. As a result,
only 38% of the estimated cases were notified. The second gap in
the continuum is registering diagnosed cases on treatment: in 2018,
84% of notified cases, were started on treatment. Treatment
involves a complex regimen lasting between 9 and 20 months,
creating the third gap in care: only 56% of MDR-TB patients were
successfully treated. In addition to challenges with treatment
adherence, MDR-TB treatment services are often centralized and
reliant on hospital-based models of care, limiting access to
care.
The USAID TB CARE II Project worked to reduce these gaps in
MDR-TB care, supporting the implementation of the U.S. Government’s
National Action Plan for Combating Multidrug-Resistant Tuberculosis
(NAP), and the USAID “Global Accelerator to End TB”. The project
built global commitment and capacity for combating MDR-TB by
Improving Capacity and Collaboration to Combat Drug-Resistant
Tuberculosis
gathering evidence and advocating for effective service delivery
models, developing guidance, and strengthening health systems. A
key focus was strengthening patient-centered care to increase
treatment success. TB CARE II supported National TB Programs (NTPs)
to decentralize MDR-TB services closer to the patient and to
improve the quality of MDR-TB care. Through long-term field support
programs in Bangladesh, Malawi, and South Africa, TB CARE II
engaged NTPs, civil society, and communities to expand clinical and
programmatic capacity in MDR-TB programming, supporting the
development of local solutions and the growth of self-reliance.
(For more information, see the country-specific briefs).
The USAID TB CARE II Project (2010-2020)▶ Provided global
leadership and technical support
to National TB Programs and other stakeholders to accelerate the
implementation of TB, TB-HIV co-infection, and multi-drug resistant
TB services.
▶ Particular emphasis on innovative technological approaches to
improve TB case detection and treatment, and interventions related
to infection control and programmatic management of drug-resistant
TB.
▶ Strengthened TB program capacity and fostered commitment to
ending TB by empowering government partners, civil society,
communities, and the private sector to develop local solutions to
address bottlenecks and strengthen health systems for TB
control.
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2 Improving Capacity and Collaboration to Combat Drug-Resistant
Tuberculosis
Key interventions and resultsClosing the gap in diagnosing
MDR-TB In 2010, TB diagnostic capability was accelerated with the
introduction of GeneXpert MTB/RIF, a fast molecular-based test. It
provides results of TB and rifampicin resistance in 2 hours, rather
than the 10 days needed for a culture methods, allowing patients to
rapidly begin treatment. However, its use in low-resource settings
was limited by the high cost of the GeneXpert system and
cartridges.
In Bangladesh and Malawi, TB CARE II provided focused technical
support to integrate diagnosis using GeneXpert into the health
system. The project supported the NTPs and National TB Reference
Laboratories (NTRL) to develop GeneXpert diagnostic algorithms,
standard operating procedures (SOP), and training modules; train
laboratory technicians on operation and maintenance of the Xpert
MTB/RIF machines; and establish referral network and sputum
collection and transportation systems linking peripheral sputum
microscopy centers with the Xpert sites.
Between 2011 and 2015, the project procured and helped
place:
• 39 GeneXpert machines in Bangladesh, which detected 9,354
cases of TB and 2,749 cases of MDR-TB.
• 11 GeneXpert machines in Malawi, which diagnosed 2,368 TB
cases and 75 MDR-TB cases.
TB CARE II also built the capacity of the laboratory networks –
from microscopy centers to the NTRL – by strengthening the supply
chain for equipment, reagents, and consumables, training laboratory
technicians, and improving biosafety. In Bangladesh, for instance,
the project helped establish a new regional TB reference laboratory
(RTRL) in Khulna, initiated a new one for Sylhet, and upgraded the
RTRL in Chittagong.
Closing the gap in starting treatmentHospital-based MDR-TB
treatment: As MDR-TB case-finding improves, hospital capacity to
manage the increasing number of MDR-TB patients is often strained.
In Bangladesh, TB CARE II supported the NTP to set up 124 new
MDR-TB beds at the National Institute of Diseases of the Chest and
Hospital and at five district chest diseases clinics. Health
workers at the facilities
received additional training and mentoring to ensure they had
the knowledge and skills for the clinical and programmatic
management of DR-TB patients.
Community-based MDR-TB treatment: Decentralizing treatment to
the community-level relieves the burden on hospitals while
continuing to provide the patient with daily support, even as they
live in their own home. The community-based programmatic management
of DR-TB (cPMDT) model involves treatment initiation at the
hospital, with discharge after sputum conversion (usually less than
two months), and finishing the remaining months of treatment at
home with the support of a community-based provider of directly
observed therapy (DOT).
TB CARE II introduced the model to Bangladesh, Malawi, and South
Africa by supporting the NTP to develop SOPs, train outpatient
DR-TB teams and DOT providers, and establish intensive monitoring
and supervision systems. (Also see technical brief on community
engagement).
The results of cPMDT were significant. For example, in
Bangladesh, the expansion of inpatient capacity and early release
of patients from hospital to continue treatment at the community
level helped reduce the delay for treatment initiation from more
than two months in 2011 to less than a week in 2014, releasing beds
for admission of newly diagnosed patients, and almost eliminating
the number of patients on waiting list for treatment.
Drawing on the lessons from Bangladesh, Malawi, and other
countries with cPMDT programs, TB CARE II identified global best
practices, developing global
Laboratory technicians in Bangladesh receive training on using
GeneXpert
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Improving Capacity and Collaboration to Combat Drug-Resistant
Tuberculosis 3
MDR-TB treatment, situations that complicate MDR-TB management,
and indications for surgical intervention in MDR-TB.
• Training webinars hosted on the project-supported DR-TB
Learning Network (since incorporated in the TB Academy and made
available on YouTube) provided instruction on topics such as basics
of clinical management of MDR-TB, pediatric TB, pharmacovigilance,
cPMDT, and TB infection control. Over 1,300 people from 64
countries participated the webinars.
• Guidelines, such as the PIH Guide to the Medical Management of
MDR-TB (2014), Management of MDR-TB in Children: A Field Guide
(2016), and Community-Based Care for Drug-Resistant Tuberculosis: A
Guide for Implementers (2017), increased access to global best
practices standards.
Improving quality of care: In Bangladesh, Malawi, and South
Africa, TB CARE II worked with the NTPs to scale-up effective
approaches to improve the quality of MDR-TB care. This included
holding MDR-TB service providers accountable through improved
supervision systems, institutionalizing regular review meetings to
monitor progress in the treatment of MDR-TB patients, and improving
recording and reporting systems to support program managers in
identifying and addressing performance gaps. For example, the
project supported TB programs to adopt digital health solutions for
data collection and reporting systems, and to use geomapping to
improve the management of MDR-TB patients and contacts.
resources such as the Community-Based Care for Drug-Resistant
Tuberculosis: A Guide for Implementers (2017).
To introduce and scale-up cPMDT in countries prioritized under
the NAP, TB CARE II organized a workshop on Best Practices in DR-TB
Community Care: Development of National Community-Based DR-TB Care
Plans in Pretoria, South Africa in 2017. It brought together 72 NTP
directors and other high-level advisors from all ten NAP countries
to draft national action plans for roll-out or scale-up of cPMDT.
Countries continued receiving focused technical assistance after
the workshop.
Closing the gap in treatment successClinical and programmatic
capacity: In its field support programs, TB CARE II worked with
NTPs to strengthen systems for training and supervising laboratory
technicians, health providers and staff from community levels to
referral facilities, and TB program managers in MDR-TB programming
and service delivery. Recognizing the urgent need for MDR-TB
capacity building globally, the project also built capacity in
other high TB-burden countries. For example:
• The PMDT Fellowship Program brought TB practitioners for
yearly training on MDR-TB at one of the project-support Centers of
Excellence in in Russia, Lesotho, or Peru.
• The online Clinical Case Discussion Series gave providers the
opportunity to discuss real-life MDR-TB cases, learning about
topics such as side effects of
TB CARE II staff visit a DOT provider’s house for supervision
and mentoring in Bangladesh
Adherence support through digital solutions: Digital health
solutions were also leveraged to improve adherence to the long
treatment regimen for MDR-TB. TB CARE II developed the ConnecTB
mobile which provides health workers with immediate access to
individualized treatment regimens, enables community DOT providers
to record DOT sessions, and flags reminders for follow-up actions,
including side effect management and contact tracing. The
application was tested and scaled-up in Bangladesh and South
Africa, where it increased MDR-TB treatment retention rates to
90%-100%. In South Africa, the application was adopted by NGOs who
work directly with multiple facilities to receive MDR-TB patient
referrals
https://tb.academy/webinar-archives/https://www.youtube.com/user/DRTBTrainingNetwork/feedhttps://www.pih.org/practitioner-resource/pih-guide-to-the-medical-management-of-multidrug-resistant-tuberculosis-2nd/the-pih-guide-to-the-medical-management-of-multidrug-resistant-tuberculosishttps://www.pih.org/practitioner-resource/pih-guide-to-the-medical-management-of-multidrug-resistant-tuberculosis-2nd/the-pih-guide-to-the-medical-management-of-multidrug-resistant-tuberculosishttp://sentinel-project.org/wp-content/uploads/2016/12/Field_Handbook_3rd-Ed-30-Nov2016.pdfhttp://sentinel-project.org/wp-content/uploads/2016/12/Field_Handbook_3rd-Ed-30-Nov2016.pdfhttps://tbcare2.org/wp-content/uploads/2018/09/Community-Based-DR-TB-20180830-1.pdfhttps://tbcare2.org/wp-content/uploads/2018/09/Community-Based-DR-TB-20180830-1.pdfhttps://tbcare2.org/wp-content/uploads/2018/09/Community-Based-DR-TB-20180830-1.pdfhttps://tbcare2.org/wp-content/uploads/2018/09/Community-Based-DR-TB-20180830-1.pdfhttps://tbcare2.org/wp-content/uploads/2018/09/Community-Based-DR-TB-20180830-1.pdf
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4 Improving Capacity and Collaboration to Combat Drug-Resistant
Tuberculosis
for subsequent follow up and management. (See technical brief on
digital solutions).
To support the scale-up of digital solutions for MDR-TB, TB CARE
II organized a global consultation 2018. The workshop brought NTPs
from thirteen countries, including eight countries prioritized
under the NAP, with technology companies, industry groups, and
civil society organizations to select solutions appropriate for
their TB control context and digital ecosystem and develop country
roadmaps. Following the workshop, TB CARE II provided targeted
technical support to support roadmap implementation.
Comprehensive support to MDR-TB patients: MDR-TB patients may
experience significant pain, face stigma and discrimination,
isolation, and financial barriers to obtaining food or transport
for facility check-ups. In 2015, TB CARE II worked with the South
African National Department of Health to develop and roll out
Comprehensive Guidelines for TB and DR-TB Palliative Care and
Support. Building on the experience in South Africa, TB CARE II
worked with other TB control partners to support USAID to develop
the USAID DR-TB Care Package (2018), a set of supportive care
elements meant to improve the quality and patient-centeredness of
community-based care for people living with DR-TB. The project
provided technical assistance to support NAP countries in adopting
the package, improving the quality of life for patients with DR-TB
and contributing to their treatment success.
New short-course for DR-TB therapy: New drugs and regimens are
urgently needed to enable faster and safer MDR-TB treatment. As two
new anti-TB drugs, bedaquiline and delamanid, were brought to
market, TB CARE II assisted the UNITAID-funded EndTB Project to
assess whether the new treatment was as good or better than the
current regimen, and to evaluate novel, short, all-oral
combinations of drugs for MDR-TB. Specifically,
TB CARE II supported NTPs in Haiti, Kazakhstan, Liberia, and
Sierra Leone to introduce and monitor the new treatment regimens by
developing and/or updating MDR-TB guidelines, SOPs, and training
materials; strengthening laboratory and diagnostic capacity; and
procuring consumables and equipment.
A key element in the introduction of new drugs and shorter
treatment regimens is preventing adverse events through active TB
drug-safety monitoring and manage-ment (aDSM). TB CARE II organized
regional workshops Eastern Europe/Central Asia, and Africa,
bringing together NTPs, national drug authorities, and
pharmacovigilance centers to develop roadmaps, action plans, and
reporting mechanisms for aDSM implementation at the country level.
TB CARE II continued to provide technical support following the
workshops, focusing on supporting pharma-covigilance electronic
reporting tool implementation.
Conclusions TB CARE II provided global leadership and focused
technical support to build capacity and foster collaboration to
combat MDR-TB. The project encouraged efforts to improve access to
high-quality, patient-centered diagnostic services and MDR-TB care
and to enhance adherence to MDR-TB treatment. cPMDT and innovative
digital solutions improved service delivery and provided patients
with choices, helping address bottlenecks to treatment success.
Aligned with the Global TB Accelerator, the project engaged
governments, civil society, communities, and the private sector in
exchanging information and developing or identifying solutions to
effectively address gaps in MDR-TB care, accelerating progress
toward ending TB. By building clinical and programmatic capacity
and strengthening commitment to reaching and curing every case of
MDR-TB, TB CARE II supported countries in advancing on their
Journey to Self-Reliance.
USAID Bureau for Global Health | TB Team500 D Street SW |
Washington, DC | 1.571.309.0217
Hala Jassim AlMossawi: Acting Director, TB CARE II •
[email protected]
University Research Co., LLC • 5404 Wisconsin Avenue, Suite 800
• Chevy Chase, MD 20815, USA • http://www.urc-chs.com
https://www.urc-chs.com/sites/default/files/Related%20URC%20publication_Palliative%20Care%20and%20TB.pdfhttps://www.urc-chs.com/sites/default/files/Related%20URC%20publication_Palliative%20Care%20and%20TB.pdfhttps://tbcare2.org/wp-content/uploads/2019/03/DR-TB-Practical-Toolkit_8-31.pdf