TB CARE I Report Quarter1 Year 4

TB CARE

TB CARE IPROGRAM YEAR 4

QUARTER ONE PERFORMANCE

MONITORING REPORTOctober 1, 2013 – December 31, 2013

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TB CARE I Partners:

American Thoracic Society (ATS)FHI 360Japan Anti-Tuberculosis Association (JATA)KNCV Tuberculosis Foundation Management Sciences for Health (MSH)International Union Against Tuberculosis and Lung Disease (The Union)World Health Organization (WHO)

February 15th 2014

Hea l t h s o l u t i on s fo r t he poo r

International Union Against Tuberculosis and Lung Disease

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Table of ContentsAbbreviations ........................................................................................................................................................................................................................................................... 4Introduction .............................................................................................................................................................................................................................................................. 5Program Management Unit (PMU) ................................................................................................................................................................................................................ 6New TB CARE I publications this quarter:.................................................................................................................................................................................................... 7Core Projects ........................................................................................................................................................................................................................................................... 8Approved Year 3 Core Projects & Completed Year 2 Projects ............................................................................................................................................................ 9

Country Projects ..................................................................................................................................................................................................................................................... 14Afghanistan ....................................................................................................................................................................................................................................................... 16Botswana ........................................................................................................................................................................................................................................................... 17Cambodia ........................................................................................................................................................................................................................................................... 17CAR-Kazakhstan ............................................................................................................................................................................................................................................. 17CAR-Kyrgyzstan .............................................................................................................................................................................................................................................. 18CAR-Tajikistan .................................................................................................................................................................................................................................................. 18CAR-Uzbekistan .............................................................................................................................................................................................................................................. 19Ethiopia ............................................................................................................................................................................................................................................................... 19Ghana .................................................................................................................................................................................................................................................................. 20Indonesia ............................................................................................................................................................................................................................................................ 21Mozambique ..................................................................................................................................................................................................................................................... 22Namibia ............................................................................................................................................................................................................................................................... 22Nigeria ................................................................................................................................................................................................................................................................. 23Senegal ............................................................................................................................................................................................................................................................... 24South Sudan ..................................................................................................................................................................................................................................................... 24Uganda ................................................................................................................................................................................................................................................................ 24Viet Nam ............................................................................................................................................................................................................................................................. 25Zambia ................................................................................................................................................................................................................................................................ 26Zimbabwe .......................................................................................................................................................................................................................................................... 27

Regional Projects ................................................................................................................................................................................................................................................... 27Center of Excellence (CoE) for PMDT .................................................................................................................................................................................................. 27East Africa Supranational Reference Laboratory .............................................................................................................................................................................. 27Djibouti ............................................................................................................................................................................................................................................................... 27

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AbbreviationsACSM Advocacy Communication Social MobilizationAFB Acid Fast BacilliART Anti-retroviral TherapyBinfar Directorate General of Pharmaceutical and Medical Devices (Indonesia)BPPM Directorate of Medical Services (Indonesia)CAR Central Asian RepublicsCB-DOTS Community-Based DOTSCTBC Community-Based TB CareCDC Center for Disease Control and PreventionCoE Center of ExcellenceCDR Case Detection RateCHW Community Health WorkerCSO Civil Society OrganizationDEWG DOTS Expansion Working GroupDOT Directly Observed TreatmentDOTS Directly Observed Treatment Short CourseDR Drug ResistanceDRS Drug Resistance SurveyDST Drug Susceptibility TestingECSA East, Central and Southern AfricaEQA External Quality AssuranceERR Electronic Recording & ReportingFIND Foundation for Innovative New DiagnosticsGDF Global Drug FacilityGFATM Global Fund for Aids, Tuberculosis and MalariaGLC Green Light CommitteeGLI Global Laboratory InitiativeHAART Highly Active Anti Retroviral TreatmentHCW Healthcare WorkerHF Health facilityHRD Human Resource DevelopmentHSS Health System StrengtheningIC Infection ControlIEC Information, Education and CommunicationICF Intensified Case FindingILEP International Federation of Anti-Leprosy AssociationsIPT Isoniazid Preventive TherapyIQC Internal Quality ControlISTC International Standards of Tuberculosis CareJATA Japan Anti Tuberculosis AssociationJSM Joint Strategic MeetingKANCO Kenya AIDS NGOs ConsortiumKAP Knowledge, Attitude and PracticeKAPTLD Kenya Association for Prevention of TB and Lung DiseasesKIT Royal Tropical Institute KNCV KNCV Tuberculosis FoundationLED Light Emitting Diode (microscopy)LPA Line Probe AssayMDR Multi Drug ResistanceMDR-TB Multi Drug Resistant Tuberculosis

M&E Monitoring and EvaluationMOA Memorandum of AgreementMoH Ministry of HealthMOST Management & Organizational Sustainability ToolMSF Médecins sans Frontières (Doctors without Borders)MSH Management Sciences for HealthNAP National Aids ProgramNCE No-Cost ExtensionNGO Non-Governmental OrganizationNIHE National Institute of Health and Epidemics (Viet Nam)NSP National Strategic PlanNTP National TB ProgramNRL National Reference LaboratoryNTRL National Tuberculosis Reference LaboratoryOD Operational DistrictOIG Office of the Inspector GeneralOPD Out-patient DepartmentOR Operations ResearchPCA Patient Centered ApproachPiH Partners in HealthPITC Provider-Initiated Treatment and CounselingPHCC Primary Health Care CenterPLHIV People Living with HIVPLWHA People Living with HIV/AIDSPMDT Programmatic Management of Drug-resistant TuberculosisPMU Program Management UnitPPM Private Public MixPPP Public Private PartnershipPSS Psycho-social SupportRUTF Ready to Use Therapeutic FoodsRIF RifampicinQMR Quarterly Monitoring ReportSANAS South Africa National Accreditation SystemSES Sanitation and Epidemiologic AuthoritySLD Second Line DrugSNRL Supra National Reference LaboratorySOP Standard Operating ProceduresSS+ Sputum Smear positiveSS- Sputum Smear negativeTA Technical AssistanceTB TuberculosisTB-IC TB Infection ControlTB CAP Tuberculosis Control Assistance ProgramTBCTA Tuberculosis Coalition for Technical AssistanceTOT Training of TrainersTFM Transitional Funding MechanismTWG Technical Working GroupUSAID United States Agency for International DevelopmentUVGI Ultraviolet Germicidal IrradiationWHO World Health Organization

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In October 2013, TB CARE I began its fourth year of implementation. This report provides a technical and financial update on progress made between October-December 2013 for TB CARE I core, regional and country projects. Implementation continued in a total of 18 countries as Kenya closed last quarter. Uganda closed at the end of December. Nine core projects were completed this quarter and 21 new core projects were approved for Year 4. In total, 28 core projects continue to be implemented. Four regional projects continued activities in Year 4. Below is a brief summary of TB CARE I’s main achievements this quarter and challenges for the next three months.

Main Achievements: – Preliminary 2013 data show that countries are closing the gap between diagnosis and treatment of MDR-TB. Although data vary country to

country, for the first time ever, more MDR-TB cases were put on treatment in 2013 than were diagnosed. In 2013, an estimated 14,565 MDR-TB cases were diagnosed – a 40% increase over 2010 levels. Second line treatment initiation (14,888) was even more impressive with 85% more MDR-TB cases started on treatment compared 2010.

– Five countries (Afghanistan, Ghana, Indonesia, Nigeria and Zambia) developed draft National Strategic Plans (NSPs) with technical support from TB CARE I. The program also played a key role during the WHO-lead National Strategic Planning workshop in Cepina, Italy in November, providing country-specific and overall technical assistance. The Toolkit for TB Strategic Planning was developed by TB CARE I and used during the workshop.

– In Afghanistan, when comparing 2013 data for TB CARE I-supported provinces with that of 2009, there was a 119% improvement in presumptive TB case identification and examination for TB, 39% increase in TB case notification (all forms), and 22% improvement in new sputum smear positive (SS+) cases.

– The outpatient care model piloted in Akmola, Kazakhstan by TB CARE I will be expanded nationwide. The revised Ministry of Health (MoH) decree that mandates the nationwide administration of outpatient care uses the admission criteria developed by TB CARE I.

– In Ghana, the prevalence survey fieldwork was successfully completed in all 98 clusters in December 2013 as scheduled (61,224 clients participating). TB CARE I ensured that data management was well-coordinated throughout the entire process.

– TB CARE I-Indonesia successfully assisted with programmatic management of drug-resistant TB (PMDT) expansion from 10 to 13 sites. The three new sites are outside TB CARE I-supported areas and are fully operational. The number of PMDT satellites increased by 38 (from 375 to 413).

– In TB CARE I-supported sites in Nigeria, the number of MTB+ cases detected by GeneXpert increased by 158% and Rifampicin (RIF) resistant cases rose by 64% from 2012 to 2013.

– In Uganda, the treatment success rate for Kampala (TB CARE I-supported) increased from 49% at baseline in 2011 to 70% in 2012 – a rate that has been maintained through the first half of 2013.

– In Zimbabwe, 17 point-of-care CD4 testing machines were installed at TB CARE I-supported integrated TB/HIV care sites in December 2013 and almost 1,000 tests were already conducted by the end of the month. This is expected to facilitate early initiation of people living with HIV (PLHIV) on antiretroviral therapy (ART), ultimately improving patient outcomes.

Main Challenges: – As TB CARE I has entered its final year of implementation, the program is working to implement activities on schedule and within budget while

also capturing results at all levels of the program.

Introduction

Microscopy Slides, Indonesia - Maarten van Cleeff

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PMU staff continued to provide technical and managerial assistance and participate in global meetings and conferences throughout the quarter (summarized below). TB CARE I countries visited by PMU members for technical or managerial purposes, October-December 2013

Purpose

Indonesia Management

Italy National Strategic Planning workshop

France Paris Union Conference

USA Stop TB Infection Control sub-working group

Zimbabwe Assessment of using Xpert for routine use in HIV settings (core 5.13)

Nigeria Assessment of using Xpert for routine use in HIV settings (core 5.13)

Knowledge Exchange

TB CARE I website:The number of visitors to the TB CARE I website dropped slightly over the quarter (see below), but this slowdown was due to the holiday period without which we were on track for a record quarter.

Summary of visitors to the TB CARE I website, January-March 2013

July-September 2013 October-December 2013

Number of Visitors 5,063 5,005

Number of Countries Visitors came from 125 136

Number of Pages Viewed 12,670 12,002

Percentage of New Visitors 71% 70%

TB CARE I website visitor locations for the quarter

This quarter, 2,397 documents were downloaded; the top ten most popular downloads (and number of downloads) were as follows:1. TB CARE I QMR April-June 2013 (Number of downloads - 195)2. Guide to Measure the Incidence of Active TB Disease Among Health Care Workers (100)3. TB CARE I Publications Complete List (99)4. Systematic Screening for Active Tuberculosis (85)5. Newsletter June 2013 (63)6. TB CARE I Annual Report Year 2 – October 2011–September 2012 (59)7. Tuberculosis Infection Prevention Procedures - Job Aid (55)8. A Roadmap for Ensuring Quality Tuberculosis Diagnostics Services within National Laboratory Strategic Plans (53)9. Guide to Measure the Prevalence of Active TB Disease Among Health Care Workers (52)10. Laboratory Assessment Form (48)

Program Management Unit (PMU)

0

300

600

900

1200

1500

NorthAmerica

CentralAmerica

SouthAmerica

Europe Africa MiddleEast

CentralAsia

WestAsia

EastAsia

South-EastAsia

OceaniaCaribbean

1066

844

1261

66

571490

259

67758 15 28

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Participant quote: “Health workers should be able to use the [data] tools themselves to make decisions. They should be able to analyze it [and] use it... If you don’t do that, staff feel demotivated and they don’t provide quality data.” Alexinah Muadinohamba, Deputy Director of the Health Sector Response for Namibia’s Ministry of Health

New TB CARE I publications this quarter:

TB CARE I Year 3 Annual ReportThe third annual report of the TB CARE I program covering October 2012 to September 2013http://www.tbcare1.org/reports/reports/TB_CARE_I_Annual_Report_Year_3_Oct_2012-Sept_2013.pdf

Modeling the Cost-Effectiveness of Multi-Drug Resistant Tuberculosis Diagnostic and Treatment Services in IndonesiaA simple-user-friendly model for conducting cost and cost-effective analysis of MDR-TB diagnostic and treatment serviceshttp://www.tbcare1.org/publications/toolbox/tools/hss/TB_CARE_I_CEA_MDR-TB.pdf

Intensified implementation of GeneXpert MTB/RIF in 3 CountriesThe methodology and outcomes of providing intensified support on the implementation of Xpert in three countries: Nigeria, Indonesia and Kazakhstanhttp://www.tbcare1.org/publications/toolbox/tools/lab/TB_CARE_I_GeneXpert_Core_Project_Final_Report.pdf

All the publications can be found on the TB CARE I website here:http://www.tbcare1.org/publications/

The Union World Conference on Lung HealthFrom October 30th-November 3rd, 2013 the 44th Union World Conference on Lung Health took place in Paris, France. TB CARE I led workshops, presented project results and engaged in numerous technical and management meetings. Below are some of the highlights.

WorkshopDuring the conference, the PMU organized and carried out a full-day workshop on ‘Data for Decision Making and Use of Data for Continuous Improvement’ (21 participants). During this full-day course, the facilitators led presentations and discussions that challenged participants to apply intuition, personal experience, and prioritization strategies to decision making. They also highlighted the importance of assessing outcomes to inform and refine decision making, rather than focusing only on the data. The interactive workshop engaged participants through exercises, discussions and group work, including an interactive case study on GeneXpert instrument placement based on epidemiological and financial data.

A news article on the post-graduate course can be found here:http://conferences.msh.org/worldlung2013/2013/11/01/informed-choices-for-improved- health-training-health-professionals-in-data-driven-decision-making/

TB CARE I posters and presentationsThe program’s results were well represented at the conference. TB CARE I presented or contributed to over 50 poster abstracts, 8 oral abstracts and 9 symposia across nine countries. A booklet listing all the posters and presentations can be downloaded here:http://www.tbcare1.org/pdfs/TB_CARE_I_Supported_Activities_Paris_2013.pdf

The TB CARE I posters and presentation from the conference can be viewed and downloaded here:http://www.tbcare1.org/publications/union/

Post-Graduate Course Participants, Paris, France - Tristan Bayly

http://www.tbcare1.org/reports/reports/download.php?file=TB_CARE_I_Annual_Report_Year_3_Oct_2012-Sept_2013.pdf

http://www.tbcare1.org/publications/toolbox/tools/hss/download.php?file=TB_CARE_I_CEA_MDR-TB.pdf

http://www.tbcare1.org/publications/toolbox/tools/hss/download.php?file=TB_CARE_I_CEA_MDR-TB.pdf

http://www.tbcare1.org/publications

http://conferences.msh.org/worldlung2013/2013/11/01/informed

http://www.tbcare1.org/pdfs/TB_CARE_I_Supported_Activities_Paris_2013.pdf

http://www.tbcare1.org/publications/union

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With the launch of Year 4, TB CARE I began 21 new core projects bringing the total number of core projects to 128 (Years 1-4). As of December 2013, 95 projects are fully complete (77% complete when excluding cancelled projects).

100% of Year 1 and Year 2 projects, 74% of Year 3 projects and 10% of Year 4 projects have been completed (when excluding cancelled projects). In total, 28 core projects continue to be implemented.

All completed tools can be found on the TB CARE I website http://www.tbcare1.org/publications/

Year 1 Year 2 Year 3 Year 4

Completed

Ongoing

Cancelled

50

42

26

25

219

9

3 1 1

40

30

20

10

0

Status of core projects started in Year 1-3

Core Projects

Sputum Sample Testing with GeneXpert, Zambia - Roberston Chibumbya

www.tbcare1.org/publications

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Code Partners Title Expected Deliverable(s) Year 4 Progress to date %Complete

C1.12 WHOATSFHI 360KNCVMSHURC

Manual for TB screening in risk groups

1. Field test, assessment (One summary report from each country case study); 2. Meeting (Meeting report); 3. Tool, Document (Manual including toolbox)

A first draft of the manual, including a tool to help prioritize risk groups and choice of screening algorithm, has been developed and is under review. Country case studies will begin in Quarter 2. 20%

C1.13 ATSWHO

ISTC ed. 3 (International Standards of Tuberculosis Care)

1. Stakeholders Meeting; 2. Publish ISTC ed. 3 as an electronic version & develop a mobile application; 3. Update existing training modules; 4. Develop collaboration & dissemination strategies between National TB Programs (NTPs) & the private sector in targeted high burden countries and update Handbook for Using the ISTC; 5. Develop a process for timely and routine updates

A stakeholders meeting held at Union conference provided input into final version of ISTC. A mobile app version was beta tested. The ISTC v3 will be launched on World TB Day and will be published in Annals ATS. An editorial will also appear in the IJTLD. 30%

C1.16 ATSWHO

Contact investigation guidelines

1. Workshop; 2. Train the Trainers on new WHO Contact Investigation

The workshop on contact investigation was held at the Union Conference and addressed guideline implementation at country level including data collection and performance evaluation.

50%

C1.22 The UnionWHO

Childhood TB online training

e-learning training tool Training material are being developed. 5%

UNIVERSAL ACCESS

Approved Year 3 Core Projects & Completed Year 2 Projects

10


C2.07 KNCV Develop the Benin NRL to join the SRLN

The Benin NRL has achieved an advanced level laboratory quality management system to achieve SNRL status and start the application process for ISO 15189:2012 accreditation.

TA visits will begin in 2014.

5%

C2.10 WHOKNCVMSH

Xpert Global Forum 1. Meeting (participants share experiences in Xpert MTB/RIF scale-up and implementation); 2. Document (summarizes meeting presentations, discussions and lessons learned)

The meeting is planned for April 10-11, 2014.

10%

C2.14 KNCVMSHThe UnionWHOCDC

Rollout of quality indicators for WHO lab techniques

1. Guide on evaluation & troubleshooting of quality performance indicators for WHO-recommended laboratory techniques (LPA and Xpert); 2. 2 meetings (1 virtual) on product development & roll-out; 3. Presentation of the final product at Geneva GLI meeting

Document structure has been agreed upon. List of indicators under review.

5%

C2.15 KNCV GLI Stepwise Process towards TB Laboratory Accreditation

A lessons learned document with experiences from 3 African NRLs and international experts

No technical progress to report.5%

C2.17 The UnionJATA

Network Accreditation 1. 3 consultants are mentored and assessed during country visits in the use of the microscopy network accreditation tool; 2. Assessment (TB microscopy networks of 3 countries have been assessed and recommendations towards accreditation have been given)

All visits have been scheduled (Benin, Uganda & Cambodia).

5%

C2.21 The Union GeneXpert Zimbabwe 14 Gene Xpert machines installed in 14 district laboratories.

Machines have been purchased. A TA visit from Antwerp SRL is scheduled for February. 10%

C2.22 FHI 360 GeneXpert Zambia 1. Supervisory support visits (4); 2. Provincial trainings (4); 3. Strategic Meetings (4)

The first strategic meeting will be held on January 7, 2014 to plan for the two trainings and quarterly supervisory visits. 10%

C2.23 KNCV GeneXpert Nigeria 1. Review and updating of Xpert MTB RIF assessment checklist, supervision checklist and calibration SOP; 2. Xpert M&E guidelines & training tools; 3. 1 workshop, 2 ToTs

National review team was developed and will convene in Quarter 2. Training activities are planned for April-May.

10%

C2.24 KNCV GeneXpert Ethiopia 1. TA for Xpert DR-TB strategy (including algorithm); 2. ToT training for laboratory personnel & clinicians; 3. TA on mentoring and supportive supervision

Preparation underway for TA in early February.

5%

LABORATORIES

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C3.07 PiHKNCV

Capacity building in TB-IC 1. Training (Harvard Summer Course); 2. 8 mentored field visits (MFVs), 1 week each, in a country where IC mentors are working and/or providing TA; 3. TB Design Roster on GHDonline.org

Mentors-to-be have been selected. Support materials for mentors (developed in Years 2 & 3) are being revised. First MFV is planned for Quarter 2. 10%


C4.05 KNCVWHOMSH

Ambulatory care 1. Comparison framework for best practices on psycho socio-economic support (PSS) for DR-TB patients; 2. Best practices document; 3. Lessons learned for sustainable patient centered PSS systems

The draft comparison framework was developed and is being refined by the partners.

5%

C4.06 PIH / TB CARE IIKNCV

Drug-resistant TB Learn-ing Site

1. Webinars (3-4 series); 2. Case Catalog 12-18 new cases from Russia, Peru, Kazakhstan, Haiti, etc.; 3. A self-guided quiz series

Two case discussions were carried out with input from the expert panel. 10%


C5.13 KNCV Strengthen Xpert use for TB case detection among PLHIV (PEPFAR)

1. Assessment visits to Nigeria & Zimbabwe to determine the requirements for GeneXpert implementation & routine use in HIV settings; 2. Final workplan

Assessment visits to both Zimbabwe and Nigeria completed. Final workplan reviewed by country teams and USAID/W--budget preparation in process. Pilot activities to start by February 2014.

90%

INFECTION CONTROL

PMDT

TB/HIV

GHDonline.org

GHDonline.org

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C6.1.5 KNCV 3rd Kenya International Lung Health Conference

Participation of 3 TB health professionals in the Kenyatta International Conference.

TB CARE I provided support in organizing the participation of the nine people from Uganda, South Sudan and Ethiopia in the conference (Oct 2013).

100%

C6.1.6 KNCV Participation in Sondalo workshop

KNCV consultant, Kathy Fiekert, assisted the NTP-Af-ghanistan in the NSP workshop (November 2013) in Italy. Additional TA was provided through country funding.

100%


C7.04 WHOThe Union

Revised Definitions and Reporting Framework (RDRF) essential practical guidance

Training package available in all 6 official WHO languages.

Translation of the RDRF-TB 2013 document into Arabic, Chinese, French, Russian and Spanish is in process (expected February). The FAQ document is under review (expected January). Revised indicators & instructions on reporting TB data to WHO are being drafted (March).

17%


C8.01 WHOKNCVThe Union

New TB drug introduction 1. Tools to guide introduction of new TB drugs and adaptation for bedaquiline introduction; 2. Capacity building on use of tools; 3. WHO Expert Group Meeting on delamanid use for MDR-TB treatment & development of a “How-to” document.

The generic roll-out plan will be peer reviewed in February and then piloted in selected TB CARE countries. The data tool for the introduction of bedaquiline will be developed in Quarter 3. An expert group meeting on delamanid is planned in Geneva for April 15-16, 2014.

5%

M&E, OR & SURVEILLANCE

DRUG SUPPLY & MANAGEMENT

HEALTH SYSTEMS STRENGTHENING

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C1.15 KNCV Adapt and pilot PCA package

- End of implementation regional workshops- Final report of pilot implementation with results, recommendations for next steps, scale up and adaptation.

Final report will be available in February. Seven abstracts were presented at The Union conference in Paris: 2 oral (overall project and QUOTE TB Light in Cambodia) and 5 posters (2 Nigeria, 2 Zambia and 1 Indonesia).

100%

C4.4 KNCVJATAMSHWHO

Assessing the costs faced by MDR -TB patients

1. Development and validation of tool; 2. Consen-sus workshop to define policy recommendations

The tool has been finalized and it will be distributed through the TB CARE I network. 100%


C1.13 ATSWHOKNCVMSH

ISTC revision Document. Develop international standards for TB care ed. 3

ISTC edition 3 is complete.

100%

C2.11 WHOJATAKNCV

Internationally standardized implementation & training material for GeneXpert

Harmonized training tools and availability of Gen-eXpert training materials

Training modules available via WHO; broader dissemination forthcoming. 100%

C3.05 FHI 360KNCVMcGillPiH

TB-IC demonstration Ndola district

Safe work practices reducing TB transmission in 15 health facilities

A total of 675/1,561 (43%) health care workers and 64/137 (47%) community volunteers were screened between April-December 2013; 33 presumptive TB cases were identified from which 5 TB cases were diagnosed. The Ndola District Community Medical Office will continue the screening as a part of routine service provision.

100%

C3.07 PIHKNCVMSH

Building Capacity for IC Ten IC consultants ready to perform independent missions with distance support by mentors. Men-tored field visits.

Two mentored field visits were implemented successfully. Suitable visits for the mentees were limited. 100%

C6.12 WHOATSMSHPMU

Toolkit for TB strategic planning

Toolkit on TB Strategic planning Toolkit for TB strategic planning was developed and used during the NSP workshop in Italy. 100%

COMPLETED YEAR 3 PROJECTS

COMPLETED YEAR 2 PROJECTS

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TB CARE I currently has 19 active country projects; the Djibouti country project officially closed at the end of March, although limited activities continue through the regional mechanism (see pg. 27 for more information). Kenya completed activities this quarter in anticipation of close out in September 2013. The map above displays the geographic distribution and investment size of TB CARE I country projects.

PMDT

Preliminary 2013 MDR-TB data obtained from NTPs in the 18 active TB CARE I countries indicate a continued steady increase in MDR-TB diagnosis and treatment initiation. In 2013, an estimated 14,565 MDR-TB cases were diagnosed while 14,888 were started on second line treatment (see below). Diagnosis increased by 40% and 12% compared to 2010 and 2012 levels respectively. Treatment initiation was even more impressive with 85% more MDR-TB cases started on treatment compared 2010 (19% compared to 2012). Most importantly, the preliminary 2013 data show that countries are closing the gap between diagnosis and treatment of MDR-TB. Although data vary country to country, for the first time ever, more MDR-TB cases were put on treatment in 2013 than were diagnosed. This indicates that the backlog of diagnosed MDR-TB cases is beginning to be addressed and countries’ capacity to treat patients is improving. TB CARE I has contributed to these successes and will continue to invest heavily in PMDT to further accelerate diagnosis and treatment. The table on page 15 summarizes the number of MDR-TB cases diagnosed and put on treatment from 2010 to 2013 (estimated) in the 18 active TB CARE I countries.

Total number of MDR-TB cases diagnosed and started on treatment in active TB CARE I countries, 2010-2013

Large Investment

Medium Investment

Medium/Large Investment

Small Investment

0

3000

6000

9000

12000

15000

2010 2011 2012 2013

Diagnosed

Started on Treatment

Country Projects

TB CARE I countries, as of December 31, 2013, with the level of program investment indicated

15

Programmatic Management of Drug Resistant TB (PMDT)

Based on data obtained from NTPs in all TB CARE I countries, it is clear that progress is being made in both the diagnosis of MDR-TB and the initiation of second line treatment. Table 5 summarizes the number of MDR-TB cases diagnosed and put on treatment from 2010 to 2012, as well as preliminary numbers for the first two quarters of 2013.

In 2012, 14,169 MDR-TB cases were diagnosed across all TB CARE I countries, with 11,865 being put on treatment. Compared to 2010 figures (i.e. the start of TB CARE I), diagnosis increased by 33% and treatment initiation rose by 44% in 2012. Yearly totals across all countries are summarized below showing an increasing trend in diagnosis and treatment initiation. As the reported numbers for 2013 are preliminary and incomplete, it is too early to comment on global PMDT progress in 2013. However, several country-specific achievements are documented in the country highlights section of this report (i.e. Ethiopia, Indonesia, Kazakhstan and Uganda).

Number of MDR-TB cases diagnosed and started on treatment in active† TB CARE I countries, 2010-2013 (2010-2012 data are from the 2013 WHO Global TB Report; 2013 data were reported through the TB CARE I quarterly reporting process, as of December 2013. Numbers in orange were extrapolated for data that were not yet available.)

Countries2010 2011 2012 2013

2013 dataextrapolated for:#dx # put

on trt #dx # put on trt #dx # put

on trt #dx # put on trt

Afghanistan 19 0 19 21 38 38 49 47

Botswana 106 114 46 46 53 58 58 53

Cambodia 31 38 56 57 75 110 131 122

Ethiopia 140 120 212 199 284 289 284 289 2013

Ghana 4 3 7 2 20 2 38 23

Indonesia 182 142 383 260 428 426 1,053 804 *

Kazakhstan 7,387 5,705 7,408 5,261 7,608 7,213 7,079 6,905 Oct-Dec

Kyrgyzstan 566 556 806 492 958 775 1,120 1,107 Oct-Dec dx

Mozambique 165 87 283 146 266 213 128 295

Namibia 214 214 192 242 210 288 220 213 Oct-Dec

Nigeria 21 23 95 38 107 125 107 233 2013 dx, Oct-Dec trt

South Sudan 6 0 3 0 3 0

Tajikistan 333 245 604 380 694 535 1,065 666

Uganda 93 10 71 7 109 44 136 212 Jul-Dec dx

Uzbekistan 1,023 628 1,385 855 1,728 1,491 1,728 2,611 2013 dx, Oct-Dec trt

Viet Nam 101 101 601 578 273 713 918 922 Jul-Dec dx

Zambia 0 0 80 97 80 97 Jul-Dec dx; 2013 dx

Zimbabwe 17 27 118 64 149 105 368 288 Jul-Dec

Total 10,402 8,030 12,292 8,648 13,056 12,519 14,565 14,888

† Data for countries where TB CARE I is no longer working have been removed (Dominican Republic, Djibouti, Kenya)* Indonesia 2013 data include Rif-resistant patients

Active Case Finding Among the Elderly, Cambodia - Rajendra Yadav

16

MSH is the lead partner in Afghanistan with collaboration from WHO and KNCV; community-based DOTS activities are subcontracted to BRAC. The project works in universal and early access (UA), infection control (IC), health system strengthening (HSS) and monitoring & evaluation (M&E).

Health System Strengthening Leads to Improved Case Notification and Treatment Outcomes TB CARE I interventions (e.g., SOP implementation, urban DOTS, CB-DOTS and TB infection control) contributed to improved health systems to notify presumptive TB cases and increased access to TB services throughout 2013. In TB CARE I-supported provinces, there was a 13% increase in notified new sputum smear positive (SS+) cases compared to 2012 (7,507 cases in 2013). Between October-December 2013, 22,723 presumptive TB cases were identified from which 3,560 TB cases (all forms) and 1,564 SS+ cases were identified. When comparing 2013 data with that of 2009, there was a 119% improvement in presumptive TB case identification and examination for TB, 39% increase in TB case notification (all forms), and 22% improvement in new SS+ cases. Treatment success also improved from 83% (2009) to 90% in 2012.

Urban DOTS Contributes to Case Notification Urban DOTS is now being implemented in 66% of public and private health facilities in Kabul (73) - 44% more than the original 22 health facilities engaged in 2009. Between October-December 2013, 11% more TB cases (all forms) were notified (804) compared to the same period in 2012.

National Strategic Plan DevelopedTB CARE I assisted the NTP Afghanistan to finalize the NSP for 2014-2018. Support was provided in country as well as during the WHO-coordinated NSP workshop conducted in Italy in November.

Community Based DOTS Brought TB Services to the Door Step of TB patientsCommunity health workers (CHWs) located at least two hours walking distance from the nearest health facilities were trained on presumptive TB case identification, referral system and DOT provision. In the first quarter of Year 4, collectively, 2,058 presumptive TB cases were identified and referred by CHWs. Of these presumptive cases, 184 (9%) were diagnosed as new sputum smear positive cases and there were 476 TB patients that received their daily anti-TB pills from CHWs.

Afghanistan

Community Health Worker Review Meeting, Afghanistan - Dr. Soltan Mahmood

17

KNCV is the lead partner and sole implementer in Botswana. In Year 4 the project focuses on UA, laboratories and PMDT.

Community TB Care (CTBC) AssessedThe in-country Senior Technical Advisor participated in a data collection exercise in two districts for the evaluation of the CTBC research project to assess how it has contributed to the attainment of TB control efforts in the country. This research will guide the NTP to adopt an appropriate CTBC approach to be scaled up, taking into consideration the decline in funding in the near future. GeneXpert Rolled Out TB CARE I supported the roll out of GeneXpert to 6/14 planned health facilities, including the training of laboratory technicians. The instruments are being used to improve case detection among the MDR risk group and HIV+ presumptive TB patients.

Laboratory Supportive Supervision Provided and Priority Activities Identified The Chief Medical Laboratory Technician supported the district laboratories with on-site supportive visits to strengthen external quality assurance and implementation of acid fast bacilli (AFB) smear microscopy in laboratories. Two key issues noted were that recording and reporting still remain a challenge in the network and new members of staff who have been recently hired will need AFB microscopy training.

National TB Reference Laboratory (NTRL) Accreditation MaintainedTB CARE I supported the NTRL quality management system to review safety SOPs and to respond to the South Africa National Accreditation System’s (SANAS) annual external audit recommendations, which resulted in the NTRL retaining its status as an ISO 15189 accredited laboratory.

JATA is the lead partner in Cambodia, with collaboration from FHI 360, KNCV, MSH and WHO. The project has activities in seven technical areas (UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E).

Diagnosis of Pulmonary TB Among Children Increased TB CARE I continued to support implementation of childhood TB in 27 operational districts (ODs). Following efforts to improve the skill and use of chest x-ray by physicians, there was an increase in the proportion of pulmonary TB diagnosis among children, as well as an increase in uptake of Isoniazid Preventive Therapy (IPT). In the 27 ODs, 9,129 children in contact with pulmonary TB cases were referred from health centers to referral hospitals for further diagnosis. Of those, 1,400 (15.3%) children were diagnosed with TB and registered for treatment. The proportion of pulmonary TB diagnosed among children has been increasing each quarter -19% in Jan-Feb 2013, 21% in Apr-June 2013, 22% in Jul-Sept 2013, and 28% in Oct-Dec 2013.

Global Fund (GFATM) Resources MobilizedNTP submitted an interim funding application to the Global Fund for April-Dec 2014, to cover the period following the end of the current GFATM grant in March 2014. TB CARE I assisted the NTP to respond to questions from the Global Fund, as a part of the grant negotiation process. TB CARE I will assist the NTP to prepare the new strategic plan (2014-2020), which will be a critical document for the GFATM standard application.

e-TB Manager System FunctioningNine of the total 11 MDR-TB treatment sites and three laboratories are implementing e-TB Manager while the remaining two sites are not functional at the moment because no patient has been registered. Ninety percent of data for DR-TB patients enrolled since 2011 are uploaded in e-TB Manager. Monthly supervision to e-TB manager implementation sites is being conducted regularly to support health staff at PMDT sites in data entry and provide on-the-job training. A new data analysis tool has been deployed for testing and generating reports according to the customization requests of the NTP.

KNCV is the lead and sole implementer of TB CARE I activities in Kazakhstan where activities are carried out in six technical areas (UA, laboratories, IC, PMDT, HSS and M&E).

TB CARE I Outpatient Care Model Adopted Nationally The outpatient care model piloted in Akmola by TB CARE I received the support of NTP and MoH and will be expanded at the national level. The revised MoH decree (expected to be signed by the MoH in early 2014) also mandates the administration of outpatient care nationwide for the first time, using the admission criteria developed by TB CARE I. The outpatient care approach is included in the draft National TB Complex Plan for 2014-2020.

Botswana

Cambodia

CAR-Kazakhstan

18

KNCV is the lead and sole implementer in Tajikistan where it implements activities in six technical areas (UA, laboratories, IC, PMDT, HSS and M&E).

Outpatient Care Increases Local Awareness of TB The most significant achievement in the implementation of outpatient care in TB CARE I pilots has been the increased local municipal attention to issues of TB control and support for the TB affected population. TB CARE I’s approach is to involve local municipal authorities and community level stakeholders to strengthen ambulatory treatment. As a result of coordination meetings with government officials and decision makers, official orders and statements on the social support of TB/MDR-TB patients were issued at the regional level for implementation in all health care facilities. As a result, local municipal bodies responded by offering social support to TB and MDR-TB patients. In this quarter, innovative interventions for social support, including relief from property taxes and utility payments, provision of food packages and disability benefits, were introduced in two pilot districts (Temurmalik and Dangara). During this quarter no patient interrupted treatment - an encouraging sign that the approach is beneficial. TB CARE I also established a psychological support taskforce at the NTP, consisting of experienced TB specialists who started to provide patient counseling services throughout the country during outreach activities.

Xpert Troubleshooting and Maintenance Training ConductedDuring the quarter, TB CARE I trained laboratory staff from all Xpert sites on troubleshooting, qualitative maintenance and development of procedures for Xpert laboratories – the first time such a training was conducted in Tajikistan.

100% Treatment Enrollment in TB CARE I-Supported Pilot Sites All MDR-TB patients (21) that were diagnosed between October-December 2013 in TB CARE I’s nine pilots were enrolled on second line treatment. This is a huge improvement over the same quarter last year where no patients from Rasht area were enrolled on treatment due to lack of second line drugs. In this quarter, with technical support from TB CARE I, PMDT started in two additional districts (Farhor and Baljuvan).

Key Stakeholders Engaged in TB-IC ActivitiesRepresentatives of the Republican Sanitary Epidemiological Service (SES) were involved in all activities this quarter, including training on development of TB-IC plans for TB health facilities, assessment of TB-IC risk transmission and supervision monitoring visits. In the past this was uncommon, and SES personnel are now expressing their interest in further collaboration.

R&R Forms Updated TB CARE I supported the revision of TB case definitions and the reporting framework in accordance with the new WHO requirements. All R&R forms were revised and instructions were developed for use in health facilities.

CAR-KyrgyzstanAs the lead and sole implementer of TB CARE I activities in Kyrgyzstan, KNCV implements activities in six technical areas (UA, laboratories, IC, PMDT, HSS and M&E).

National Laboratory Plan Finalized TB CARE I facilitated the finalization of the National Laboratory Plan and its submission to the MoH for approval.

Xpert Machine Access Improved Relocation of two former TB REACH Xpert machines to Batken and Talas sites was approved by the MoH in accordance with the National Laboratory Plan and the GeneXpert strategy to ensure better coverage and access to GeneXpert across the country. TB CARE I organized the relocation and installation of the two Xpert machines this quarter. TB CARE I-Support Policies Approved Several policy documents developed through TB CARE I support, were approved this quarter, including Instructions on TB-IC, methodical recommendations on palliative care of TB patients, regulation of MDR-TB consiliums, regulations on day care hospital, and regulations on inpatient department for MDR-TB.

Reporting & Recording (R&R) Forms Updated TB CARE I facilitated the process of the revision of National R&R forms in accordance with the new WHO case definitions and submitted them to the MoH for approval.

CAR-Tajikistan

19

WHO is the lead partner in Uzbekistan with KNCV as a close collaborating partner. Activities in Year 4 cover six technical areas (UA, Laboratories, IC, PMDT, HSS, and M&E).

PMDT Pilots AssessedImplementation of the MDR-TB program in three new TB CARE I pilots (Kashkadarya, Bukhara and Navoi regions) was assessed during the regional Green Light Committee (GLC) mission by a WHO PMDT consultant. Key recommendations were to improve PMDT operations and functionality through the PMDT coordinating body (expert commission/consiliums), establish a Central Consilium for country level supervision and consultation, empower regional consiliums, strengthen follow-up of treatment effectiveness and case management, and improve adherence to treatment. TB CARE I will support the piloting of regional level expert commissions.

KNCV is the lead partner in Ethiopia, working closely with collaborating partners MSH, WHO and The Union, as well as subcontractor German Leprosy and TB Relief Association. The Year 4 workplan has activities in all eight technical areas.

Increased Attention on Childhood TBTB CARE I has been leading the preparation of the childhood TB control framework and lobbying for improved emphasis and action by the MoH on childhood TB issues. Strengthening childhood TB prevention and control in the country is now being given due emphasis by the MoH and the five year strategic plan is now aligned with the new global roadmap for childhood TB.

Engaging Civil Society Organizations (CSOs) Contributes to Active Case FindingEngagement of a women’s association in TB activities in two sub-cities has shown positive results. The CSO has contributed to active case finding (176 presumptive TB patients referred, 109 reached health facilities, and eight new TB diagnosed), conducted awareness raising activities (~50,000 people received TB messages) and started two patients who were previously lost to follow up back on treatment.

Contact Investigations Piloted Contact investigations have been piloted in one zone since April 2013. TB CARE I-supported activities have included supportive supervision and follow up, and tool roll-out and training in 20 health facilities. Case notification has increased (900/100,000) compared to estimated case finding in the general population (168/100,000). Provision of IPT has also started among pediatric contacts under five with 28% (64/227) of pediatric contacts having started IPT. Moreover, operations research to assess implementation of contact investigations among children ≤5 yrs who are contacts of smear positives has been conducted in Addis Ababa by TB CARE I; based on the findings, an intervention plan was developed to strengthen pediatric contact screening and IPT in the region.

Ethiopia

TB Infection Control Lab Assessment, Bukhara, Uzbekistan

CAR-Uzbekistan

20

MSH is the lead partner in Ghana with support from KNCV and WHO as collaborating partners. The Year 4 workplan focuses on seven technical areas (UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E).

Zero Draft of the New NSP DevelopedIn November 2013, TB CARE I helped the NTP developed a zero draft of the new five year NSP during the WHO-coordinated NSP workshop in Italy. The proposed goal of the plan is “To reduce TB prevalence by 25% by 2020 compared to the 2013 baseline level of 92 per 100,000 population”. As the previous strategic plan expired in December 2013, this new plan will meet the requirements for the NTP to access funds from the Global Fund under the new funding model. It is expected that the final NSP will be ready in July 2014. TB CARE I will provide technical assistance in the finalization of the strategic plan (including performing epidemiological analysis), as well as the development of the GFATM concept note.

National Tuberculosis Prevalence Survey Field Work Successfully CompletedThe prevalence survey fieldwork in all 98 clusters was successfully completed in December 2013 as scheduled. Overall 101,767 people were surveyed of which 69,020 were ≥15 years; 67,710 clients fulfilled eligibility criteria for the survey and 61,477 were screened as per the survey standard operating procedures (SOPs). To date, a total of 61,224 clients consented to fully participate in the survey thus analyses will be focused on these participants. TB CARE I contributed to the success of the field data collection by ensuring that data management was well-coordinated throughout the entire process. Currently the survey team is performing data cleaning before a comprehensive and final data analysis begins. Preliminary data could be available in March 2014.

TB Performance in the Six Hospitals Improved In January 2014 monitoring and support visits were undertaken in the six hospitals implementing the intensified hospital based TB case detection intervention. Comparative analysis between 2013 and 2012 shows that there was an overall 2% increase in TB case detection (529), 29% increase in TB cases among children aged 0-14 years (22) and a reduction in TB mortality by a factor of 38% (33 deaths in 2013).

TB Case Finding Data of the Northern Region ValidatedIn November 2013, TB CARE I supported the validation of TB case data in the 26 districts of the Northern Region. Districts swapped district TB treatment registers to review each other’s data and then compared the district data with the regional level record. During the first three quarters of 2013, 14 districts under reported by 50 TB cases (all forms) and two districts over reported by 10 TB cases (all forms). TB CARE I and the NTP have worked with the Districts and the Region to address the reasons for the inconsistencies. This approach is being rolled out nationwide.

Ghana

TB CARE I Worker with Stop TB Drug Kit, Indonesia - Maarten van Cleeff

21

Indonesia is the largest of the TB CARE I countries in terms of financial investment; KNCV is the lead partner with collaboration from all other Coalition partners; TB CARE I-Indonesia works in all eight technical areas.

Lessons Learned From Engaging Private Pulmonologists CapturedBest practices and lessons learned on engagement of private pulmonologists in DKI Jakarta, Banten and West Java have been collected. These lessons will contribute to the finalization of a best practices document for pulmonologist involvement. It includes linking the data and management information system to SITT (TB Information System) to enable online upload of data from private practices and hospitals.

Key Guidelines for Engaging Private Providers DevelopedTo ensure service quality of private providers, the Indonesian Medical Association with assistance from TB CARE I has drafted guidelines for implementation of the private provider certification system. This certification guideline is also based on the TB CARE I-supported Clinical Practice Guideline for TB Care (PNPK) (finalized), which provides the legal umbrella for ISTC, which is essential to ensure standardization of quality TB care from private providers and hospitals.

Xpert Use Scaling Up TB CARE I supported the installation of one Xpert machine in Riau this quarter, bringing the total number of operational machines to 18/41 planned. Five more Xpert machines will be installed in January 2014 and another 18 machines will be installed following establishment of the new PMDT sites. This quarter 1,831 cartridges were used for screening presumptive MDR-TB patients and PLHIV. This resulted in 1,016 new MTB+ cases being diagnosed (699 RIF-sensitive, 317 RIF-resistant).

Certified Drug Sensitivity Testing (DST) Laboratories Being EstablishedThe BLK Jayapura has been officially certified for first line DST, which brings the total number of certified C/DST laboratories in Indonesia to seven.

PMDT Expansion ContinuesTB CARE I successfully assisted PMDT expansion from 10 to 13 sites. The three new sites are outside TB CARE I-supported areas and are fully operational. The number of PMDT satellites increased by 38 (from 375 to 413). During the quarter, all sites succeeded in screening 1,241 presumptive MDR-TB cases, of which 272 were confirmed as MDR-TB and 239 (88%) were put on treatment.

Piloting Planned to Address MDR-TB Patients Lost to Follow Up To address the increasing MDR-TB patient loss to follow up rate, TB CARE I has prepared a proposal for DR-TB cohort review to be piloted at Persahabatan Hospital in February. The proposal includes a format for the cohort review process, adapted cohort tools for Indonesia, evaluation of available databases to assess what information is available for the cohort review, and a country-specific SOP for pilot review. IPT Scaling Up The successful IPT approach piloted in four hospitals resulted in inclusion of IPT in the national policy. The National TB/HIV Forum now supports IPT scale up in eight provinces with TB CARE I’s technical assistance.

National Strategy Developed The current TB national strategy plan 2010-2014 was updated with TB CARE I support to bridge the period of 2014-2016. This updated plan, which is currently being finalized, maintains the objectives and seven strategies of the original version of 2010-2014 but in line with the Post 2015 Strategy and puts more emphasize on stronger policy regulation, broader and more rapid DOTS, TB/HIV and MDR-TB services expansion, and wider civil society engagement.

Results of Operations Research on TB Financing AppliedTB CARE I completed operations research on the role of national health insurance in financing TB services, the cost of scaling up TB services in Indonesia, the economic burden of TB in Indonesia, and a study on the impact of TB on patients’ household expenditures. The results of these studies are being disseminated to high level officers in all provinces and used for development of the updated NSP. These studies will also be used to develop effective advocacy messages to influence national and local government to provide sufficient funding.

Preliminary Results of Prevalence Survey AvailableTB CARE I continued its technical assistance for monitoring the National TB Prevalence Survey, conducting field supervision to DKI Jakarta, West Java and West Kalimantan. Assistance was also provided for data cleaning and data analysis of preliminary results (data from 67 clusters have been analyzed). Preliminary ‘halfway’ results of the NPS suggest that SS+ prevalence levels are higher than previously estimated (319/100,000), rural prevalence levels are higher than urban, 15% of symptomatic SS+ cases are accessing health services and currently on treatment, gaps between prevalence and notifications are greater in men and the oldest age group, and roughly one third of detected TB cases do not have any symptoms.

Global Fund Audit Supported TB CARE I assisted NTP in preparation of the audit from the Office of the Inspector General (OIG) of GFATM. The audit team focused on assessing ‘quality of services’’ as a measure of ‘value for money’. Following the OIG recommendation to improve supervision, TB CARE I assisted in the inclusion of Rapid Service Quality Assessment elements into the NTP supervision checklist. The OIG’s report has not yet been released.

Indonesia

22

FHI 360, the lead partner for Mozambique, works with collaborating partners KNCV and MSH on a dual TB/malaria workplan. The Year 4 workplan has activities in all eight TB technical areas, as well as malaria control.

Active Case Finding Scaling UpMSH has started rolling out the active case finding strategy to two more provinces (Zambézia and Nampula), after successfully piloting the use of SOPs in selected hospitals of Gaza Province. The strategy will intensify TB case detection efforts both in the health system and community level to ensure that all presumptive TB cases are diagnosed.

CHWs Engaged in TB ControlDuring the quarter, trained CHWs in all seven TB CARE I provinces referred 8,011 presumed TB cases (51% female) to health facilities for diagnosis. Among those referred, 1,930 were diagnosed with TB (all forms), representing a detection rate of 24%; and 1,451 were SS+TB cases. Contacts tracing improved, with 1,227 contacts of all SS+ cases being referred. In terms of TB/HIV co-infection, 404 cases were identified among the SS+ identified cases.

National Laboratory Strategic Plan DraftedTB CARE I supported the drafting of a national laboratory strategic plan, which detailed steps to ensure quality implementation of the microscopy network. The plan is under review and will be finalized early in 2014.

Barriers to TB Services IdentifiedThe Knowledge, Attitude and Practice (KAP) study was finalized and results were presented at a dissemination meeting. The study identified individual barriers as myths, misconceptions and lack of knowledge on TB transmission and prevention. Institutional barriers included lack of involvement and weak collaboration between TB services and local leadership in improving and strengthening access to TB services.

Drug Funding Gap IdentifiedTB CARE I supported NTP in updating the funding gap analysis for anti-TB drugs. The analysis was done in line with the drug quantification exercise for 2014 and US$ 6,847,745 was identified as needed for 2014 of which 58% (US$ 3,977,610) will be covered by the Global Fund (TFM year 1 and 2), 8% (US$ 555,932) by Supply Chain Management System, 3% (US$ 200,788) by the Government of Mozambique and 31% (US$ 2,113,415) without an identified funding source.

Malaria National Meeting SupportedThe project supported the Malaria National Meeting, a venue for sharing and discussing major malaria achievements and challenges at all levels. All Provincial Medical Heads, Provincial Malaria Program Managers, central level staff and partners participated in the 3-day meeting.

KNCV is the lead partner in Namibia and collaborates with WHO and The Union. Activities are implemented in six technical areas (UA, IC, PMDT, TB/HIV, HSS and M&E); TB CARE I also plays a role in the 3 I’s project being implemented in Namibia.

TB/HIV Symposium Disseminates Results The first ever TB/HIV symposium was held in Windhoek as a result of collaboration between the MoH and Social Services, University of Namibia, and University of Borstel from Germany with the technical and financial support of partners, including TB CARE I. The symposium increased awareness on TB/HIV collaborative activities in the country as well as raised the interest in operations research and information sharing/results dissemination. As a result, a local forum for sharing research results was created.

Operations Research Results AnalyzedAn operations research training course was conducted in Namibia during the quarter. This follow-up training course focused on data analysis and report writing and was attended by 30 participants who consisted of authors of the five research topics that were approved by the Ministry. Data collection was complete for all teams and data cleaning and analysis dominated most of the training period.

Strategic Plans Aligned The annual retreat for the Directorate of Special Programs was held in which strategic plans of the directorate were reviewed to align them with the Ministerial strategic plan. Participation of TB CARE I in these retreats was found to be very useful in identifying gaps in funding and for ensuring inclusion of relevant activities in the project and NTP planning process.

3 I’s Project UnderwayThe joint USAID/CDC 3 I’s plan is being finalized, but key activities are being implemented. CHW recruitment guidelines were developed and presented to the TB/HIV Steering Committee for endorsement. The training curriculum for CHWs was developed and is currently under review by the TB/HIV technical working group and implementing partners.

Mozambique

Namibia

23

KNCV is the lead partner for Nigeria and works closely with collaborating partners, FHI 360, MSH and WHO. The Year 4 workplan addresses all eight technical areas using both PEPFAR and Child Survival and Health (CSH) funds.

Partners Mapped at State levelThe most significant achievement was the detailed mapping of state level partner areas of intervention in collaboration with the NTP. A mapping of PMDT activities and a harmonized workplan was developed to ensure effective state level coordination. TB CARE I will be supporting the commencement of 100 patients on ambulatory PMDT in these eight states starting next quarter. Additionally, two new e-TB manager sites were activated at JUTH and Sacred Heart Hospital, Abeokuta. All existing PMDT sites in country have e-TB manager.

National Strategic Plan DraftedTB CARE I supported the development of an NSP for Nigeria through a three-week TA visit from KNCV and WHO consultants. A draft was developed and the plan is expected to be finalized in January 2014.

GeneXpert testing and results in TB CARE I-supported sites, 2012-2013

Xpert Scale up Continues The graph above illustrates an improvement and uptake in GeneXpert service utilization in TB CARE I-supported sites. In 2013, there was a 189% increase in sputa tested over 2012 data. Similarly, the number of MTB+ cases detected increased by 158% and RIF-resistant cases by 64% from 2012 to 2013.

Community Volunteers Help to Diagnose TB TB CARE I also continued to promote CTBC activities in selected states through involvement of key community leaders and community volunteers to identify and refer patients appropriately. Through these initiatives, a total of 1,596 presumptive TB cases were referred for AFB microscopy testing from which 30% or 486 TB cases (all forms) were notified. A total of 220 TB patients are being managed by community volunteers.

Active Case Finding Being Scaled upHouse-to-house screening, community awareness outreach and contact tracing of index patients were carried out in communities of Edo, Niger, Oyo and Katsina states to increase the number of notified cases. A total of 1,058 presumptive TB patients were referred from which 315 TB cases (all forms) were notified. Due to the yield in additional case finding, the NTP and other partners are reprogramming GFATM funds to scale up such interventions.

0

2000

4000

6000

8000

10000

12000

Total Sputa Tested MTB+ Detected MTB+ With RIF+

10407

2953

5393281144

3595

2012

2013

MDR-TB Patient Supported by CB-DOTS Provider, Nigeria

Nigeria

24

The Union is the sole implementer of this small project. The Union met with NTP staff at the Annual Conference in Paris and reached agreement on the organization of a national stakeholder workshop in the first quarter of 2014. This workshop would review national progress and challenges in PMDT scale-up and develop technical guidance on the introduction of ambulatory MDR-TB care, as well as a short MDR-TB regimen of nine months.

MSH is the lead partner in South Sudan and works closely with collaborating partners KNCV and WHO. The project implements activities in seven technical areas (UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E).

Laboratories RenovatedRenovation of seven laboratories was completed during the quarter. Due to the travel ban outside Juba, TB CARE I is planning to engage partners supporting these facilities to take photos of the renovated laboratory to verify the work performed.

Advocacy Conducted for TB servicesThe NTP and the TB CARE I Country Director presented an overview of TB services in South Sudan to the NGO health forum. As a result, three NGOs agreed to start TB services in the areas where they work.

Epidemiological Analysis ConductedTechnical assistance was provided with the support of TB CARE I core funds to improve the capacity for and availability of high quality data for supporting TB program review, planning and management in South Sudan. The report of the epidemiological analysis produced through this TA will be used to guide the upcoming program review and development of the new strategic plan for TB. The main recommendation is to ensure a more systematic and sustainable approach to M&E for TB including the development of necessary standardized M&E guidelines for all levels in the system.

TB CARE I-Uganda closed out officially in December 2013. KNCV was the lead and sole implementing partner in Uganda. The project focused on four technical areas (UA, PMDT, TB/HIV and HSS). Key results from the 21-month project are highlighted below.

Treatment outcomes Improved in Kampala To address poor patient adherence and weak M&E systems in Kampala, TB CARE I implemented several activities including conducting trainings to boost support supervision capacity; providing airtime to TB clinics and division TB focal persons to follow-up TB patients on treatment to improve adherence, mentoring division TB focal persons and TB clinic staff on management of TB patient records, and supporting quarterly data exchange and performance review meetings. As a result, TB treatment success rate for Kampala increased to 70% in 2012 from the baseline of 49% in 2011 and it has been sustained at nearly the same level in 2013 with rates of 68%, 70% and 71% for first, second and third quarter, respectively.

PMDT is Being Scaled Up TB CARE I supported the NTP to strengthen capacity to initiate and implement a quality MDR-TB program through numerous activities. Mulago National Referral Hospital was fully remodeled and equipped as a 39 bed capacity MDR-TB isolation ward. The number of MDR-TB patients enrolled on treatment at three TB CARE I-supported PMDT sites has increased from 16 in 2011 to 44 in 2012 and 81 between January-September 2013.

ART Uptake Improved To improve ART uptake by HIV+ TB patients TB CARE I helped to reactivate the National Coordination Committee and to conduct TB/HIV joint support supervision nationwide. In 2012, ART uptake for HIV+ TB patients increased to 49% compared to only 32% in 2011. Improvements continued in the first (51%) and second quarters (57%) of 2013.

National Planning Supported TB CARE I supported the development of the 2012/2013-2014/2015 TB National Strategic Plan and the 2012/13 Annual implementation plan. Both documents have been approved by the MoH and are being implemented.

Nationwide Treatment Success Improved TB CARE I support has likely contributed to the improvement in the national TB treatment success rate, which rose from 71% in 2011 to 77% in 2012.

Senegal

South Sudan

Uganda

25

KNCV is the lead partner in Viet Nam and works with collaborating partners MSH and WHO. The Year 3 workplan has activities in all eight technical areas.

TB Diagnosed and Treated Among Children As of Dec 2013, management of TB in children has been implemented in four provinces with TB CARE I support and in three other provinces with GFATM support. In TB CARE I-supported provinces a total of 629 children were screened and managed during the last quarter of 2013 from which 49 pediatric TB cases (all forms) were detected. Among 276 children eligible for IPT, 188 (68%) were put on IPT.

Xpert Continues to Diagnose TB and RIF-ResistanceIn the final quarter of 2013, 1,924 presumptive MDR-TB patients and 630 presumptive TB patients (PLHIV and children) were tested with Xpert. Among the presumptive MDR-TB patients, 1,146 (60%) were MTB+ of which 301 (26%) were RIF-resistant. Among the presumptive MDR-TB patients, 78 (12%) were MTB+ of which 14 (18%) were RIF-resistant. Through a UNITAID project, TB CARE I helped the NTP to expand Xpert use into five new provinces.

Advocacy Results in Increased Government FundingFollowing multiple advocacy activities by the NTP and partners including TB CARE I, the threat of a 50% government budget cut in 2014 for TB control has been averted. The MoH in December requested the NTP develop a VND 153 billion workplan (63 billion government budget). Together with the STOP TB Global Drug Facility grant for 2014, the looming TB drug crisis will be averted.

Government Collaboration HighlightedTB CARE I was selected as an example of the joint efforts of Viet Nam and US government (PEPFAR) in responding to TB and HIV-related issues. Representatives from the US Department of State and USAID-Viet Nam toured a TB CARE I-supported PMDT site.

Viet Nam

Hanoi Lung Hospital, Viet Nam - Matthieu Zellweger

26

FHI 360 is the lead partner in Zambia and works closely with collaborating partners KNCV, WHO, and MSH. Two workplans are being implemented in Zambia: a CSH-funded workplan (consisting of UA, laboratories, IC, PMDT, HSS and M&E) and a 3 I’s workplan (UA, laboratories, IC, TB/HIV, HSS and M&E)

National Specimen Referral System EstablishedTB CARE I supported the finalization of the establishment of a national specimen referral system that will be initially implemented in the Central, Copper belt, Eastern, Muchinga and Northern Provinces. Sixty-seven people received training on SOPs and algorithms for specimen packaging for transport to the NTRL. The participants included MOH provincial laboratory staff members, TB focal point persons and ZAMPOST staff. The transportation contract was also finalized with ZAMPOST and the transportation of samples to the NTRL started this quarter. TB CARE I will be monitoring the turnaround time for the laboratory results for the samples from the referring facility to the NTRL and anticipates the time to be reduced. Prevalence Survey on Track TB CARE I conducted six TA visits this quarter to support the ongoing prevalence survey. The survey began in August 2013 and the consultants are providing support to the Data Management Unit, the three referral laboratories and field implementation. A table of indicators was developed to capture the data from the sampling sites in the household survey that consists of 66 participating clusters of households. The clusters were calculated from the census supervisory areas (CSAs) by the National Central Statistics Office. Recommendations were also provided to the NTP and partners that included the support for field travel of staff members to check the quality of the digital data collection process.

National Strategic Planning SupportedTB CARE I and other key partners supported the NTP at the NSP workshop in Italy. The Zambia NSP was revised in line with WHO and GFATM recommendations for the new funding model. The team continued to integrate these changes following the workshop; a stakeholders meeting to review the plan will be held in January 2014.

3 I’s workplanIntensified Case Finding (ICF) Quality measurement Tool Implemented TB CARE I, working with partners implementing the 3 I’s project, developed a quality measurement tool that focuses on measuring process indicators in a health facility, thereby providing information that would otherwise not be routinely reported through the TB notification system. This methodology, TB QUAL (for TB ICF quality assessments under the 3 I’s), uses patient chart abstraction to identify gaps in facility ICF processes, thereby alerting providers where the lapses are in the health system. TB CARE I carried out chart abstraction in three of the 18 target sites this quarter.

Community Volunteers Trained TB CARE I project conducted TB/HIV trainings for community based TB/HIV volunteers (105) supporting the 3 I’s project in Kabwe, Central Province. The volunteers will participate in the implementation of both facility and community level activities in ICF efforts that include case finding, contact tracing and patient counselling on TB and HIV management.

Zambia

Patient Centered Approach Data Collection Exercise, Zambia - Steven Bwalya

27

Djibouti

Center of Excellence (CoE) for PMDT

East Africa Supranational Reference Laboratory

Zimbabwe is led by The Union and has KNCV and WHO as collaborating partners. The Year 4 workplan focuses on seven technical areas (UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E).

CD4 Testing Machines Will Facilitate Early Initiation of ARTA total of 17 point-of-care CD4 testing machines were installed at 17 integrated TB-HIV care (ITHC) sites in December 2013; the remaining six will be installed in the first week of January 2014. Two nurses from each site were trained on the use of the machines in December 2013. By the end of the reporting period, 994 CD4 count tests were done at the ITHC sites. This is expected to facilitate early initiation of PLHIV on ART. Early initiation of patients on ART and constant monitoring of CD4 counts will improve patient outcomes.

Xpert Being Scaled Up Seven GeneXpert machines were installed in November 2013. Eight out 14 PEPFAR core project machines were installed in December 2013. The remaining six will be installed in early January. A total of 1,087 Xpert tests were conducted in the period under review. From these tests, 236 (22%) patients were MTB+, of which 46 (19%) had RIF resistance. The patients diagnosed were managed according to the national guidelines.

Waiting Area Infection Control Improved A total of five patient waiting shelters were completed this quarter, which reduced overcrowding and improved ventilation.

TB/HIV Integration Continues to ImproveBy the end of the quarter, all 23 supported ITHC clinics were screening patients for TB, practicing health facility-based DOT, and initiating patients on TB treatment; 21 clinics were initiating patients on ART. At the 23 ITHC sites, 38,869 HIV+ patients were screened for TB. The national targets for TB/HIV are to test all registered TB patients for HIV, and to commence all HIV+ TB patients on CPT and ART. At the 23 ITHC sites, 779 out of 908 TB patients (86%) had recorded HIV test results. Of the 568 TB patients with HIV+ results, 490 (86%) were started on CPT and 381 (67%) were started on ART. Training, mentorship of nurses at established centres of excellence, and supportive supervision have been intensified to reach the desired targets.

Implementation of an Electronic Register CostedA situational analysis was conducted followed by the development of a costed operational plan for the national electronic TB register. The piloting in 14 districts and one city will be done in Quarter 2.

In addition to the aforementioned country and core programs, TB CARE I currently manages four regional projects.

The CoE for PMDT project is implemented by KNCV. The project developed the schedule and publicity material for international trainings planned for 2014 (March: Basic TB Infection Control, May: PMDT, July: Integrating TB/HIV management, September: Laboratory services for MDR-TB).A poster summarizing past trainings was exhibited at the Union Conference in Paris.

The Union, the lead partner, works closely with KNCV/KIT on the SNRL project. Year 4 technical activities began after the reporting quarter as the workplan was approved (along with a costed business plan) in January 2014.

The ECSA project is led by KNCV. A policy document on management of MDR-TB failures will be completed in Year 4.

Djibouti has closed as a TB CARE I country project, but Regional funding and country project savings supported a few key activities conducted by KNCV through December 2013. A training of trainers was held in December for 15 doctors and program officers on TB-IC, and the TB-IC guidelines (in French) were finalized, approved by the MoH, and printed.

Zimbabwe

Regional Projects

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TB CARE

We would like to acknowledge all the people across the world who make TB CARE I possible; our gratitude and thanks go out to all our partners and everyone in the field.

Design and layout - Tristan Bayly

© TB CARE I 2014

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www.tbcare1.org

TB CARE I Report Quarter1 Year 4

Documents