TB CARE IPROGRAM YEAR 3QUARTER ONE PERFORMANCE MONITORING REPORTOctober 1, 2012 – December 31, 2012

February 14, 2013 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)

TB CARE

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Table of Contents

List of Abbreviations .................................................................................................................................................................................................... 31. Introduction .................................................................................................................................................................................................. 42. Program Management Unit (PMU) ............................................................................................................................................................. 43. Knowledge Exchange ................................................................................................................................................................................... 64. Core Projects .................................................................................................................................................................................................. 75.1 Afghanistan .................................................................................................................................................................................................... 145.2 Botswana ........................................................................................................................................................................................................ 155.3 Cambodia ........................................................................................................................................................................................................ 155.4 CAR-Kazakhstan ............................................................................................................................................................................................ 155.5 CAR-Kyrgyzstan ............................................................................................................................................................................................ 165.6 CAR-Tajikistan .............................................................................................................................................................................................. 165.7 CAR-Uzbekistan ............................................................................................................................................................................................. 165.8 Djibouti............................................................................................................................................................................................................. 165.9 Dominican Republic ...................................................................................................................................................................................... 175.10 Ethiopia ........................................................................................................................................................................................................... 175.11 Ghana .............................................................................................................................................................................................................. 185.12 Indonesia ....................................................................................................................................................................................................... 185.13 Kenya .............................................................................................................................................................................................................. 195.14 Mozambique .................................................................................................................................................................................................. 205.15 Namibia........................................................................................................................................................................................................... 205.16 Nigeria ............................................................................................................................................................................................................ 205.17 Senegal ........................................................................................................................................................................................................... 215.18 South Sudan .................................................................................................................................................................................................. 215.19 Uganda ............................................................................................................................................................................................................ 215.20 Vietnam .......................................................................................................................................................................................................... 225.21 Zambia ............................................................................................................................................................................................................ 225.22 Zimbabwe ...................................................................................................................................................................................................... 236. Regional Projects .......................................................................................................................................................................................... 236.1 Center of Excellence (CoE) for PMDT ....................................................................................................................................................... 236.2 East Africa Supranational Reference Laboratory (SNRL) ..................................................................................................................... 236.3 ECSA (East, Central and Southern Africa) ............................................................................................................................................... 23

List of Figures

Figure 1: Map of TB CARE I website visitor locations for the quarter ...............................................................................................................6Figure 2: Status of core projects started in Year 1-3.............................................................................................................................................7Figure 3: Map of TB CARE I Countries, as of December 31, 2012 ......................................................................................................................12Figure 4: MDR-TB cases diagnosed and put on treatment, 2010-Projected 2012 ...........................................................................................13Figure 5: Urban DOTS coverage in health facilities in Kabul, Afghanistan (2007-2012) ................................................................................14Figure 6: TB patients who died in the six demonstration hospitals comparing pre-intervention (January-April 2012) and intervention periods (May-November 2012) ..................................................................................................................................................................................18Figure 7: Quarterly EQA coverage in Kenya, 2009-2012 ......................................................................................................................................19

List of Tables

Table 1: TB CARE I countries visited by PMU members for technical/managerial purposes, October-December 2012 ........................4Table 2: Summary of visitors to the TB CARE I website, October-December 2012 .......................................................................................5Table 3: Overview of approved Year 3 core projects and Year 2 projects completed during the quarter ...................................................8Table 4: Number of MDR-TB cases diagnosed and put on treatment, 2010-2012 ..........................................................................................13Table 5: CB-DOTS contributions to sputum smear positive case notification in four provinces, Afghanistan (2008-2012) ...................14

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List of Abbreviations

ACSM 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 DOTSCBTBC 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 InitiativeHCW Healthcare WorkerHRD Human Resource DevelopmentHSS Health System StrengtheningIC Infection ControlIEC Information, Education and CommunicationIPT Isoniazid Preventive TherapyIQC Internal Quality ControlILEP International Federation of Anti-Leprosy AssociationsJATA Japan Anti Tuberculosis AssociationJSM Joint Strategic MeetingKANCO Kenya AIDS NGOs ConsortiumKAPTLD 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 (Vietnam)NTP National TB ProgramNRL National Reference LaboratoryNTRL National Tuberculosis Reference LaboratoryOPD Out-patient DepartmentOR Operations ResearchPCA Patient Centered ApproachPiH Partners in HealthPITC Provider-Initiated Treatment and CounselingPHCC Primary Health Care CenterPLHIV People Living with HIVPMDT Programmatic Management of Drug-resistant TuberculosisPMU Program Management UnitPPM Private Public MixPPP Public Private PartnershipRIF RifampicinQMR Quarterly Monitoring ReportSANAS South Africa National Accreditation SystemSLD 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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1. Introduction

This quarterly monitoring report covers the period of October-December 2012 and marks the start of Year 3 for the TB CARE I program. Implementation continued in a total of 21 countries (Senegal began activities and Djibouti closed out) via Year 2 or Year 3 approved workplans. Twenty-six new core projects began this quarter in addition to ten Year 2 core projects being completed. Four regional projects continued activities in the transition between Year 2 and 3.

This report provides a technical update on the progress made during the quarter for TB CARE I core, regional and country projects. Below is a brief summary of TB CARE I’s main achievements this quarter and the challenges for the next three months.

Main Achievements: – In Afghanistan, considerable progress is being made due to community-based DOTS and urban DOTS efforts. Currently, there are

68 health facilities (61% of all), both public and private, engaged in urban DOTS in Kabul. This is a significant increase in coverage from 22 (21%) in 2008. Furthermore, it led to the identification of 14,732 suspected TB cases, 1,142 sputum smear positive cases and 2,728 TB cases (all forms) in 2012. The treatment success rate increased from 44% in 2009 to 70% at the end of 2011.

– In Cambodia, the number of laboratory confirmed MDR-TB cases has increased from 31 cases in 2010 to 56 cases in 2011 and 117 cases in 2012. The estimated number of MDR-TB cases in Cambodia is 350 cases per year, which indicates an increase in detection from 9% in 2010 to 33% in 2012.

– The high rate of primary defaulters (i.e. confirmed smear positive cases who are not enrolled on treatment) in Juba county, South Sudan was noted as a big challenge last quarter. Following a meeting with key staff from TB Management Units (TBMUs) in Juba, the primary defaulter rate has dropped from 32% (April – June 2012) to 13% (July – September 2012). This shows that simple strategies can be employed to minimize the number of primary defaulters in TBMUs.

– In Zimbabwe, 62% of new sputum positive patients from five districts were diagnosed through a pilot sputum transport system. Before the transport system virtually 100% of suspects (and patients) had to personally travel from their villages to the district hospital where the lab is usually located; since the introduction of the transport system, suspects and TB patients do not have to go beyond the local health center for sputum collection.

– At the Cape Town African Society for Laboratory Medicine (ASLM) conference in December 2012, the Uganda National Reference Laboratory (NRL) was accorded the prize for the best national and supra-national reference lab in Africa.

– When comparing the projected MDR-TB totals for 2012 with 2011 figures, an estimated 10% increase in diagnosed cases is seen in 2012 (13,861 cases projected) and a 22% increase in MDR-TB patients being put on treatment (10,827 cases projected for 2012) is expected.

Main Challenges: – Having complete and timely MDR-TB data for this report continues to be a challenge with data on diagnosis and treatment being

unavailable or incomplete for many countries. TB CARE I is working in several countries to strengthen programmatic management of drug-resistant TB (PMDT) recording and reporting efforts and the PMU is exploring how else the program can support PMDT data management efforts.

– As Year 3 is in process, planning for Year 4 will be starting soon. The program must determine how best to provide support to core, regional and country projects going forward when the funding ceiling is anticipated to be reached in Year 4.

2. Program Management Unit (PMU)

During this quarter, PMU staff made monitoring visits to countries, attended meetings and conferences and provided technical assistance (summarized in Table 1). A special section below highlights TB CARE I’s key activities and outcomes from the Union World Conference on Lung Health in Kuala Lumpur, Malaysia.

Table 1: TB CARE I countries visited by PMU members for technical/managerial purposes, October-December 2012

Country Purpose

Kyrgyzstan Training of trainers Xpert MTB/RIF

Kazakhstan Xpert MTB/RIF monitoring

Malaysia See Union World Conference on Lung Health section for more detail

Moldova Regional Workshop on National Strategic Planning for TB Control organized by TBTEAM/WHO

USA Ndola project meeting

Uganda Technical assistance on renovations of MDR-TB sites and mentorship of a TB-IC consultant

France Integrated Health Care for TB and HIV workshop

The Union World Conference on Lung Health

From November 13th–17th, 2012 the 43rd Union World Conference on Lung Health took place in Kuala Lumpur, Malaysia. TB CARE I led workshops, presented project results and engaged in numerous technical and management meetings. Below are some of the highlights.

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WorkshopDuring the conference, PMU organized and carried out a full-day workshop on performance-based management: “Linking outcomes to finances”. The workshop took place on November 14 and was attended by 30 persons (16 female, 14 male). The workshop was

based on the ‘challenge model’ and taught participants the essentials of performance-based management and provided necessary tools and techniques. The interactive workshop engaged participants through exercises, discussions and group work. On average it was evaluated by the participants as “very good” or “excellent”.

Participant quote: “Workshop methodology and delivery with participant involvement – needless to say – was excellent. You take the prize for the best of all workshops today. I look forward to more of these “working-shops”!”

TB CARE I Country MeetingsDuring the conference, PMU organized TB CARE I country meetings for all TB CARE I-supported countries as country project staff and often USAID missions were present. Meetings involved the project Country Director, NTP if available, PMU, coordinating partners and USAID Washington/Country mission representatives. The agenda focused on Year 3 progress and Year 4 preparations. Experiences and feedback from the donor, the NTP and TB CARE I were shared and discussed.

TB CARE I Partners MeetingOn November 15th, a TB CARE I partners meeting took place with all the partner Board Members, the PMU and USAID Washington. The objective was to discuss the progress and challenges of implementation and agree on the steps needed for the further improvement of TB CARE I performance in the second half of the program.

TB CARE I posters and presentationsThe program’s results were well represented at the conference. TB CARE I presented or contributed to over 13 posters and nine oral presentations across ten countries. The TB CARE I posters and presentation from the conference can be viewed and downloaded here:

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

OtherDuring the TB Alliance Stakeholder’s meeting, TB CARE I’s Program Director, Maarten van Cleeff, was thanked for his service and valuable contributions to the TB Alliance, not only as the President of the Stakeholders Association but also as a Board Member. His three-year term as Chair of the Stakeholders Association ended in December 2012.

TB CARE I hosted a meeting on “TB Technical Assistance for Global Fund grants and the new Global Fund architecture: with TBTEAM partners, TB CARE, NTPs and other country stakeholders”. Most PMU staff and project country directors attended to have a better understanding of Global Fund processes and to explore how to improve Global Fund grant implementation with the support of TB CARE I/TBTEAM partners at country level.

Workshop participants and facilitators

Two posters were produced and displayed at the KNCV/TB CARE I booth to highlight the success of the TB CARE I program in the countries where it works.

The full size posters can be downloaded here:

http://www.tbcare1.org/pdfs/Country_Highlights.zip

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3. Knowledge Exchange

The number of visitors to the TB CARE I website rose slightly during the quarter, as did the number of page views and the number of countries (126) from which visitors came (see Table 2). The website had visitors from 65% of the countries in the world. Figure 1 maps the frequency and location of TB CARE I website visitors during the quarter.

Table 2: Summary of visitors to the TB CARE I website, October-December 2012

Previous Quarter(July-September 2012)

October-December 2012

Number of Visitors 3,017 3,799 (26% increase)

Number of Countries Visitors came from 121 126

Number of Pages Viewed 8,061 8,880

Percentage of New Visitors 62% 63%

Figure 1: Map of TB CARE I website visitor locations for the quarter

833

821233

716

54104

97

621

11 39

71

19

This quarter, 1,024 documents were downloaded; the top ten most popular downloads (and number of downloads) were as follows:1. Guidelines for Measuring the Prevalence of TB in Healthcare Workers (57)2. TB CARE I Quarter 3 Report (48)3. TB Infection Control Job Aid (42)4. Electronic Recording and Report in TB Care and Control (38)5. Patient-Centered Approach Package (32)6. TB CARE I Annual Report Year 1 (33)7. Strategic Guide for Building PPM Partnerships to Support TB Control (32)8. TB CARE I Newsletter – September 2012 (32)9. Rapid Implementation of Xpert MTB-RIF Diagnostic Test (28)10. Integration of HIV-testing in Routine TB Drug Resistance Surveillance in Kazakhstan and Kenya (25)

New TB CARE I publications this quarter:

Year 2 Annual Report

The second annual report of TB CARE I highlights the program’s latest achievements and results across country, regional and core projects.

http://www.tbcare1.org/reports/reports/TB_CARE_I_Annual_Report_Year_2_Oct_2011-Sept_2012.pdf

Recommendations for Investigating Contacts of Persons with Infectious Tuberculosis in Low- and Middle-income Countries

These recommendations are designed to assist national and local public health TB control programs in low- and middle-income countries to develop and implement case finding among people exposed to infectious cases of TB.

http://www.tbcare1.org/publications/toolbox/tools/hss/Guidelines_on_TB_Contact_Investigation.pdf

RECOMMENDATIONS

FOR INVESTIGATING CONTACTS

OF PERSONS WITH

INFECTIOUS TUBERCULOSIS

IN LOW- AND MIDDLE-INCOME

COUNTRIES

OMS_Brochure Tuberculose_Mise en page 1 09.11.12 14:51 Page1

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Building the Capacity of Civil Society Organizations in TB Control - An Approach

An approach to develop the capacity of civil society organizations in TB control has been developed and pilot tested in three countries. This package includes the approach, the training materials and the monitoring and evaluation framework, as well as the pilot results.

http://www.tbcare1.org/publications/toolbox/tools/hss/Capacity_Building_Approach.zip

Infection Control Module - Russian (Модуль - Инфекционный контроль)

This module is aimed at healthcare workers who work in TB facilities and/or with TB patients. The purpose of this module is to improve TB infection control knowledge.

http://www.tbcare1.org/publications/toolbox/tools/ic/Module_IC_Russian.pdf

4. Core Projects

Since the start of TB CARE I (Year 1-3), the coalition has implemented 98 core projects; as of December 2012, 57 projects (58%) are fully complete. Figure 2 shows the status of completion for projects by project year; excluding cancelled projects, 100% of Year 1 projects, 71% of Year 2 projects and 4% Year 3 projects are complete. All completed tools and publications from Year 1 and 2 can be found on the TB CARE I website (http://www.tbcare1.org/publications/).

Figure 2: Status of core projects started in Year 1-3

Year 1

Cancelled Ongoing Completed

Year 2

Year 3

3

100 20 30 40 50

Number of Core Projects

26

30121

125

Twenty-six new Year 3 core projects were initiated this quarter. Table 3 below provides an update on these new projects and the ten Year 2 projects that were completed this quarter.

Модуль: Инфекционный контроль

Building the Capacity of Civil Society Organizations in TB Control - An Approach

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Table 3: Overview of approved Year 3 core projects and Year 2 projects completed during the quarter

Technical Areas CodeLead

PartnerOther

PartnersTitle Expected Deliverable(s) Year 3 Progress to date

%complete

Level of spending

1 Universal Access

C1.3 KNCV RHAP TB in mining project

Coordination visits to Mozambique (2) and Botswana (3); Regional visits to SADC and TB CARE I countries (6); HQ meeting (1)

The Regional Consultant for TB in the Mines visited Mozambique (2) for a situational analysis & National TB Strategic Plan development, attended a South African Development Community meeting in Botswana to finalize the Code of Conduct on TB in the Mines and attended the Project Directors meeting in The Hague.

33% 75%

C1.13 ATS WHO, KNCV, MSH

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

Steering Committee selected and meeting arranged. Areas for review and revision under development.

25% 49%

C1.16 ATS WHO Contact investigation guidelines

Tools for use with guidelines for evaluation of contacts to infectious cases of TB

Data analysis for country validation is underway. 25% 22%

C1.21 WHO KNCV, ATS Global PPM Workshop Global PPM Workshop Not yet started. 0% 4%

C1.30 ATS Performance assessment and feedback to improve TB Diagnosis

Validate performance evaluation approaches for the diagnosis of TB. Validation

Tanzania, Vietnam and Indonesia have been selected for validation of performance evaluation approaches. MOUs are under development and data development formats are being constructed for field implementation.

25% 50%

2 Laboratories C2.09 KNCV JATA, WHO Capacity building for Xpert imple-mentation & quality-ensured usage

Regional workshop in African to support quality of routine use of GeneXpert

Not yet started.0% 0%

C2.10 WHO KNCV,The Union

Global Forum on Xpert MTB/RIF Imple-mentation

Convene global forum for sharing experiences from countries and partners implementing Xpert/TB RIF

The Global forum on Xpert MTB/RIF is scheduled for 16-17th April 2013 in Annecy, France.

0% 0%

C2.11 WHO JATA, KNCV

Internationally standardized implementation and training material for GeneXpert

Harmonized training tools and availability of GeneXpert training materials

Awaiting revised GeneXpert training materials.

0% 0%

C2.12 The Union

KNCV, MSH, WHO

Update of TB CAP lab tools

Updated lab training tools Microscopy guide

The Microscopy Manual of the Adelaide SRL was reviewed. The list of SOPs to be developed for the microscopy guide was developed.

30% 1%

9

Technical Areas CodeLead

PartnerOther

PartnersTitle Expected Deliverable(s) Year 3 Progress to date

%complete

Level of spending

2 Laboratories C2.13 WHO ASLM-QMS workshop for NRL managers

Participation of 6 NRL managers in a 3-day workshop in Cape Town, South Africa

Activity completed borrowing funds from Year 2. The Quality Management System workshop was convened in December at the ASLM con-ference in Cape Town, South Africa. Meeting report and presentation made are available at http://www.stoptb.org/wg/gli/accreditation.asp

100% 100%

C2.20 WHO KNCV, MSH Consultants’ manual for TB laboratory consultants

Consultants manual for TB lab consultants

Not yet started.0% 1%

3 Infection Control

C3.05 FHI 360 KNCV, Mc Gill, PiH

TB-IC demonstration Ndola district

Safe work practices reducing TB transmission in 15 health facilities

Some management activities effectively transferred to the Ndola District Medical Office (i.e. compliance with safe work practices, supervision of district health facilities and ensuring proper utilization of renovated areas in the health facilities). The MoH gave approval for the protocol on TB screening among HCWs. Three posters were presented on project achievements at the Infection Control Africa Network conference held in Cape Town, South Africa in November. See project-specific quarterly report for more details.

25% 4%

C3.06 PIH KNCV, MSH FAST Core Package for TB-IC

Final FAST Core Package The project awaits guidance from the TB-IC Advisory Group on potentially selecting Vietnam as an implementation site for the FAST strategy.

5% 3%

C3.07 PIH KNCV, MSH Building Capacity for IC Ten IC consultants ready to perform independent missions with distance support by mentors. Mentored field visits.

One mentee went with Max Meis to Uganda. All support documents and tools were developed.

5% 16%

C3.08 URC KNCV Occupational Safety approach

Attend a consensus workshop on occupational safety in South Africa by URC

The workshop is planned for the second half of Year 3. 0% 0%

4 PMDT C4.04 KNCV MSH Assessing the costs faced by MDR-TB patients

Consensus workshop to define recommendations for policy

Planned for third or fourth quarter.0% 4%

C4.06 TB CARE II

KNCV, The Union

TB DR Learning site Training: 3-4 series of webinars and tool: Collection of 12-18 new cases in website for download and direct discussion with experts

Partners provided input for two case discussions on clinical and programmatic case management.

10% 3%

C4.10 TB CARE II

KNCV, The Union, WHO

TB CARE partners’ PMDT scale-up meeting

PMDT scale up meetingTB CARE priority interventions for PMDT scale up

Meeting planning in process.2% 0%

10

Technical Areas CodeLead

PartnerOther

PartnersTitle Expected Deliverable(s) Year 3 Progress to date

%complete

Level of spending

4 PMDT C4.11 TB CARE II

KNCV, The Union, WHO

Pocket guide for the Medical Management of MDR-TB

Pocket guide for clinicians treating MDR-TB in English

Not yet started.0% 0%

C4.12 KNCV WHO Develop guidance for engaging and implementing PMDT in private sector

Development of guidance for linkage of PPM and PMDT

Not yet started.

0% 2%

6 Health Systems Strengthening

C6.12 WHO ATS, MSH, PMU

Toolkit for TB strategic planning

Toolkit on TB Strategic planning Planning in initial stages.10% 0%

7 M&E, OR and Surveillance

C7.05 MSH KNCV, PMU, Measure

Support M&E efforts of NTPs

Five day training in TB surveillance, Training curriculum on TB data management and use developed, in-person TB data training for M&E staff in CAR-region and assessment to four selected countries.

Planning in initial stages.

0% 1%

C7.08 WHO KNCV Making use of Surveillance checklist

Assessment of TB surveillance followed by a workshop to share and discuss results

Not yet started.0% 1%

C7.09 KNCV MSH, PMU, WHO

Data quality handbook Development of a data quality handbook

Highlights of the Data Quality Handbook have been drafted.

5% 6%

C7.10 WHO KNCV, MSH Handbook on analysis of TB surveillance data

Handbook on analysis of TB surveillance data

Not yet started.0% 0%

Year 2 projects completed this quarter

C1.2 WHO KNCV, The Union

Engaging pharmacists in TB care and control

- baseline assessment - documentation of working models- preparation of a tool to engage pharmacists in TB care and control

Baseline assessment of working models conducted in Ghana, Cambodia and India. Tool to engage pharmacists in TB care developed and under final review.

100% 97%

C1.4 WHO ATS, KNCV, The Union

PPM Toolkit workshop A multi-country global workshop of selected countries on the PPM toolkit

The PPM toolkit workshop on engaging the for-profit private sector was organized on November 11, 2012 (>80 participants from >19 countries).

100% 91%

C1.13 ATS KNCV, MSH, WHO

ISTC ed. 2 review Review of ISTC ed. 2. Decision made on the topics that need to be updated and/ or renewed

A preliminary review of the standards was done and a plan for updating the standards was developed including the establishment of a steering committee.

100% 76%

C2.1 KNCV The Union Lab strategic plan handbook

Practical laboratory strategic handbook, piloted and finalized

A practical laboratory strategic handbook was drafted. Layout and dissemination pending.

100% 94%

C2.2 The Union

KNCV, WHO Tool for lab network assessment

A consensus tool for assessment and accreditation of microscopy laboratory networks is available, pilot tested by trained assessors and endorsed by GLI

A tool for assessment and accreditation of microscopy networks has been developed, but awaits GLI review and endorsement. 100% 71%

11

Technical Areas CodeLead

PartnerOther

PartnersTitle Expected Deliverable(s) Year 3 Progress to date

%complete

Level of spending

Year 2 projects completed this quarter

C2.7 The Union

KNCV Develop Benin NRL to SNRL

- A functional supra-national TB reference laboratory (SRL) in Benin- The Benin NRL accreditation process is advanced

Year 2 activities completed to advance Benin NRL towards becoming a functional and accredited SRL.

100% 91%

C2.8 The Union

Uganda TB Supra National Reference Lab

The Uganda NRL has started functioning as a SRL, integrated in the network (SRLN) as designated SRL, and actively linked with 2 countries in its area

The Uganda NRL is functioning as an SRL and it has been formally linked to South Sudan.

100% 94%

C3.5 PMU-PEPFAR

FHI 360, KNCV

TB-IC demonstration Ndola district

Study reports to describe approaches and demonstrate results

In 9 months, compliance with TB-IC practices in 15 flagship health facilities (HFs) rose from 27% to 58% using a standard CDC monitoring tool. In line with the stepwise introduction of TB IC in the HFs, all 15 HFs are expected to reach the target of 80% compliance in Year 3. Progress reports and presentations available.

100% 61%

C6.1.2 WHO Support to Stop TB Partnership Working Groups

Support to Childhood TB, PPM and TB-IC subgroups

Meetings for the Childhood TB, PPM and TB-IC STOP TB Partnership subgroups all took place in November 2012 in Malaysia.

100% 100%

C7.7 WHO The Union Improving the estimates of childhood TB

A featured in-depth analysis of childhood TB case notifications in the 2012 WHO Global TB Control Report. An approach for countries to identify gaps in the childhood TB activities of their surveillance systems that need to be addressed.

Improving the estimates of childhood TB disease burden and assessing childhood TB activities at country level is available on the TB CARE I website.

100% 100%

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5. Country Projects

As Year 3 began in October 2012, one new country project was added to the TB CARE I portfolio: Senegal. Djibouti officially closed out during the quarter, resulting in a total of 21 country projects as of December 31, 2012. Roughly half of the projects began Year 3 workplan implementation during the quarter while the remaining countries continued Year 2 activity implementation. Figure 3 displays the geographic distribution and the investment size of TB CARE I country projects.

Figure 3: Map of TB CARE I Countries, as of December 31, 2012

19

14

20

21

22

20

21

22

12

1

1

34

5 6 98

7

1011

13

14

12

3

4

5

6

9

8

7

10

11

13

15

1617

18

1915

16

17

18

Dom. Republic

Medium Investment

Ghana

Nigeria

Large Investment

Namibia

Medium/Large Investment

Botswana

Mozambique

Zimbabwe

Zambia

Vietnam

Kazakhstan

Kyrgyzstan

Uzbekistan

Small Investment

Tajikistan

Afghanistan

Cambodia

IndonesiaSouth Sudan

Uganda

Kenya

Ethiopia

Djibouti2 Senegal

2

Programmatic Management of Drug Resistant TB (PMDT)

As PMDT scale-up at country level continues, TB CARE I tracks national data on MDR-TB cases that are diagnosed and put on treatment on a quarterly basis. Table 4 summarizes the number of MDR-TB cases diagnosed and put on treatment from 2010 to 2012. Since several countries do not yet have complete data for 2012, the table shows reported totals as well as projected totals for the year (the table also indicates what data has not been reported).

In 2012, an estimated 13,861 MDR-TB cases were diagnosed across all TB CARE I countries, with 10,827 being put on treatment (roughly 78% - as the diagnosis and treatment cohorts are not always the same). When comparing the projected totals for 2012 with 2011 figures, an estimated 10% increase in diagnosed cases is seen in 2012 and a 22% increase in MDR-TB patients being put on treatment. Yearly totals across all countries are summarized in Figure 4 showing an increasing trend in diagnosis and treatment initiation.

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Table 4: Number of MDR-TB cases diagnosed and put on treatment, 2010-2012 (includes number reported as of December 2012 and projected for 2012)

CountriesJan-Dec 2010 Jan-Dec 2011

ReportedJan-Dec 2012

Projected Jan-Dec 2012 2012 Data Not

Yet Available for:#dx

# put on trt

#dx# put on

trt#dx

# put on trt

#dx# put on

trt

Afghanistan 19 0 19 21 38 38 38 38

Botswana 106 114 46 46 52 18 52 46 Apr-Dec (trt)

Cambodia 31 38 56 57 117 130 117 130

Djibouti 7 0 0 71 26 95 35 Oct-Dec

Dom. Rep 108 114 117 107 54 56 108 112

Ethiopia 140 120 212 199 85 222 113 296

Ghana 4 3 7 2 20 0 20 0

Indonesia 182 142 383 260 568 382 568 382

Kazakhstan 7,387 5,705 7,408 5,261 6,009 4,589 8,012 6,119 Sep-Dec

Kenya 112 118 166 156 74 74 99 99 Oct-Dec

Kyrgyzstan 566 556 806 492 677 638 903 851 Oct-Dec

Mozambique 165 87 283 146 79 79 158 158 Jul-Dec

Namibia 214 214 192 242 216 216 216 216

Nigeria 21 23 95 38 185 113 247 151 Oct-Dec

South Sudan 6 0 0 0 0 0

Tajikistan 333 245 604 380 780 536 780 536

Uganda 93 10 71 7 109 44 109 44

Uzbekistan 1,023 628 1,385 855 0 0 1,385 855

Vietnam 101 101 601 578 0 621 621 621 2011 & 2012 (dx)

Zambia 0 0 44 18 88 36 Jul-Dec

Zimbabwe 17 27 118 64 100 78 133 104 Oct-Dec

Total 10,622 8,262 12,575 8,911 9,278 7,878 13,861 10,827

Figure 4: MDR-TB cases diagnosed and put on treatment, 2010-Projected 2012

0 3000 6000 9000 12000 15000

2010

2011

Projected2012

10,622

12,575

13,861

10,827

8,911

8,262

Number Diagnosed Number Put On Treatment

Progress and achievements from the quarter for each TB CARE I country are summarized below.

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5.1 Afghanistan

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 Systems Strengthening (HSS) and Monitoring & Evaluation (M&E).

TB CAP/TB CARE I assistance to the NTP on Standard Operating Procedures (SOPs) revision and implementation resulted in increased access to TB services. Identification and examination of suspected TB cases increased from 85,000 in 2008 to 199,000 in 2011 countrywide (134% increase). Consequently, it led to increased TB case notifications which rose from 26,356 in 2009 to 28,167 in 2011 (7% increase). The treatment success rate was already high and rose to 90% in 2011 compared to 88% in 2009.

Urban DOTS expanded to five additional health facilities (HFs) in Kabul city. Currently, out of 111 functioning health facilities in Kabul, there are 68 HFs both public and private engaged in DOTS. This represents a significant increase in coverage, from 21% (22/106) in 2008 to 61% (68/111) in 2012 (Figure 5). Furthermore, it lead to the identification of 14,732 suspected TB cases, 1,142 sputum smear positive cases and 2,728 TB cases (all forms) in 2012. Also, the treatment success rate increased from 44% in 2009 to 70% at the end of 2011.

Figure 5: Urban DOTS coverage in health facilities in Kabul, Afghanistan (2007-2012)

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During this period, community-based DOTS (CB-DOTS) implementation continued in four provinces. This resulted in identification of 6,114 suspected TB cases, and 603 sputum smear positive TB cases in 2012. Also, in 2012, 1,451 TB patients received their DOT from Community Health Workers (CHWs) at their door step. The considerable achievements of CB-DOTS include early suspect identification and notification of approximately 34% of all sputum smear positive cases in 2010 (compared to 0% in 2008) (Table 5). More importantly, its contribution to treatment outcomes was astonishing - the treatment success rate for those TB patients that received their DOT from CHWs was 98% compared to 90% for facility based DOTS; this made the NTP recommend the expansion of the full package CB-DOTS implementation in TB CARE I intervention areas (13 USAID supported provinces). Thus, TB CARE I suggested to USAID that they increase the funds to expand full CB-DOTS package implementation to all 13 USAID supported provinces. The full package of CB-DOTS was implemented in only four provinces and TB CARE I was complementing the global fund CB-DOTS component in the remaining nine provinces.

Table 5: CB-DOTS contributions to sputum smear positive case notification in four provinces, Afghanistan (2008-2012)

Year Total TB SS+ notified TB SS+ referred by CHWs % of TB SS+ referred by CHWs

2008 1,741 0 0%

2009 1,469 359 24%

2010 2,100 710 34%

2011 2,250 810 36%

2012 3,765 603 16%

During the quarter, DOTS training was extended to female health care staff in insecure provinces and 156 female staff were trained in five provinces: Wardak, Zabul, Helmand, Nimroz and Farah.

Joint NTP and TB CARE I teams conducted data accuracy assessment field work in 15 provinces of Afghanistan. The aim of this study was to identify the magnitude of data quality issues, to develop an action plan for its improvement and also to identify the magnitude of improvements in this field compared to the baseline values of 2008.

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5.2 Botswana

KNCV is the lead partner and sole implementer in Botswana. In Year 3 the project focuses on UA and laboratories. TB CARE I contributed to the development of a draft roll-out plan for GeneXpert implementation. The plan incorporated the anticipated cost projections for the next five years by considering all costing items and a revised diagnostic algorithm. In collaboration with CDC Botswana, TB CARE I supported GeneXpert MTB/RIF testing training at four facilities with 12 nurses and laboratory technicians.

With support from TB CARE I, an operational guideline was developed to integrate the key aspects of Community-based TB Care (CTBC) and Community [HIV] home-based Care (CHBC) services in-line with the national strategy and guidelines (semi-final draft). This will facilitate the harmonization of the two services both at program and implementation level.

The in-country Senior Technical Advisor led the finalization of the PPM framework for TB care through a consultative process with all stakeholders. The guideline is being printed for launching and dissemination. The project also supported the development of a Technical Assistance (TA) plan for the implementation of the Strategic Plan 2013–2017. This was developed per the requirement of the new Global Fund model and the recommendation during the TBTEAM meeting in Nairobi, December 2012. The TA plan has been incorporated into the strategic plan.

5.3 Cambodia

JATA is the lead partner in Cambodia, with collaboration from FHI 360, KNCV, MSH and WHO. The project in Year 3 has activities in seven technical areas (UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E).

The number of laboratory confirmed MDR-TB cases has increased from 31 cases in 2010 to 56 cases in 2011 and 117 cases in 2012. The estimated number of MDR-TB cases in Cambodia is 350 cases per year, which indicates an increase in detection from 9% in 2010 to 33% in 2012.

Following intense efforts from the TB CARE I and CENAT team, community-based Isoniazid preventive therapy (IPT) for children is now picking up. During the quarter, 108 children in contact with TB were initiated on IPT in two project sites - Svay Antor OD (92 children) and Kg Cham OD (16 children), up from the first 66 children enrolled on IPT in the previous quarter (64% increase).

During the quarter, 1270 TB smear negative TB suspects were referred by health centers to the referral hospitals (RH) for further evaluation and x-ray examination. Of those referred, 518 cases (41%) were diagnosed as smear negative TB.

Performance of lab staff under external quality assurance (EQA) for sputum microscopy continues to be satisfactory. As of December 2012, 84 of the 88 (95%) TB labs supported by TB CARE I participate in the exercise. Eighty-eight percent (74/84) of the TB labs performed with over 95% correct results, a further improvement from the previous quarter result of 84%.

Also this quarter, 455 TB suspects were examined with the Xpert MTB/RIF test. This includes 60 who were HIV+ TB suspects, 111 MDR-TB suspects and 284 from other groups. 84 cases were detected as MTB+/RIF-, 9 cases were MTB+/RIF+ (MDR-TB) and 24 cases were error/invalid. All TB and MDR-TB cases were registered for TB and MDR treatment.

5.4 CAR-Kazakhstan

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).

From the start of the implementation of GeneXpert in July 2012 through the end of December 2012, 2,575 tests were conducted in four Xpert sites (Almaty city TB dispensary, Akmola oblast TB dispensary, East Kazakhstan oblast TB dispensary and the NRL). Three out of four sites reported 1,737 patients tested (NRL patient data is expected next quarter). Out of 1,737 individuals, 704 (40.5%) tested positive for TB of which 368 (52.3%) were detected with resistance to rifampicin; out of these 368 patients, 274 (74.5%) were enrolled in MDR-TB treatment in less than two weeks.

In early December, TB CARE I conducted supportive supervision visits to the four GeneXpert sites. The initial performance assessment of the sites was positive (i.e. detection rates, timely enrollment in treatment, laboratory procedures, etc.). At the same time, a new GeneXpert M&E tool that was recently developed by the PMU was presented to the NTP. The new tool is expected to be incorporated in the national M&E system in 2013. This will provide the means for standardized GeneXpert data collection and analysis nationwide, an important development since nine additional machines will be installed in the country in 2013 through GF.

TB CARE I provided technical assistance to the NTP on the finalization of National Guidelines on Infection Control which were approved by the MoH. The project also helped to finalize the main NTP indicators of the PMDT Action Plan to be achieved through 2015. The final draft of the PMDT plan was submitted to MoH in December 2012. In addition, TB CARE I developed a tool for the evaluation of the psychosocial profile of TB patients and a list of indicators for monitoring the patient support system that will be incorporated into the National TB Electronic Data Register.

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5.5 CAR-Kyrgyzstan

As 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).

Advances were made on the introduction of a new outpatient care model in urban settings (Bishkek city). The technical working group on outpatient care has developed a draft model, outlining roles and responsibilities of relevant stakeholders that will be finalized in January 2013. Two family medicine centers were selected as pilot sites where piloting is scheduled to being in early 2013.

In November 2012, TB CARE I organized a four-day ToT on GeneXpert for 20 clinicians and 10 laboratory specialists. The training covered current international developments, WHO recommendations and guidelines, national GeneXpert strategy, programmatic aspects of GeneXpert implementation, diagnostic algorithms, clinical protocols, and M&E. The laboratory specialists ToT contained practical laboratory training on how to use, maintain and troubleshoot problems with the Xpert machines. In addition, the GeneXpert national strategy, including the diagnostic algorithm, was finalized and submitted to the NTP for approval. The document was also sent to WHO and SNRL for review and endorsement.

With support from the Regional IC Officer, TB-IC plans were updated and introduced in seven TB facilities. In addition, two guidelines, on DR-TB and TB in children, have been approved by the MoH with external review provided by TB CARE I.

5.6 CAR-Tajikistan

KNCV is the lead and sole implementer in Tajikistan. Activities for TB CARE I include UA, Laboratories, IC, PMDT, TB/HIV, HSS and M&E.

TB CARE I and the GeneXpert Technical working group (TWG) finalized the GeneXpert MTB/Rif strategy and reviewed recording and reporting (R&R) forms. A ToT was conducted for 18 lab specialists and clinicians on the proper use of Xpert MTB/Rif technology. As part of the ToT, participants developed a GeneXpert ToT curriculum, which will result in a cascade of further Xpert trainings. (Photo: Clinical discussions during GeneXpert training.)

Following the start of the MDR-TB program in Dangara and Temurmalik in the summer of 2012, NTP specialists and TB CARE I staff conducted the first monitoring and supportive supervision visits to sites in November. During the mission, clinical aspects of MDR-TB case management, including GeneXpert and timely enrollment in treatment were discussed and practical recommendations were provided to implementers. In addition, TB CARE I visited two other pilot sites (Rasht and Tojikobod) to assess the quality of the DOTS program as well as its readiness to pilot the MDR-TB program. Together with local TB staff, estimates were made for the number of MDR-TB cases in 2013. The results of the visit were presented and discussed during the TWG meeting with key partners.

5.7 CAR-Uzbekistan

WHO is the lead partner in Uzbekistan with KNCV as a close collaborating partner. Activities in Year 3 include UA, Laboratories, IC, PMDT, HSS, and M&E. TB CARE I provides technical capacity building and support to strengthen the coordination and supervisory roles of the NTP to effectively implement Xpert MTB/Rif technology in Uzbekistan. During the quarter, the diagnostic algorithm for Xpert was finalized, assignments were made for data collection and reporting and legal documents were revised to ensure smooth implementation of Xpert MTB/Rif. TB CARE I supported a four-day ToT on the practical use of Xpert MTB/Rif for laboratory specialists, managers and clinicians of TB and primary healthcare services. The draft 2013 implementation workplan for Xpert MTB/Rif in Uzbekistan, the draft training curriculum and the schedule for Xpert MTB/Rif trainings were developed during the event.

An assessment mission on infection control was performed in December. The team assessed four sites and made specific recommendations for each facility.

5.8 Djibouti

WHO was the lead and sole implementer of activities in Djibouti. The Year 2 workplan focused on UA, laboratories, PMDT, HSS, M&E and drug management. This was the final quarter of the project, which mainly focused on close out; limited activities were conducted.

The national guidelines on PMDT are being finalized with support from TB CARE I. In addition, TB CARE I conducted a PMDT training for doctors from the TB National Reference Center. The training focused on MDR regimens endorsed at the national level, side effects and their management, and the critical requirements for quality PMDT.

Clinical discussions during GeneXpert training

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5.9 Dominican Republic

KNCV is the lead partner and sole implementer in Dominican Republic. Activities are conducted in UA, IC, PMDT, HSS and M&E. The project will be ending in March 2013. The TB CARE I closing ceremony, A Cycle Which Continues, was held in December to present the main achievements of the project and to hand over the methodologies and lessons learned to all TB stakeholders. Before the closing ceremony, an interactive half day meeting was held where 136 community members, health authorities and other local representatives participated, representing the 71 Stop TB Committees. Committee members discussed and shared their annual workplans and renewed their commitment with local health centers to continue and expand their service.

A final draft version of the ‘Guide for Implementing Infection Control Measures in Hospitals’ was developed in December and is ready for validation by the NTP and the TB-IC Committee as well as final endorsement by the MoH. Seventy TB awareness raising murals were painted by groups of secondary school students during the quarter as part of their health education curriculum. The purpose of this activity was to actively involve young people in TB education efforts, to reduce myths, stigma and discrimination, and to encourage the community to seek health services earlier when experiencing symptoms. The murals are on public streets and hospital walls in order that the messages reach as wide an audience as possible. At the end of project a total of 102 murals will be present at key points throughout Santo Domingo and other provinces. Eighty postmen were trained as “TB and health messengers” in Santo Domingo. They were taught the basics of the disease and to actively participate in the distribution of TB education leaflets to visited households.

5.10 Ethiopia

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 (GLRA). The Year 2b and Year 3 work plans have activities in all eight technical areas.

Second line drugs (SLDs) for 100 MDR-TB patients that were procured using TB CARE I funds arrived in the country in December 2012. At that time the number of MDR-TB patients enrolled on treatment was about 600. The procured SLDs will help the treatment sites to enroll an additional 100 patients who are on the waiting list.

TB CARE I support on MDR-TB continued in Year 3 with a four-round orientation workshop on MDR-TB recording and reporting tools. The workshop was aimed to equip experts currently

working in MDR-TB units with adequate knowledge and skill on MDR-TB R&R tools. A total of 99 individuals from five regional health bureaus, MDR-TB treatment sites and referring health facilities participated. PMDT training was also conducted with the Oromia Regional Health office for health facilities selected as potential MDR-TB service expansion sites in Oromia region and at the ALERT Center.

Ethiopian Health Nutrition Research Institution (EHNRI) and Oromia Health Bureau in collaboration with TB CARE I conducted a series of laboratory trainings this quarter. A TOT on AFB microscopy using Ziehl-Nelsen, LED and EQA was conducted in three rounds of 10 days each; a total of 102 laboratory personnel from regions were trained. Basic training on AFB microscopy in Oromia Region was also conducted (31 trained).

A National TB Research Advisor Committee (TRAC) stakeholders’ workshop was conducted in October to discuss a Roadmap for Operations Research (OR) and to launch a three year initiative for the development of sustainable OR capacity in Ethiopia. Accordingly, the national OR assessment findings were presented; a draft national TB OR roadmap with OR priority agenda was finalized and endorsed. In addition, the first operational research training was conducted this quarter for the first cohort of OR trainees during which draft proposals were developed.

Champions for TB - Cured TB Patients, Prison Interns, Health Managers, MoH representatives – being acknowledged during the TB CARE I closing ceremony

Practical session during PMDT training

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5.11 Ghana

MSH is the lead partner in Ghana with support from KNCV and WHO as collaborating partners. The Year 3 work plan focuses on UA, laboratories, IC, TB/HIV, HSS and M&E.

TB CARE I has been implementing intensified hospital-based TB case detection in six hospitals in two districts of Eastern Region from May-November 2012. During the seven month intervention period, a total of 335 TB cases (all forms) and 203 (new smear positive TB cases) were detected representing a monthly average of 48 TB cases and 29 TB cases detected for all forms and new smear positive TB cases respectively. This showed a 28% increase in the number of TB cases (all forms) detected on a monthly basis compared to the first four months of 2012 (pre-intervention period). The monthly average of TB cases detected during the pre-intervention period was 37 TB cases (all forms) and 23 (new smear positive).

Through the aforementioned intensified hospital based TB case detection intervention, strategies for reducing TB deaths were introduced through improved clinical and nursing care. As a result, the average monthly number of TB deaths reduced from six in the pre-intervention period to two TB deaths during the intervention period. There was a 54% decrease in deaths between pre-intervention and intervention periods (see Figure 6). Although the intervention period has been short and the number of deaths were trending down already in early 2012, hopefully the reduction in TB deaths will continue to remain low or decrease even further.

Figure 6: TB patients who died in the six demonstration hospitals comparing pre-intervention (January-April 2012) and intervention periods (May-November 2012)

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The project Country Director and NTP officials participated in the WHO/AFRO Regional Workshop on National Strategic Planning for Tuberculosis Control held in Nairobi, Kenya. During the workshop participants were updated on the development of good TB strategic plans. The strategic planning roadmap for Ghana was developed.

5.12 Indonesia

Indonesia is the largest of the TB CARE I countries in terms of financial investment; KNCV is the lead partner with collaborating partners ATS, FHI 360, JATA, MSH, The Union and WHO. TB CARE I-Indonesia works in all eight technical areas.

During this quarter, four more GeneXpert machines were installed in BBLK Surabaya, BLK Bandung, Syaiful Anwar Hospital in Malang and Microbiology UGM. In total, nine machines are currently operational. A total of 1,370 suspects have been examined through Xpert this quarter (971 were MDR-TB suspects, 399 were TB/HIV suspects); 340 Rif-resistant cases were detected. Of the Rif-resistant cases, 193 (57%) were put on treatment. TB CARE I also assisted in the procurement of an additional 2,500 cartridges.

TB CARE I provided extensive support for the preparation and implementation of the national TB prevalence survey. The preparation activities such as revision of the field survey manual, schedules, data forms, processes and databases were conducted through workshops with the survey team and TB CARE I consultants. Additional activities undertaken were based on a needs assessment and included preparation for the laboratory and chest X-ray procurement.

The draft of TB medical care standards (SPK) was developed under the leadership of the Directorate of Medical Services. This standard of care for medical professionals is a major step forward in achieving the regulation of medical practitioners that expectably will press them to follow ISTC in diagnosis and management of TB. SPK will be a powerful tool since it provides criteria for provider certification, which will be the legal basis for financial compensation through the National Universal Coverage scheme (JPS) that will be implemented from 2014 onwards.

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TB costing models were developed and data are being reviewed by the MoH in connection with an insurance financing strategy. Costing was discussed with the Vice Minister in November 2012 and costs for AIDS, TB and malaria were reviewed in a technical meeting in December 2012. Along with this, the finance M&E data were analyzed, the financing roadmap was finalized, and the NTP Director presented financing papers at the Beijing Health Systems Research Symposium and the Kuala Lumpur International Union Conference, both in November 2012.

TB CARE I has been providing technical assistance to both the NTP and NAP for initiation of IPT for PLHIV. To date, 267 PLHIV from four hospitals were screened for IPT, 204 (76%) were found as eligible and agreed to start on IPT. Five patients (2%) have finished the IPT course (i.e. 6 month INH regimen), 191 are still on prophylactic treatment (94%), and 8 had stopped treatment (4%).

5.13 Kenya

KNCV is the lead partner in Kenya; MSH is the only collaborating partner. Sub-agreements are in place with the Kenya Association for Prevention of TB and Lung Diseases (KAPTLD) and Kenya AIDS NGOs Consortium (KANCO). The project conducts activities in all eight technical areas through the Year 2b workplan.

TB CARE I played a key role in the planning and implementation of the national biennial planning meeting held in November; the meeting was attended by Ministry of Health staff, NTP staff (national, provincial and district level) and partners implementing TB control activities in Kenya. The objective of the meeting was to discuss both progress and challenges, and to develop a two year strategic implementation plan for TB control activities in the country.

The new Information, Communication and Technology (ICT) innovation, “TIBU” (‘to treat’ in Swahili) - developed to improve program management for the NTP - was launched in November. This is a partnership between the Government of Kenya, Safaricom Limited and USAID. The TIBU system provides real time electronic data to help improve program management, decision-making at all levels and service delivery of TB care. It also enables efficient money transfer to NTP staff and TB patients through M-pesa, a mobile phone-based money transfer service. TB CARE I participates in the policy, management and operation teams. TB CARE I also financially supports implementation of the system, as well as facilitating the M-pesa payments to NTP staff and TB patients. During the biennial meeting, the M-pesa system was used to make bulk payments for the allowances of all NTP staff (national, provincial and district staff). The launch was an exciting event and was covered by several major media companies in the country.

The TB CARE I Laboratory Technical Officer presented the poster “Improving AFB Microscopy Services in Kenya through Strengthening of EQA System” at the Union World Conference on Lung Health in Kuala Lumpur. TB CARE I’s support of the EQA system continues and impressive EQA coverage results from the last four years are displayed in Figure 7 below. Major improvements in EQA coverage dovetail with the start of USAID’s investment in EQA (in 2009 through TB CAP) and TB CARE I’s start in October 2010.

Figure 7: Quarterly EQA coverage in Kenya, 2009-2012

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Group work during the Advanced Course on DOTSAcceleration

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5.14 Mozambique

FHI 360, the lead partner for Mozambique, works with collaborating partners KNCV and MSH on a dual TB/malaria workplan. The Year 3 workplan has activities in all eight TB technical areas, as well as malaria control.

CB-DOTS activities expanded to five new districts this quarter, bringing the total number of districts covered by TB CARE I to 50 (83% of the 60 district target for Year 3). The Implementing Agencies (those providing CB-DOTS services with support from the project) during this quarter referred 6,670 TB suspects and 3,690 malaria suspects to health facilities. A total of 1,214 TB (all forms) were diagnosed of which 807 (66.5%) were diagnosed as SS+, 332 (27.3%) as SS-, and 75 (6.2%) as having extrapulmonary TB. Of the total TB patients, 203 were HIV+, representing a co-infection rate of 16.7% of all referred TB patients during this quarter. Out of the total number of malaria suspects referred by community volunteers, 3,184 (86%) were diagnosed as having active malaria.

TB CARE I in close coordination with the NRL, the NTP and other partners working in TB control, set up a GeneXpert TW). The group discussed and developed the guidelines for the implementation of GeneXpert, which includes the algorithm for GeneXpert use. A total of 82 clinical staff from the three sites where GeneXpert has been placed were trained on the introduction of GeneXpert technology, the algorithm, and sample referral from remote areas to the testing sites.

TB CARE I supported a TB-IC training targeting national and provincial infrastructure technicians on infection control and IC standards for construction and rehabilitation of health facilities. This training was the first in the country and it was a unique opportunity to introduce construction technicians to TB-IC concepts and to share information and experiences between provinces and the MoH.

The project supported the PMDT workshop co-organized by WHO-AFRO in close coordination with NTP for participants from Portuguese speaking African countries. This workshop was held in Maputo with participants from Mozambique, Angola and Sao Tome and Principe. Doctors from five selected provinces in Mozambique attended the workshop.

The project also procured a one-year supply of lab commodities and reagents for the malaria laboratory component. This will avoid stockouts in health facilities and thus improve the laboratory diagnosis of both malaria and TB in the country.

5.15 Namibia

KNCV is the lead partner in Namibia and collaborates with WHO and The Union on the Year 3 workplan. Activities are implemented in UA, IC, PMDT, TB/HIV, HSS and M&E.

TB CARE I continued to provide TA and financial support to the NTP in the provision of quality PMDT. Weekly Central Case Review Committee (CCRC) meetings were held throughout the quarter, a curriculum review for MDR-TB training was conducted and tents to be used for the ambulatory care of TB patients were purchased and handed over.

A data verification and supportive supervision visit was conducted to the two Northern regions of the country; a total of five districts were visited and on each site, data quality audits were carried out, the TB registers were checked for completeness and accuracy, and ETR.net entries were compared with those in the paper-based TB registers. This was an achievement as no such visit was conducted the previous year due to competing priorities. Five quarterly zonal review meetings were held in all five zones of the country’s 13 regions to ensure continued data quality; these meetings are crucial for improved data quality.

Two out of five research proposals that were submitted to the Ministry’s Department of Policy Planning Human Resources Development have already received ethical approval: 1) An ecological study of the reasons for the variance in Namibian TB case notifications by district, and 2) Risk factors for development of leprosy in Namibia.

5.16 Nigeria

KNCV is the lead partner for Nigeria and works closely with collaborating partners, FHI 360 and MSH. The Year 3 work plan focuses on UA, laboratories, PMDT, HSS and M&E.

A highlight for the quarter was the successful completion of the MDR-TB ward renovation in Kano and the launch by the Executive Governor of the State. It becomes the first MDR-TB treatment center in the whole of the North Western region of Nigeria, which will serve not only Kano state and all other adjoining states within the region but equally absorb overflow from other treatment centers situated outside the region. Based on the high quality of renovation work at the facility, the governor gave the commitment of his government to ensure strict maintenance of the treatment center. He consequently directed that the entire facility be upgraded to the standard now set by the new MDR-TB treatment center. There are 13 patients currently admitted to the ward.

TB CARE I has also continued to provide support to the NTP in the coordination of the Country GeneXpert Advisory Technical (CGAT) committee meeting. The meeting provides a venue for identifying new partners to support the NTP and for mapping Xpert use and

Kano MDR-TB ward

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coverage for scale up. With the installation of the additional six GeneXpert machines, there is increased access to Xpert services (15 total operational machines). During the quarter a total of 1,619 persons were tested with Xpert MTB/RIF; 468 (29%) were diagnosed with TB of which 125 (27%) patients were found to have RIF resistant TB.

TB CARE I also continued intervention on the intensified case detection practices with the training of 14 people as master trainers. Since the completion of the training, cascade trainings were conducted for 182 persons in 30 facilities in Kwara, Taraba and Akwa Ibom states. The facilities have commenced implementation of the SOP-approach for improving TB case detection.

5.17 Senegal

TB CARE I began conducting PMDT activities in Senegal this quarter; The Union is the sole implementer. The first PMDT TA mission to Senegal was conducted in December 2012. Key findings from the trip include: 1) The current approach of ambulatory MDR-TB treatment will be not possible for all MDR-TB patients, and some capacity for hospitalization and appropriate TB-IC needs to be created. 2) Infection control aspects must be developed but this can be done on a pragmatic basis and does not appear to require the support of a specialist in TB -IC. 3) The arrival of new rapid diagnostic techniques (in particular GeneXpert MTB/RIF), requires an adaptation of the laboratory strategic plan. 4) Community involvement for MDR-TB treatment delivery is very important, for implementation of DOT, patient support, and tracing of patients lost to follow-up.

5.18 South Sudan

MSH is the lead partner in South Sudan and works closely with collaborating partners KNCV and WHO. TB CARE I-South Sudan implements activities in UA, laboratories, PMDT, TB/HIV and HSS.

Universal and early access to TB services remains a focus for the TB CARE I project. Following an assessment conducted in Duk Payuel County in Jonglei state, Duk Lost Boys’ Clinic (DLBC) was identified to have met the minimum standards for integrating TB services. Through the support of TB CARE I, NTP and IMA, TB services have been established in DLBC. The facility is expected to start reporting in January 2013. The high rate of primary defaulters (i.e. confirmed smear positive cases who are not enrolled for treatment) in Juba county was noted as a big challenge in the previous quarter. Following a meeting with key staff from TB Management Units (TBMUs) in Juba, the primary defaulter rate has dropped from 32% (April–June 2012) to 13% (July–September 2012). This shows that simple strategies can be employed to minimize the number of primary defaulters in TBMUs. TB CARE I procured 11 sets of microscope kits, equipment kits, consumable kits and sputum containers to complement NTP efforts to expand quality TB diagnosis in newly established diagnostic centers and to maintain quality standards at established sites. In order to improve case finding among HIV patients, a three-day training was conducted for 25 Voluntary Counseling and Testing (VCT) counselors from the Eastern Equatoria State. TB screening tools that were jointly revised by the TB and HIV working groups have been introduced and referral mechanisms established. South Sudan (NTP and TB CARE I) participated in the Union World Conference on Lung Health that was held in November 2012. Two presentations were given on DOTS expansion and partnering for results in South Sudan in a symposium titled “Saving lives in areas of conflict or disaster”. A poster presentation was also displayed on “Integration of TB into primary health care in South Sudan: challenges and lesson learnt”.

5.19 Uganda

KNCV is the lead and sole implementing partner in Uganda. The project runs through June 2013 and focuses on UA, PMDT, TB/HIV and HSS.

Supportive supervision was provided to 35 out of 38 health facilities (92%), visited by a team of technical officers from TB CARE I, the Kampala City TB control officer and the five division supervisors. The focus of the supervision was on recording, reporting and requisitioning of anti-TB drugs. A number of issues hindering efficient DOTS implementation in Kampala were

TB Register at DLBC before the assessment

Introduction of standardized TB recording and reporting tools by the NTP and TB CARE I

Health care workers undergoing practical exercises in report compilation

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also noted during these visits, including the need for a drastic improvement in R&R, operationalization of electronic TB registers, especially in high volume facilities, and a skill gap at health facilities in TB logistics management. TB CARE I contracted a consultant to further study the situation in Kampala and to identify practical strategies that can be implemented by TB CARE I to improve DOTS implementation.

The Mulago MDR-TB ward renovation commenced in October 2012. The renovation is scheduled to be completed in February 2013 and the new ward will provide capacity for a total of 30 MDR-TB patients. An assessment of TB-IC in MDR-TB wards at Mulago, Mbarara and Fort Portal hospitals was conducted by the PMU TB-IC Technical Officer. Recommendations for architectural improvements to these hospitals were drafted and are pending approval by the respective hospital administrations.

TB CARE I spearheaded the finalization of the National TB Strategic Plan and the NTP Annual Implementation Plan. The strategic plan has been submitted for endorsement by the MoH.

5.20 Vietnam

KNCV is the lead partner in Vietnam and works with collaborating partners MSH and WHO. The Year 3 work plan has activities in UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E.

Three supervisory visits by the NTP childhood TB team were carried out in Ha Noi, Ho Chi Minh City & Can Tho. A total of 12 district TB units and 25 communes were visited. The Mission provided on-the-job training for staff at district and commune levels, monitored the implementation status and provided recommendations for improvement.

The NTP GeneXpert group carried out monitoring and supervision visits for pilot implementation of Xpert MTB\RIF in five pilot sites (Da nang, Binh thuan, HCMC, Thanh hoa and Quang ninh). As of November 2012, 1,999 tests were done for three target groups: MDR suspects (82.5%), PLHIV suspected of having TB (15.4%) and children suspected of having TB (0.1%). Among those tested, 52.7% were MTB positive, of which 17.5% were Rifampicin resistant.

The SOP for data collection using the Xpert data extraction form has been prepared and the protocol of operations research in support of Xpert introduction in Vietnam has been finalized.

e-TB manager implementation in 45 treatment sites is on-going with almost 90% of patients registered in the system. The first TA visit on PMDT expansion and TB CARE I implementation (childhood TB, GeneXpert, LED FM) was carried out in November 2012.

5.21 Zambia

FHI 360 is the lead partner in Zambia and works closely with collaborating partners KNCV, WHO, and as of Year 2, MSH. Activities are implemented in all eight technical areas.

The Patient Centered Approach (PCA) initiative is being implemented in the North Western province in three districts. The initiative has three main phases that include a baseline survey, the implementation of PCA tools and an end-of-project survey. TB CARE I staff members participated in the collection of baseline data via a quantitative survey questionnaire (three districts) and qualitative in-depth interviews (two districts). This data will provide information on the current health needs and preferences from a patient perspective.

Implementation of the national sputum specimen courier system began with a baseline assessment in four selected pilot provinces of Central, Eastern, Copperbelt and Northern provinces for a total of 60 health facilities in 24 districts. A team of MoH and TB CARE I laboratory staff conducted a baseline assessment using structured questionnaires, interviews (84 participants) and collection of additional data. In total, 30,636 smears were examined of which 4,171 (14%) were positive. The Copperbelt Province had the highest number of smears done (13,451) and the highest percentage of smear positive results (2,045; 15%).

TB CARE I provided technical support to the NTP to reconstruct PMDT data at two referral hospitals using the newly printed MDR-TB reporting and recording tools. The data reconstruction will help the NTP to provide MDR-TB patient data for the country. Revision of the national guidelines for PMDT was completed this quarter by a sub-committee that included TB CARE I.

Group work during the Advanced Course on DOTSAcceleration

PCA interview team visiting a village elder

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Preparatory work has been underway for the implementation of the WHO 3 I’s project in four provinces in Zambia, in partnership with the Centre for Infectious Diseases Research in Zambia (CIDRZ). The partners developed a set of baseline assessment and monitoring tools this quarter. The tools have been reviewed by local and international technical staff from MoH, TB CARE I, CDC and USAID.

Four draft OR protocols were developed by a team of MoH staff members, research staff from the University of Zambia and TB CARE I local and international partners by December 2013. The project plans to finalize the protocols for local ethical approval in the next quarter. The draft protocols are under the following themes: 1) What are the best strategies to promote and scale up integration of screening of HIV and TB amongst household contacts of smear positive TB patients? 2) What factors contribute to long turnaround time for sputum smear microscopy results for TB suspects and follow up patients? 3) Assessing barriers to timely screening and diagnosis of TB in prison inmates in Zambia; and 4) Study to determine barriers in the identification and referral of MDR-TB suspects for diagnosis in Zambia.

5.22 Zimbabwe

Zimbabwe is led by The Union and has KNCV and WHO as collaborating partners. The Year 3 work plan focuses on UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E.

For the last two quarters, 61% of new sputum positive patients (83/135 this quarter) from five districts were diagnosed through a pilot sputum transport system. Before the transport system, virtually 100% of suspects (and patients) had to personally travel from their villages to the district hospital where the lab is usually located; since the introduction of the transport system, suspects and TB patients do not have to go beyond the local health center for sputum collection. This illustrates the key role the transport system is playing in increasing access to TB diagnosis. A greater impact is anticipated when an additional 32 motorcycles are introduced in 32 districts late in the second quarter.

Another positive development is the greater yield of sputum positive TB patients from suspects in the five districts during the past quarter: 13% of suspects were diagnosed with TB this quarter (135/1,020) compared to 10% (103/1,078) last quarter. The trend will be monitored for significance during the year. The system also helped strengthen the overall health system in the districts by transporting 933 other non-sputum medical samples and results to and from the laboratories.

TB CARE I participated with the NAP in the first practical steps of rolling out IPT in Zimbabwe. Three supported integrated TB/HIV care centers are among the 10 pilot sites. Training for the pilot has equipped health workers in the pilot sites with a better understanding of the IPT intervention. The pilot has also presented an opportunity for inclusion of IPT indicators in the R&R tools.

6. Regional Projects

In addition to the aforementioned country and core programs, TB CARE I currently manages four regional projects. Three of these projects are a continuation from Year 2 and their Year 3 work plans were approved in January 2012. The fourth project, the Regional HIV/AIDS Program, TB in Mining - South Africa, was approved during the quarter. This project receives both core and regional funding and will be reported on under the core section of this report (see page 7).

6.1 Center of Excellence (CoE) for PMDT

The CoE for PMDT project is implemented by KNCV. No specific activities were planned for this quarter as the majority of activities planned for Year 2 were already achieved by October.The project coordinator represented the CoE at the Union World Conference on Lung Health in Malaysia. She gave an oral presentation on CoE PMDT activities and achievements.

6.2 East Africa Supranational Reference Laboratory (SNRL)

The Union, the lead partner, works closely with KNCV/KIT on the SNRL project. At the Cape Town African Society for Laboratory Medicine (ASLM) conference in December the Uganda NRL was accorded the prize for the best reference lab in Africa.

This quarter, the MoH agreed to fund additional positions at the SNRL/NRL using government funds. The change will occur when the reorganization of various MoH services is implemented.

An official link between the SNRL and South Sudan was signed by both countries. It was determined that WHO funds could be used to provide technical assistance to reinforce or prepare NRL/SNRL links (i.e. to South Sudan or Somaliland).

6.3 ECSA (East, Central and Southern Africa)The ECSA project is led by KNCV. This quarter two ECSA staff attended the three-week International Tuberculosis Course held in Arusha, Tanzania.

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.

© TB CARE I 2013

E-mail pmu@tbcare1.orgPhone +31-70-7508447Website www.tbcare1.orgTwitter #tbcare1 TB CARE