tb care i year 1 qmr 4 december 7 2011 nf...• rapid scale up of genexpert should continue, but...

TB CARE I PROGRAM YEAR 1

Fourth Quarter Performance Monitoring Update July 1, 2011 – September 30, 2011

November 30, 2011

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TB CARE I Partners

• American Thoracic Society (ATS)

• FHI 360 (FHI)

• Japan 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)

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Table of Contents 1. Introduction ........................................................................................................................ 5 2. Project Management Unit (PMU) ............................................................................................ 6 3. Core projects ...................................................................................................................... 6 4. Country projects ............................................................................................................... 16

4.1 Afghanistan ...................................................................................................... 16 4.2 Botswana ......................................................................................................... 17 4.3 Cambodia ........................................................................................................ 17 Central Asian Republics (CAR) ............................................................................................. 17 4.4 CAR-Kazakhstan: .............................................................................................. 17 4.5 CAR-Kyrgyzstan ............................................................................................... 18 4.6 CAR-Uzbekistan ................................................................................................ 18 4.7 Djibouti ........................................................................................................... 19 4.8 Dominican Republic ........................................................................................... 19 4.9 Ethiopia ........................................................................................................... 19 4.10 Ghana ............................................................................................................. 20 4.11 Indonesia ........................................................................................................ 21 4.12 Kenya ............................................................................................................. 22 4.13 Mozambique ..................................................................................................... 22 4.14 Namibia ........................................................................................................... 24 4.15 Nigeria ............................................................................................................ 25 4.16 Pakistan .......................................................................................................... 26 4.17 South Sudan .................................................................................................... 26 4.18 Vietnam ........................................................................................................... 26 4.19 Zambia ............................................................................................................ 27 4.20 Zimbabwe ........................................................................................................ 27

5. Regional Projects ............................................................................................................... 28 5.1 Center of Excellence (CoE) for PMDT ................................................................... 28 5.2 East Africa Supranational Reference Laboratory (SNRL) ......................................... 29 5.3 ECSA (East, Central and Southern Africa) ............................................................ 29

List of Tables Table 1: Overview of Year 1 Core Projects, July 2011 to September 2011 .................................. 7 Table 2: Geographical distribution of TB CARE I partner countries ........................................... 16

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List of Abbreviations ACSM Advocacy Communication Social Mobilization AFB Acid Fast Bacilli CAR Central Asian Republics CDC Center for Disease Control and Prevention CoE Center of Excellence CDR Case Detection Rate CSO Civil Society Organization DOT Directly Observed Treatment DOTS Directly Observed Treatment Short Course DR Drug Resistance DRS Drug Resistance Survey DST Drug Susceptibility Testing ECSA East, Central and Southern Africa EQA External Quality Assurance ERR Electronic Recording & Reporting FIND Foundation for Innovative New Diagnostics GDF Global Drug Facility GFATM Global Fund for Aids, Tuberculosis and Malaria GLC Green Light Committee GLI Global Laboratory Initiative HRD Human Resource Development HSS Health System Strengthening IC Infection Control IEC Information, Education and Communication ILEP International Federation of Anti-Leprosy Associations JATA Japan Anti Tuberculosis Association KIT Royal Tropical Institute KNCV KNCV Tuberculosis Foundation MDR Multi Drug Resistance MDR TB Multi Drug Resistant Tuberculosis M&E Monitoring and Evaluation MOA Memorandum of Agreement MOH Ministry of Health MOST Management & Organizational Sustainability Tool MSF Médecins sans Frontières (Doctors without Borders) MSH Management Sciences for Health NAP National Aids Program NGO Non Governmental Organization NIHE National Institute of Health and Epidemics (Vietnam) NTP National TB Program NRL National Reference Laboratory NTRL National Tuberculosis Reference Laboratory (Uganda) OR Operational Research PMDT Programmatic Management of Drug-resistant Tuberculosis PMU Program Management Unit PPM Private Public Mix PPP Public Private Partnership RIF Rifampacin QMR Quarterly Monitoring Report SLD Second Line Drug SNRL Supra National Reference Laboratory SOP Standard Operating Procedures SS+ Sputum Smear positive SS- Sputum Smear negative TA Technical Assistance TB Tuberculosis TB CAP Tuberculosis Control Assistance Program TBCTA Tuberculosis Coalition for Technical Assistance USAID United States Agency for International Development WHO World Health Organization

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1. Introduction TB CARE I is pleased to present USAID with a Quarter 4 update for the TB CARE I program. This is not a full report as the Year 1 Annual Report covers a great deal of information that is usually provided in a quarterly report. This report provides a technical and financial update on progress made during the quarter towards planned outputs and main activities for approved core, regional and country projects. The Year 1 Annual Report (separate document) provides a summary of achievements over the entire project year as well as progress towards core and technical outcomes. The financial section in this report is similar to that found in the Year 1 Annual Report as the financial situation at the end of Quarter 4 reflects the cumulative financial picture at the end of the year. Below is a brief summary of TB CARE I’s main achievements to date and challenges for next year. Main Achievements: • Although this is the first year of the program with many core, regional and country projects

started at different times due to ongoing TB CAP work, overall TB CARE I has accomplished quite lot: 58% of country workplans, 81% of regional workplans and 76% of core workplans have been successfully implemented.

• The total expenditures and accruals for the fourth quarter were $15.7 million, an increase of 75% compared to the previous quarter, and reaching the desired quarterly burn rate.

• A 3-day meeting on Leadership and Management was conducted in The Hague, attended by 17 TB CARE I Country Directors to build capacity on technical and managerial expertise.

• A workshop "Using TB Information for Decision Making: A Monitoring & Evaluation Workshop for NTP M&E Officers and TB CARE/TB TO 2015 M&E Officers" was held in September in The Hague. Participants from 16 TB CARE and TB 2015 countries developed mini M&E plans for their countries, which will be implemented in Year 2.

• A lab accreditation toolbox and templates were developed. The toolbox can be found on the GLI website: www.GLIquality.org.

• Action plans for implementing the HRD strategy are in place in six NTPs that participated in the Virtual Leadership Development Program (Afghanistan (2), Ghana, Indonesia, Pakistan, and Uganda).

• In Afghanistan, TB-IC measures were extended to an additional 15 public health facilities in just three months time, four in Kabul city and 11 in the provinces.

• In Ethiopia, second line drugs for 100 MDR TB patients arrived in the MDR treatment sites in June 2011. At that time the number of MDR TB patients enrolled on treatment was 235. Within three months, the enrollment increased by an additional 68 patients, which brings the total number of MDR TB patients put on treatment to 303.

• Extensive GeneXpert trainings were conducted in Indonesia and Nigeria to prepare for roll-out in Year 2. Training curricula, diagnostic algorithms and clinical guidelines were developed.

• The draft Drug Resistance Survey (DRS) protocol was prepared by TB CARE I and submitted to the NTP of Nigeria.

Main Challenges and Next Steps: • Rapid completion of Year 1 workplans while also transitioning to Year 2 in some countries. • More emphasis must be given to support countries to develop or improve National Laboratory

Strategic Plans in Year 2. The development of a TB Lab Strategic Plan will be supported by a “Practical Handbook for TB Laboratory Strategic Planning”, which is being developed under a TB CARE I core project and will be completed in Year 2.

• Rapid scale up of GeneXpert should continue, but while still maintaining quality of services and results.

• Quality of TB/HIV data appears to be a problem across many countries. A strategy to improve current M&E systems for routine data collection of TB/HIV indicators is needed.

• The availability of first and second line drug stock information is inconsistent across countries. Interventions to address this information gap should be developed at country level.

• The delay in the signing of Global Fund Round 10 agreements in several TB CARE I countries has impacted the project’s ability to complement the implementation of the interventions to be funded through the Global Fund Round 10 Grant.

• Although nine core projects have been completed only two of them have reported 100% spending while two of them reported 85% spending, five of the completed projects report spending ranging from 56% to 36% of the approved budgets. This is mainly due to not reporting on accruals in addition to over budgeting.

• Some country projects show delays in implementation and spending and need closer follow up (e.g. Djibouti, Dominican Republic, Mozambique, Vietnam, and Zambia). Also the overall management budget shows serious under spending (51% of the budgeted amount) despite

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the fact that four quarters of Year 1 have been completed. Similarly 64% of all projects (core regional and country) did not report accruals in Quarter 4, which the PMU will continue to request and monitor.

2. Project Management Unit (PMU) The first TB CARE I Country Directors Meeting was held September 22-24th in The Hague with 17 Country Directors in attendance. The aim was to maintain and strengthen the Director’s leadership and management skills in supporting NTP and leading the TB CARE I in-country coalition. A major emphasis was put on the fundamentals of leadership and management fundamentals, while also building knowledge in pediatric TB, PMDT, laboratories, and infection control, and discussing program management issues. Special emphasis was given to the introduction of GeneXpert and the challenges and issues related to an adequate supply of SLDs.

3. Core projects As of September 30th, nine of the 28 Year 1 core projects have been completed and are published on the website. Nineteen projects require extensions; seven of these projects have approved 3-month no-cost extensions through December 2011 and the others have requested 3-month (4), 6-month (6), or 9-month extensions (2). The following table (Table 1) provides detailed information on the progress of each of the 28 core projects.

Table 1: Overview of Year 1 Core Projects, July 2011 to September 2011

Technical Areas Code Lead Title Year 1 Expected Outcome(s) Progress to date %

complete Level of spending

1. Universal and Early Access

C1.1.1 KNCV Tool to identify TB most at risk and vulnerable populations

• Framework format developed

The NTP Risk Groups Need Assessment Report was written and presented in a symposium on marginalized populations in Lille. The first draft of the meta-synthesis of literature on 29 risk groups will undergo expert editorial group review in December. Pragmatic workplans for each partner and timeline were developed in Lille. Transition to the Year 2 Screening Guidelines project was discussed. With the continued high level of partner collaboration, the budget and paper-version of the tool can be finished by December. The Beta web version of tool will be ready for piloting by February 2012 as external scientific oversight is needed.

75% 56%

C1.1.5 KNCV Adapt and pilot patient centered package

• Methodology developed • Two kick-off workshops conducted

The first regional kick off workshop, originally planned for Indonesia, was changed to Cambodia in October. The core teams were formed in close collaboration with the respective NTP Directors and TB CARE I focal persons for both Indonesia and Cambodia and each team prepared a presentation on the current status of patient centeredness in their respective TB programs. The second regional workshop will take place in Lagos, Nigeria in November with participation from Nigeria, Mozambique and Zambia.

50% 11%

2. PMDT C2.1.1 PMU & TB CARE II joint project

Strengthening of regional and local technical collaboration centers (TCC) for PMDT

• Assessment of technical collaboration center in India • Functioning exchange between TCCs

The assessment visit to India Gujarat was cancelled as approval was never received from NTP-India. The questionnaire/mapping tool that was developed in the previous quarter was disseminated by email to ~100 stakeholders. At the end of the quarter, 17 Technical Collaboration Centers (TCCs) had responded and other responses are expected. A meeting in Lille is planned to present the preliminary findings of the inventory and for NTP representatives, TCCs and project partners to discuss challenges faced by TCCs and ways forward. Proposals will be elicited on options for how a regional TCC network could support national TCCs and country PMDT scale-up. The end-report with recommendations is expected by December.

75% 60%

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3. Infection Control

C3.1.1 WHO Develop a tool to measure TB incidence in health care workers

In July, WHO led a two-day meeting in The Hague. Thirty five participants from TB CARE I/II countries and partner organizations attended. Consensus was reached on the content of the two guides (one on measuring prevalence – led by KNCV, and another on monitoring incidence – led by WHO). Writing is in progress. It is expected that advanced drafts of both guides will be discussed in the upcoming TB Infection Control Core group meeting that will take place in Lille, France. Editing and lay out of the tool is planned for November.

75% 94%

C3.2.1 PMU & TB CARE II joint project

Core Package of IC Interventions

• Core TB IC package developed

In July, PIH led the organization of a two-day consultative meeting in The Hague with 26 participants from 20 organizations attending. A proposed core package that is easy to understand at the facility, district, and regional level was discussed. The components of the Core Package are captured by the acronym, F-A-S-T: “Find cases Actively, Separate safely, and Treat effectively”. The four major components that a ‘core’ package should incorporate are: 1. Active surveillance, 2. Rapid Diagnosis, 3. Exposure control, and 4. Effective treatment. The next steps are to identify a marketing and messaging group to further develop the acronym, develop materials, and pilot test them. Zambia and Tajikistan were considered possible TB CARE sites for Year 2.

100% 56%

C3.3.2 KNCV Training and mentoring on TB IC

• 9 IC consultants trained and underwent one mentored field visit

Training was delivered to 12 consultants (20% female), of which 11 received follow up. Nine mentored field visits were completed, two persons were referred to other trainings (including Harvard IC training by TB CARE II) and distance support was provided to 10 trainees. All nine mentored trainees are active in TB IC (providing IC training, conducting facility assessments, preparing operational research), three can act as regional IC consultants (to be registered with TBTEAM), and the other six can act as national consultants. A facilitator's guide was prepared for an advanced TB-IC course.

100% 85%

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4. TB/HIV C4.1.1 FHI TB Infection Control at Community Level

• ToT Curriculum developed • How-to manual developed

Successful "TB Infection Control at Community Level" TOTs were held with 20 TB treatment supporters, focal persons and adherence workers in the Copperbelt, Zambia and with 26 Community Health Extension Workers and TB program supervisors in Nakuru, Kenya to pilot and receive feedback on the TB IC Community Handbook. Scale-up plans for the Simplified Checklist for TB Infection Control were developed in each country. The handbook has undergone final review by the collaborating partners and is currently in the design/ production stage. The handbook and checklist will be finished by mid-December and will be posted on the TB CARE I website; 1,000 copies of the checklist will be shipped to Zambia & Kenya for initial scale-up.

90% 33%

C4.2.2 ATS Guidelines for evaluations of contacts to infectious cases of tuberculosis

• WHO-approved set of guidelines developed

Recommendations were discussed and formulated on: (i) the TB case indexes around whom contact investigation should be carried out; (ii) in order of priority, the TB contacts who should be assessed for active TB; and, (iii) the counseling and testing for HIV infection and the isoniazid preventive therapy that needs to be undertaken in the framework of TB contact investigation activities. The document is being drafted and the preliminary draft will be further discussed in a symposium at the Union Conference in Lille, France. The draft will then be circulated to the Guideline Development Group members and the External Review Group for final comments. The final version of the document will be sent to the WHO Guideline Review Committee by mid-December. Editing and printing of the guidelines' document is expected by early March.

75% 84%

C4.3.1 KNCV Assessment of TB/HIV mortality data

• Five high-burden countries assessed• Strategy to improve M&E systems developed

A successful half-day workshop was conducted with 35 M&E Officers on advanced methods of M&E for TB/HIV mortality. Three assessments were conducted; Zambia (MSH) and Namibia (KNCV) are delayed by an election travel ban and a pending ethics waiver. Kenya (KNCV), Mozambique (KNCV) and Ethiopia (MSH) assessments all reveal data quality problems. The target of end of December is unlikely unless data are available by mid-November.

75% 41%

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5. M&E, OR and surveillance

C5.1.1 WHO Guide on electronic recording & reporting for TB care and control

• Guide on ERR developed

Two chapters have been revised and two new chapters have been written, with all four sections incorporating suggestions made at the April contributors’ meeting. Revised material will be sent to ~10 external reviewers. A PDF will be published on the WHO website by 31 December.

75% 64%

C5.1.2 WHO Guide on inventory studies to assess the level of TB under-reporting

• Guide on inventory studies developed

About 65% of the guidelines content has been written. Work is ongoing and will accelerate in November/December. An electronic version is expected by the end of the year and a printed version during the first quarter of 2012.

50% 39%

C5.2.1 MSH Develop M&E COP for NTPs

• Increased use of data for decision-making in TB CARE countries

A workshop "Using TB Information for Decision Making: A Monitoring & Evaluation Workshop for NTP M&E Officers and TB CARE/TB TO 2015 M&E Officers" was held in September in The Hague. It was attended by 31 participants from 16 countries and facilitated by PMU M&E Officers and M&E experts from MSH and MEASURE Evaluation. During the workshop participants developed mini M&E plans for their countries, which will be implemented in Year 2. Evaluations of the workshop indicate a high level of satisfaction with the content, but many believed that the time was too short for the amount of material covered.

100% 85%

6. Laboratories C6.1.1 KNCV Practical handbook for the development of a national laboratory strategy

• Practical handbook developed

Several chapters of the tool have been drafted. An in-country pilot of the draft tool is planned for Botswana in November. Lab experts representing NRLs from Benin and Pakistan were subcontracted to provide input on selected chapters. After the Botswana pilot, the draft will be revised and shared with stakeholders for further input. A draft tool is expected by the end of December, which will need more validation in Year 2.

40% 38%

C6.1.2 Union Tool for lab network assessment

• Consensus tool developed and tested

A first draft of the tool has been developed and is currently being revised. A group meeting is planned at the Lille conference to better define the structure of the document, the actual contents of a checklist, and the accreditation process.

75% 81%

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6. Laboratories C6.1.3 Advisory Group members LEO

Completed. Advisory Group members, coming from all coalition partners participated in the Joint Strategic Meetings and conference calls in order to establish themes and indicators for their respective Technical Area.

100% 38%

C6.1.4 WHO Training for Global Fund Round 11 Consultants

Consultants are trained on new tools and approaches in TB control and have the necessary skills to provide consistent and quality TA for successful Global Fund Round 11 proposal development.

Completed. The 3-day training workshop for consultants supporting countries to prepare for Global Fund Round 11 was held in Geneva in August. Consultants supporting 15 priority countries as selected by TBTEAM in consultation with partners were joined by six self-funded participants from Papua New Guinea, Sri Lanka, and Population Services International (PSI) (in total, M=25, F=17). Participants were updated on the latest developments in TB care and control by experts from the Global Fund, the WHO TB Department, the WHO HIV Department, the WHO Maternal & Child Health Department, UNAIDS, by community experts, and members of the external Technical Review Panel to the Global Fund. All consultants received electronic versions of all forms, lectures and background documents.

100% 100%

C6.2.1 KNCV Lab accreditation tools and roadmap

• Lab accreditation toolbox and templates drafted

The template was drafted and presented with GLI at the WHO-Geneva stakeholder meeting in July; Roll-out will begin in Lille. Further development and roll-out is expected in Year 2. Harmonization with former SLIPTA African Step-wise accreditation tool is also expected.

100% 46%

C6.3.1 WHO Guiding and coordinating Xpert MTB/RIF implementation

• Guidance made available on scaling up and implementing new testing algorithms incorporating Xpert MTB/RIF

Completed. The “Rapid Implementation of the Xpert MTB/RIF diagnostic test: Technical and Operation “How To” practical considerations” is the deliverable, which is available on the TB CARE I website: http://www.tbcare1.org/publications/toolbox/tools/lab/Rapid_Implementation_of_Xpert_MTB-RIF_diagnostic_ test.pdf

100% 42%

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6. Laboratories C6.4.1 WHO Assess quality of WHO-GLI SRLN and individual SRLs using GLI assessment tool

• Draft of GLI assessment tool revised

A field evaluation of the revised tool was conducted at the National TB Reference Laboratories in Uganda and Kenya in May. A follow-up up visit was made to the Central Reference laboratory in Kenya. The revised tool underwent peer review and was finalized in Geneva in August as part of a comprehensive review of technical training materials.

100% 36%

C6.4.2 Union Develop Benin NRL in Africa to join SRLN

• Benin NRL is staffed with trained and competent personnel; quality management system in place and adherence to procedures ensured

The Benin NRL was recognized as a candidate SRL by WHO and is part of the network as of this year. They now have two years to show that they are capable of assuming these tasks, i.e. proficiency in DST and assisting neighboring countries with quality assurance, training and supportive supervision. These aspects were addressed during a visit by a consultant and links with Togo and Niger are being prepared. Proficiency testing as well as rechecking of DST were performed in Antwerp, showing excellent performance. Problems with management tools at the Cotonou lab were solved, and the outline of a lab strategic plan was made. No less than four visits for quality management were made. Next year will be needed to continue quality management & accreditation preparations, to introduce DST panel testing organization, to activate the links with Togo and Niger and to finalize the strategic plan.

75% 37%

C6.4.3 WHO Meeting of the SRLN

• Meeting of SRLN convened and consensus workplan and strategy developed

A consultation of the SRLN was planned to take place in October as part of a larger annual meeting of the GLI. The purpose of the meeting was to review the lab strengthening efforts of the SRLN for the previous 18 months, develop plans for 2011-2013 and identify funding gaps. The meeting is postponed until April 2012 in Annecy, France, which will include one day devoted to the SRL network, one day focused on the laboratory strengthening activities of the GLI partners and one day to review progress with the implementation of the Xpert MTB/RIF.

50% 1%

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7. Health Systems Strengthening

C7.1.1 WHO Increased and sustained political and financial commitment to TB prevention, care and control

• Improved TB plans, indicators and budget embedded within national health plans and/or strategies.

The National Health Plan database was completed based on available materials. Summary comparisons of National Health Plans and National TB Strategic Plans were completed for four countries. A contract was initiated for completion of reviews of eight additional countries. A workshop is planned in early December to review results with partners and three country representatives from two high performing countries and one country with challenges. A no cost extension is requested through March to enable field assessments and finalization of a lessons learned document for improved synergies of national plans to improve TB care and control implementation.

25% 0%

C7.1.2 ATS Create political commitment and financing database

• Political commitment (measured by domestic financing for TB) increased

WHO/STB has done preliminary analysis of financing trends for TB CARE countries based on 2009 data, which can now be updated with final 2010 data (per the WHO 2011 Global TB Report). Piggybacking on the planned workshop regarding national health plans, national financing will also be considered at the December workshop looking at trends in several selected low and lower-middle income countries, and how financing was addressed in the development of national health strategies and national TB plans. The work will be continued in Year 2 with advocacy and capacity building related to domestic financing negotiations in selected countries.

25% 0%

C7.1.3 WHO Enhancement of the planning and budgeting tool

• Planning and budgeting tool enhanced • 15 participants trained on its use

91 contacts from 41 countries using the tool filled out the feedback questionnaire. The tool has been updated and a new version is available on the WHO website. The update does not yet include a new platform. Two important activities are to be conducted: 1) changing the platform and, 2) a workshop (planned in second quarter of 2012) to train the countries interested in continuing use of the tool. Analysis of the feedback will happen in November after which the platform will be updated.

50% 11%

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7. Health Systems Strengthening

C7.4.1 MSH Training national leaders on HRD Tools

• Action Plan on HRD in place in NTPs

In total, action plans from six of the eight teams were received (Afghanistan (2), Ghana, Indonesia, Pakistan and Uganda). Kenya and Zimbabwe did not submit their plan. The project team will hold an after-action review in November to discuss the results of the course and finalize the report.

90% 90%

C7.5.1 KNCV Build capacity of civil society in TB Control

• Methodology to build capacity of civil society organizations in TB control developed and pilot tested • 6 civil society organizations in 2 countries have a TB activity plan and started implementation • 6 civil society organizations in 2 countries have partnered with national and/or local stakeholders in TB control

Four CSO's in Nigeria and four CSO's in Indonesia have finalized and started implementing their workplans. The M&E framework has been introduced and CSO's monitor the implementation of their workplans and the performance growth of their organization. CSO's in Nigeria and Indonesia are coached by a mentor organization. CSO's continue implementation of workplans and self-monitoring. Teleconferences with the project teams in country and the international consultants are planned to improve communication and collaboration.

75% 83%

8. Overarching elements

C0.0.1 WHO Support to the Sub Working Groups of the Stop TB Partnership

• Strategic areas of work discussed and agreed in seven groups • Reports from all meetings available

The 7th PPM meeting, TB-IC subgroup meeting and the HRD-TB core group meeting will all take place in Lille, France. The GLI meeting has been postponed due to the substantial reorganization of the WHO Stop TB Department. A joint GLI/MDR-TB working group meeting is proposed for April, which would also be linked to the Xpert early implementers meeting.

75% 63%

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8. Overarching elements

C0.0.2 KNCV Support to CSHGP and CORE Group

• CORE PVOs improved competence in providing TB services

Final evaluation of "TB control in Southern Malawi" was carried out in July/August. This was a five year, USAID-Malawi funded project implemented by Project Hope. The evaluation established that TB control in both Mulnaje and Phalombe Districts of Malawi had improved very much in the last five years. A final report was submitted to USAID.

100% 114%

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4. Country projects As of September 30th, all 20 Year 1 country work plans have been approved by both the USAID missions and USAID Washington. The first country plan, approved on February 18, 2011 was Djibouti while the last country workplan, approved on July 25, 2011, was Afghanistan. See Table 2 for the geographical distribution of the countries. Table 2: Geographical distribution of TB CARE I partner countries

Africa (11) Asia (8) Latin America (1) Botswana Djibouti Ethiopia Ghana Kenya Mozambique

Namibia Nigeria South Sudan Zambia Zimbabwe

Afghanistan Cambodia Indonesia Pakistan Vietnam

Kazakhstan Kyrgyzstan Uzbekistan

Dominican Republic

Each country will now be briefly discussed in turn.

4.1 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, laboratories, IC, health system strengthening (HSS) and M&E. The screening of TB suspects showed an upward trend over the past two quarters. 57,000 TB suspects were identified in the provinces and of them, 3,904 were sputum smear positive (positivity rate = 6.9%). 49% of all TB suspects identified in the country are attributable to 13/34 provinces and 52% of all new sputum smear positive TB cases identified over the past two quarters of 2011 are related to TB CARE I intervention areas. In Kabul, 46 health facility staff received refresher training and 36 HCWs from newly covered health facilities received first-time training on SOPs for TB case detection, diagnosis and treatment. This maintains the 53 health facilities implementing quality DOTS in Kabul City. To supplement the Urban DOTS approach, community events were conducted in Kabul city to increase awareness of TB and reduce stigma. During this period, four events for municipality workers, two school events and one event for Ibn-Sina higher educational students were conducted. In total, 1,280 individuals attended these events and were oriented on the basic TB messages regarding TB suspect identification, the availability of free TB services, and the fact that TB is a curable disease. Events at community level were also conducted by community health workers under CB-DOTS in TB CARE I intervention provinces. TB CARE I Afghanistan extended its support to the NTP on TB-IC. TB-IC measures were extended to an additional 15 public health facilities in Year 1, four in Kabul city and 11 in the provinces. In these facilities, TB-IC committees were established, TB-IC focal points were identified and health facility staff assisted in developing a TB-IC plan and integrating it into the facilities general Infection Prevention (IP) plan. TB CARE I assisted the NTP in conducting provincial quarterly review workshops in seven targeted provinces. During these workshops 350 individuals were trained in basic data analysis, interpretation and feedback. Each health facility identified their gaps and prepared action plans to address these gaps in the new quarter. The findings from the workshop were also shared with NGOs and provincial health offices for further action and follow up. TB CARE I-Afghanistan met its target of helping the NTP to successfully implement 75% of the planned quarterly supervisory visits. Joint visits with NTP, TB CARE I, PTC and NGOs were conducted to strengthen the coordination and feedback. Deteriorating security limits TB CARE I and NTP staff to conduct visits to health facilities in the south and south east of the country.

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4.2 Botswana KNCV is the lead partner and sole implementer in Botswana. The project focuses on universal and early access, laboratories, IC, PMDT, TB/HIV and M&E. Twenty laboratory technicians were trained in AFB smear microscopy at the National Tuberculosis Reference Laboratory External Quality Assurance Unit from August to September 2011 (13 females and 7 males). All participants successfully completed a competence assessment test. There were delays in the validation of the first and second line drug susceptibility testing using MGIT due to staffing challenges and laboratory renovation. A TB CARE I consultant facilitated the development of a costed TB prevalence survey protocol (co-financed by the Global Fund) in collaboration with in-country stakeholders. The National Strategic Plan was also costed with assistance from a budget expert subcontracted by TB CARE I. Costing of both the Botswana strategic plan and the prevalence survey protocol will strengthen the country’s proposal for the Global Fund Round 11.

4.3 Cambodia JATA is the lead partner in Cambodia, with collaboration from FHI, KNCV, MSH, and WHO. The project has activities in all eight TB CARE I technical areas (universal and early access, laboratories, IC, PMDT, TB/HIV, HSS, M&E and drug supply and management). The TB CARE I team successfully supported the country to mobilize more than $1 million USD for 2011-2012 from TB REACH/WHO for active case finding among migrants, urban poor and contacts of TB patients in the 15 poorest operational districts. Active case finding (ACF) activities were launched for TB among migrants who came from Thailand, Malaysia and Vietnam. The WHO/TB CARE funds are being used especially for initiating ACF activities for the 15-20% of the 98,000 deportees who are detained in detention camps in Thailand for more than one month. TBREACH/ WHO funds will be used to screen even the 80-85% who are detained for less than one month, or not detained at all. Digital x-ray and two GenXpert machines were procured and installed at CENAT and training was conducted. The national lab strategic plan for 2011-2015 was drafted. Following approval of proposed X-pert algorithm and revised R&R forms, Xpert will be used for MDR-suspect, PLHIV and for ACF among high risk groups. A communications strategy for TB -IC was developed and a branded logo ("Saksit", which means effectiveness/blessing in Khmer) for the initiative was designed. This will be piloted in Year 2 and its effectiveness will be evaluated through baseline and end line surveys in the pilot sites. The development of an SMS system for delivery of lab test results to Health Centers (HC) and DOT watchers (DW)/community volunteers was completed. Field testing of protocol, demonstration of the system design, and trainings were also completed. After completion of orientation for DW planned for October, the SMS system will begin to be used by TB labs, HCs linked to these labs and select DW linked to these HCs. This is likely to decrease the time for relay of lab results to HCs, and through the inclusion of DW in the network, aid in earlier initiation of treatment for diagnosed TB patients.

Central Asian Republics (CAR) KNCV is the lead and sole implementer of TB CARE I activities in all three CAR countries: Kazakhstan, Kyrgyzstan and Uzbekistan. All three CAR country projects have activities in the eight technical areas (universal and early access, laboratories, IC, PMDT, TB/HIV, HSS, M&E and drug supply and management).

4.4 CAR-Kazakhstan: Four specialists from prison TB services from project sites (Akmola, South Kazakhstan, North Kazakhstan and East Kazakhstan) participated in a two-day workshop on the revision of protocols on management of DR TB. Draft PMDT plans have been developed for three new project sites (Akmola, South Kazakhstan and North Kazakhstan) where the prison system was included. TA was provided to the prison system on reorganization of MDR-TB care in prisons. The transfer of the

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prison system from the Ministry of Justice to the Ministry of Internal Affairs influenced implementation of TB in prisons activities. As a result, supervision visits to prison systems were postponed and representatives of prison TB services were not allowed to participate in some activities. Five TB pediatricians were trained in childhood TB at the WHO Collaborative Center in Latvia. They were involved in drafting clinical protocols on Childhood TB. Draft guidelines, laboratory plan and SOPs on laboratory maintenance have been developed. The draft national laboratory plan was developed by the laboratory working group established under the NTP. PMDT action plans for project sites have been drafted during supervision visits and pre-final versions have been discussed during a one-day workshop. A thematic working group on the development of clinical protocols and revision of guidelines on MDR TB was established. A technical working group on the development of a National TB-HIV plan and revision of clinical protocols on the management of TB-HIV was established. Specialists from NTP, NAP, SES and partners organizations are involved. Agreement was reached on a draft National plan. Two specialists from the NTP (one from national level and one from North Kazakhstan oblast) were trained in strategic planning organized by The Union. A tool for monitoring patient support activities has been developed and tested in East Kazakhstan oblast. One-hundred eighty TB/MDR TB patients who are still on treatment were enrolled in a patient support system in Eastern Kazakhstan. A two-day workshop on the involvement of local NGOs in TB control was conducted for 15 local NGOs from four project sites. Two ex-MDR TB patients who also participated in that workshop have expressed their intention to establish an NGO to provide support to TB patients. During the quarter, 108 specialists responsible for data collection, recording and reporting from prison and civil TB services of four project sites (Oblast and Rayon levels) have been trained in data management and analysis during a one-day workshop and on-the-job trainings conducted during monitoring visits.

4.5 CAR-Kyrgyzstan A joint assessment mission on different aspects of TB control in civic and prison TB services (TB in prisons, PMDT, TB in children, TB in migrants, TB-HIV, TB-IC, patient support system and HR) was conducted by a team of local and international specialists. Agreement and support were obtained from the MOH, the Ministry of Labor and Social Affairs, and the Ministry for Labor, Employment & Migration State Registration Service to establish a working group on TB in migrants. One TB pediatrician from the NTP was trained in childhood TB at the WHO Collaborative Center in Latvia. An assessment of laboratory services was conducted to inform the development of the national laboratory strategic plan. The situation around GeneXpert procurement is not clear yet but as of now five machines are planned to be procured by other projects (2 by MSF, 2 by TB REACH and maybe 1 by Quality). Therefore, procurement of GeneXpert within TB CARE I has been cancelled. A technical working group made up of specialists from the NTP, NAP, SES and partner organizations was established to develop the National TB-HIV plan. The framework/design of the national plan was agreed upon. One specialist from NTP responsible for planning of anti-TB activities was trained in strategic planning organized by The Union. Dr. Bakyt Murzaliev started work as the Country Representative for TB CARE I in July.

4.6 CAR-Uzbekistan A TB-IC assessment was conducted by international and regional TB-IC experts in TB facilities in Tashkent City, Nurabad, Andijan and Nukus. The main recommendations from the mission where: 1) Finalize and update the legislative basis for TB-IC according to international recommendations, 2)

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Develop a budgeted TB-IC Activity Plan, 3) TB-IC training courses are highly recommended for all HCWs and technical staff of TB facilities, 4) Ensure timely diagnosis of TB patients by implementing rapid diagnostic tests (GeneXpert), 5) Separation of patients according to their DR status should be implemented in all TB facilities and all DR patients should be located in one ward, 6) Minimize duration of in-patient care especially after smear conversion and develop the policy on ambulatory care, 7) Organize surveillance and monitoring of TB incidence among HCWs and technical personnel 8) Proper use of UVGI lamps, extractor fans in combination with natural ventilation (cross ventilation, opening windows, doors etc), 9) All TB facilities should be supplied with surgical masks for patients and with FFP2/N95 respirators for medical staff in sufficient quantity. To strengthen the local capacity to implement international recommendations on childhood TB, one TB pediatrician from the NTP participated in the international training course on childhood TB in Latvia. In order to improve the NTP's capacities in strategic planning, one specialist from NTP participated in The Union training on strategic planning and innovations. Representatives of the NTP and prison medical service participated in the regional meeting on the harmonization of action plans for TB control. The plans of the NTP and prison medical service were shared and discussed during the meeting.

4.7 Djibouti WHO is the lead and sole implementer of activities in Djibouti. The project focuses on laboratories, IC, PMDT and HSS. The update of the National TB control guidelines has been the main activity of the quarter. The guidelines are being revised to adopt new WHO treatment guidelines including treatment of pediatric cases and new diagnostic algorithms as a result of the upcoming introduction of rapid diagnostic tests. The process is in its final stage, which has been discussed with the NTP staff and experts in WHO, FIND and KNCV. With TB CARE I local technical assistance the technical documents for GF R10 TB grant negotiation phase were developed (the Performance Framework, the Workplan-Budget, and the Technical Assistance Plan). TB CARE I technical assistance also contributed, as part of GF R11 HIV, to a situation analysis of priority settings and preparation of the roadmap for the proposal development. TB CARE I also assisted with the Performance Framework for the GF R9 Malaria grant negotiation.

4.8 Dominican Republic KNCV, the lead partner and sole implementer in Dominican Republic, began activity implementation in April 2011. Activities are conducted in universal and early access, IC, PMDT, HSS and M&E. The provincial capital San Pedro de Macoris has one of the biggest industrial areas of the country with 103 industrial sub areas and 49 factories. The medical services for employees are provided by one medical dispensary near to the premises and are part of the National Medical Insurance Institute (IDSS). The purpose of establishing public private links with this industrial area is to intensify the case detection among these employees. Many of them are temporary workers coming from Haiti and the IDSS is not yet actively involved in the application of the Stop TB strategy in their medical services. Relationships were established with the provincial health authorities and TB program. Advocacy visits were conducted with managers from five major factories in the Industrial Park (employing more than 5,000 employees). The second step was the training of managers and "hygiene and security" committees of three of the factories on TB symptoms, transmission, infection control and the importance of early diagnostics and treatment. A referral instrument for suspects was established with these factories. Next steps will be a follow up via the provincial coordinator and a TB CARE I PPM officer and to expand to other factories.

4.9 Ethiopia KNCV is the lead partner in Ethiopia, working closely with collaborating partners MSH and WHO, as well as subcontractor German Leprosy and TB Relief Association (GLRA). The project implements activities in all eight technical areas. Second line drugs for 100 MDR TB patients procured using TB

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CARE I funds arrived in the MDR treatment sites in June, 2011. At that time the number of MDR TB Patient enrolled on treatment was 235 (217 in St Peter Hospital and 18 in Gondar Hospital). During this quarter, the enrollment increased by an additional 68 patients, which brings the total number of MDR TB patient put on treatment to 303 (275 in St Peter Hospital and 28 in Gondar Hospital). The National TB prevalence survey field operation was successfully completed on June 25, 2011. TB CARE I played an active role in providing financial, logistical & technical support. The field survey was started in October 2010 at Wolliso, West shoa, Zone, Oromia Region. In the 4th quarter, joint supportive supervision was conducted as part of the regular case detection follow up activities. The supervision was conducted by a multi disciplinary team of TB/HIV experts from West Arsi zonal health department and TB CARE I-Ethiopia. During the supervision the team visited a total of 26 health facilities (3 hospitals and 23 health centers). Based on the gaps identified, training on laboratory, TB/HIV and TB case detection SOPs was conducted from September 25-29 and a total of 39 clinicians were trained.

4.10 Ghana MSH is the lead partner in Ghana with support from KNCV and WHO as collaborating partners. TB CARE-Ghana conducts activities in universal and early access, laboratories, TB/HIV, HSS and M&E. In an effort to address the NTP's key challenge of low TB case detection, TB CARE I supported the NTP to conduct a Training of Trainers (TOT) Workshop for Health Care Workers who will serve as trainers in their respective regions and districts for the implementation of the SOPs for TB case detection. The key deliverable for the TOT was the development of action plans for the implementation of the SOPs for TB case detection in all the regions. During this meeting it became clear that although Ghana achieved 100% DOTS coverage in 2005, based on anecdotal information provided by Regional TB Coordinators public health facility, DOTS coverage was about 50%. As a result of this all regions were tasked to conduct a TB situational analysis to assess the true DOTS coverage for Ghana. So far seven out of the 10 regions have submitted their reports and health facilities DOTS coverage in these seven region ranges from 8% to 70%. This information will offer an opportunity for the NTP and TB CARE I to systematically organize targeted TB case detection intervention in big hospitals and urban areas and in Districts that have high HIV rates. The objective is to increase the number of TB cases by 10% in 2012 relative to the 2010 figure. This has been included in the TB CARE 1 FY 12 (Year 2) work plan. TB CARE I provided technical assistance to the NTP through a senior consultant from the WHO Regional Office for Africa (Dr. Daniel Kibuga). The consultant supported the NTP in developing a practical road map for scaling up PPM DOTS in Ghana. This road map will be implemented within the context of the Global Found Round 10 Grant. Within the context of Health Systems Strengthening (HSS) TB CARE I supported the Ghana Health Service to finalize the health sector M&E plan. This support was provided knowing very well that contributing to the rolling out of a national health sector M&E plan, with the aim of improving data collection and data analysis quality, will in turn contribute to the strengthening of TB data since TB Control Services are integrated into the general health services. Through periodic NTP reviews and routine TB program monitoring and supervision TB data quality has been comprehensively documented as one of the challenges facing the NTP Ghana. During the quarter under review TB CARE I completed an analysis of the routine TB data from the Eastern Region for the purpose of identifying potential areas of errors and inconsistencies. Through this analysis several gaps in data quality were identified as follows: transcription errors, data incompleteness and misclassifications of various key TB data variables. There were also discrepancies between data at the health facility, District, Regional and the national level for the same cohort. These identified errors have been presented and discussed with the NTP Central Unit and in October a feedback meeting has been planned for the Eastern Region. In the FY 12 (Year 2) work plan TB CARE I will build capacity of the Health Facility and District TB Coordinators in Eastern Region in data management based on these findings. TB CARE I supported the NTP to conduct a midyear review meeting focusing on Monitoring and Evaluation for the purpose of assessing the progress of implementing the NTP work plan during the first six months of 2011 and review activities to be implemented during the remaining months of the year. The meeting also offered the opportunity for the NTP Central Unit to guide the regions on

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how to develop implementation plans that will utilize resources from the Global Fund Round 10 Grant. The NTP also disseminated an outline of the budget proposal application form that the regions will be using to request funds from the Global Fund Round 10 grant. The TB CARE I Country Manager (Rhehab Chimzizi) continued to serve as the Chair of the HIV-TB Oversight Committee of the CCM-Ghana. During the quarter under review Rhehab Chimzizi participated in the site visits to Principal Recipients (PRs) for the Global Fund Round 5 and 8 Grants. He also participated in the review of the Progress Update and Disbursement Request (PUDR) and Dashboard and based on this review the HIV-TB oversight committee submitted a report to the main CCM Committee for action. The TB CARE FY 11 workplan was developed in anticipation that the Global Fund Round 10 Grant would be signed and funds would become available for the comprehensive implementation of basic DOTS and other new approaches. However, to date the Grant signing has not taken place and this posed a challenge for TB CARE I to play its role of complementing the implementation of the interventions to be funded through the Global Fund Round 10 Grant.

4.11 Indonesia Indonesia is the largest of the TB CARE I countries in terms of financial obligations ($10 million per year); KNCV is the lead partner with close collaboration from ATS, FHI, MSH, The Union and WHO. TB CARE-Indonesia works in all eight technical areas. TB CARE I procured 17 GeneXpert machines and 1,700 cartridges for Indonesia. GeneXpert implementation is performed in close collaboration with the NTP and BPPM, in line with National TB Strategic Plans. TB CARE I is working in close contact with representatives from the NTP, BPPM, TB Lab Working Group, national TB Operational Research Group (TORG), WHO/Indonesia, FHI, USAID mission, National Reference Laboratories, and other relevant partners in the field. The C-GAT and local collaborating partners perform the actual implementation of Xpert MTB/RIF, including site preparation, lab staff training and supervision. PMU conducts country visits to discuss implementation plans and monitoring and evaluation plans. PMU also facilitated an Xpert training workshop and training of trainers in Indonesia. Training curricula and training modules were developed and used in five sites (FM UI, Persahabatan hospital, Pengayoman hospital, Hasan Sadikin hospital and Lung Clinic Bandung). Between April – September 2011, there were 730 MDR TB suspects found, of which 194 were confirmed MDR cases; 120 were enrolled on PMDT. The cumulative figures are as below: Aug-Dec 2009 Jan-Dec 2010 Jan-Sept 2011 Total Confirmed MDR cases 34 182 255 471 MDR cases put on treatment 20 142 170 332 Follow up smear and culture was done for 120 new enrolled cases and 162 cases enrolled earlier. 137 patients received support for side effect management. TB CARE I supported the comprehensive course on Clinical Management of DR-TB for medical specialists in collaboration with the Faculty of Medicine at University of Gadjah Mada. TB CARE I supported a Jakarta-based Workshop on TB/DR-TB Surveillance in September resulting in a detailed strategy framework or work plan (including timeline) for the further development of the electronic TB/DR-TB surveillance and TB/DR-TB data management in Indonesia. Solutions were proposed and activities will be harmonized within current stakeholders and partners, and across on-going initiatives. TB CARE I supported the horizontal collaboration between NTP, BUK, professional organizations, NGO, insurance company, and MoLHR on PPM implementation through agreement development. This agreement serves as the cornerstone of PPM implementation. TB CARE I supported renovations for TB IC in Labuang Baji Hospital, Moewardi Hospital, Saiful Anwar Hospital, five health centers in Solo, and three health centers in Malang. TB CARE I supported the development of materials and documentations in various technical areas: * TB training module for medical specialists,

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* SOP book for SLD, * PPM assessment tools, * TB in Prison IEC materials, * Final PMDT guidelines for treatment scale up.

4.12 Kenya KNCV is the lead partner in Kenya; the collaborating partners are ATS, FHI and MSH and subcontracts are in place with Kenya Association for Prevention of TB and Lung Diseases (KAPTLD) and Kenya AIDS NGOs Consortium (KANCO). The project conducts activities in universal and early access, laboratories, IC, PMDT, TB/HIV, HSS and M&E. The improved tuberculosis (TB) case detection, including smear negative disease often associated with HIV as well as expanded capacity to diagnose multidrug resistant tuberculosis (MDR-TB), is a global priority for TB control. With support from TB CARE I, Kenya has acquired three GeneXpert machines, which have been installed in three public health facilities. These are the first GeneXpert machines within the public sector in the country. The NTP decided to have the three machines clustered in Coast province based on WHO recommendation of clustering while the region was chosen due to the high workload. The machines were installed in Provincial General Hospital (Coast PGH), Port Reitz District Hospital and Likoni Sub‐District Hospital. Port Reitz hospital has the highest workload in the country. The laboratory staff from these facilities were trained and have started using the machines. Follow up visits are planned. The Kenya Ministry of Public Health & Sanitation through the NTP organized and hosted the Second International Scientific Lung Health Conference in Kenya from in early October. TB CARE I took part in the planning as a member of the secretariat and coordinating committee. The theme of the conference was “Towards Universal Access to TB/HIV and Comprehensive Lung Health Service”. The conference gathered researchers from all over the world and encouraged interaction among representatives of various disciplines involved in addressing lung health. It brought together partners from 16 organizations involved in TB Control activities in Kenya with participants coming from the East African Region, Europe and USA. The conference registered a total of 530 participants including 50 international participants. TB CARE I supported 313 local and 18 East African participants to attend the conference. During the conference other lung health diseases including non communicable and pneumonia were discussed in the platform of TB Control. TB CARE I has supported quarterly TB and Leprosy Control Program review meetings in all 12 operational TB control provinces. During these review meetings validation of district data, challenges of TB control, and technical and operational issues were discussed. The first semi-annual meeting for 2011 was held in September 2011 to review activities of the TB & Leprosy Control Program from January to June 2011. Presentations from all TB operational provinces, central unit and partners were made. During the meeting, provincial planning for the next year was done based on the Strategic Plan of the NTP. During the reporting quarter, technical assistance for Quality Assurance of Chest X-Ray, PMDT combined with GLC, surveillance systems, TB patient engagement guidelines development and operational research/survey support was provided by international consultants.

4.13 Mozambique FHI, the lead partner for Mozambique, submitted two separate work plans to USAID: one for its malaria activities, and one for its TB activities. The TB workplan focuses on universal and early access, laboratories, IC, PMDT, TB/HIV, HSS and drug management. FHI works with collaborating partners KNCV, MSH and WHO on the TB workplan. TB workplan: Baseline assessments have been conducted in the 24 new districts across seven provinces to be included in Year 2. This includes an assessment of all TB control activities, the collection of baseline data and identification of potential local partners. This assessment also represents an opportunity to discuss coordination mechanisms with the Provincial and District Health Directorate and with the CB-DOTS implementing agencies.

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In July the project started to roll out the training of traditional healers in CB-DOTS by training 29 trainers. The training carried out in Gaza province involved 12 TB district supervisors, 12 traditional healer focal points, two traditional healers and three provincial staff (including the provincial traditional healer focal point). In collaboration with other FHI 360 projects that implement HIV-related activities in Mozambique, a community reference form was developed. This form is now being used by community health workers and health staff for referral of patients between the community and health services. Other important achievement in this area was the completion of seven out of the planned 11 sub-agreements with CB DOTS implementing agencies which were signed and the implementation of CB DOTS began in 25 districts after a year of interruption. The remaining four agreements are being finalized. An assessment of the microscopy network was conducted in the seven provinces covered by TB CARE I. In general there are 190 laboratories in the seven focus provinces and 102 health centers with nurses trained in AFB microscopy. TB CARE I will provide technical support to ensure adequate TB smear microscopy diagnosis coverage. A needs assessment was performed in the six laboratories to be renovated. The assessment revealed problems in terms of infrastructure, training and supervision. Most of these laboratories did not have a room dedicated to smear microscopy and in some cases the infection control measures were not adequate. Although all staff had been trained to perform smear microscopy there was no plan for refresher trainings, and the supervision visits were not regular. All laboratories had enough reagents, but almost all of them were experiencing shortages of slides. The project supported supervision visits to 17 laboratories of three provinces; Zambézia, Manica and Nampula. The findings of these visits have been discussed with each province and with provincial health directorates and a plan of recommendations was drafted. These recommendations highlight the need for continuing on-the-job training of laboratory technicians on SOPs, laboratory management, good laboratory practices, bio-safety and the basic maintenance of equipment. TB CARE I also supported the procurement of some laboratory equipment (such as negative pressure, analytic balances, blender, pH meters, etc.) for the National Reference Laboratory and the Beira Regional Reference Laboratory, which have been delivered. An assessment of the PMDT situation in the country was carried out in three regions and a national workshop to launch the process of developing a national PMDT strategic plan was conducted. A draft strategy is under development and we expect to have a final document by the end of December 2011. During the reporting period, two NTP/TB CARE I supervision visits to Zambézia and Nampula were conducted. A supervision guide was used to discuss the identified problems and possible solutions, and to share good practices. The teams also prepared a report which was shared with each province. The findings of these visits were also used to update training materials for TB supervisors and to identify areas to improve the collaboration between the TB and HIV programs. For instance, it became apparent that IPT coverage is still low and that more needs to be done to ensure the adequate implementation of the “One Stop Shop”. The implementation of TB/HIV collaborative activities is likely to improve in the coming months as new guidelines are being developed, finalized and implemented in 2011-2012. The project concluded the recruitment of two TB CARE I provincial TB/HIV technical officers for Zambézia and Nampula in close coordination with the local health authorities and the NTP. These officers will provide TA to TB provincial supervisors and to the implementing agencies and will support the provincial TB/HIV task forces. Thirty six thousands pamphlets with TB/HIV messages have been reproduced for all seven target led provinces. The project supported the participation of two NTP staff (the NTP manager and a pharmacist) in a drug management training, carried out in Johannesburg in July. During this quarter the team participated in a training workshop on quality improvement. As a result the team identified a quality improvement project to be implemented in Chibuto district. The objective of the project is to contribute to the reduction of the turnaround time of TB smear microscopy results.

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Two important visits were carried out during this quarter. Dr. Marteen van Cleeff, TB CARE I Program Director, visited the country in July. The main objective of his visit was to support the team in reaching an agreement with USAID to develop an integrated TB and malaria workplan for Year 2. Professor Carol Hamilton also visited to provide technical assistance for the development of the Year 2 workplan and for the development of the research protocols for the two studies included in Year 1. A challenge faced by the project was the lack of disbursements by The Global Fund. Under TB CAP two reference laboratories, one in Maputo and in Beira, were renovated. It was expected that the Global Fund would provide the resources to procure materials and reagents and cover the equipment maintenance costs to keep these laboratories running. However, the lack of Global Fund disbursements is affecting the work of these laboratories, which are now realigning only on the TB CARE I project to support their activities. Malaria workplan: A TB CARE I-supported study is aimed at monitoring the therapeutic efficacy of Artemether-Lumefantrine and Artesunate-Amodiaquine combinations in five sentinel sites in Northern, Central and Southern Regions. The study protocol has been developed and approved, and implementation is in progress. During this quarter, the TB CARE I trained 497 (47.6% of the total planned) laboratory staff. The cascade training was conducted in six provinces. The remaining lab staff will be trained by November 2011. The project supported the printing and distribution of 8,000 copies of malaria guidelines and 8,000 copies of treatment algorithms and charts. All these materials have been delivered to National Malaria Control Program (NMCP).

4.14 Namibia KNCV is the lead partner and sole implementer in Namibia under TB CARE I. Activities are implemented in universal and early access, IC, PMDT, TB/HIV, HSS and M&E. Apart from the routine and regular TA to the NTP, TB CARE I achieved the following: TB CARE I hosted a TB/HIV Training workshop in July with 32 participants in attendance (25 females, 7 males). Participants are tasked with developing realistic plans on TB/HIV collaborative activities in their respective regions based on the knowledge and skills they gained at the training. A follow-up visit by two of the faculty members is planned in Year 2 to review progress made in planning and implementing the collaborative activities. The project supported the NTP to prepare and submit the Single Stream of Funding (SSF) and Consolidated Performance Framework for the approved GF Round 10 and GF Round 2 Rolling Continuation Channel (RCC). TB CARE I staff provided technical inputs in development of the OGAC-funded TB/HIV proposal which was technically approved for funding worth 6 million USD; the country is awaiting guidance from OGAC and USG agencies (USAID and CDC) on the fund-disbursement processes. The project coordinated and participated in 10 out of the planned 12 Central Clinical Review Council (CCRC) meetings at which consultations on clinical management, including selection of appropriate DR-TB regimens, take place with member clinicians, pharmacists, lab personnel, social workers and staff from NTLP and TB CARE I. All planned fifteen zonal TB quarterly review meetings were supported with TB CARE I funding. Three national level staff attended and provided technical support to two of these review meetings (a total of the five regions which were thus supported) TB CARE I continued to directly support CBTBC activities in Erongo and Karas regions, including expansion to two new districts in Erongo and one new district in Karas Region.

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The ambulatory DR-TB treatment programme among members of the San community ("Bush Men") in Tsumkwe constituency was supported by TB CARE I. The support also included life skills training for DR-TB patients who are taking their medication on an ambulatory basis. SOPs on how to conduct quarterly TB data review meetings were prepared by the NTP and TB CARE I; SOPs to be shared with all regions to standardize zonal and district review meetings and maximize data quality and utility.

4.15 Nigeria KNCV, the lead partner for Nigeria, works closely with collaborating partners, FHI, MSH and WHO. These partners are implementing two work plans: one for TB and the other for TB/HIV-funded activities through PEPFAR. TB Workplan: The TB workplan focuses on universal access, laboratories, PMDT, HSS and M&E. The highlights of the current quarter were the recently held Control Officers Retreat. The retreat was organized on request of the Control Officers who wanted to have a frank discussion on their respective program performance. The agenda contained topics on Teambuilding, Being an effective Control Officer and financial accountability. The next meeting in November will be used to report back on progress made in the areas of general office management, supervision and reporting of data. During the same quarter monthly mentoring visits were organized to challenge states. During these visits attention was focused on general office management: development of organograms and job descriptions, filing systems, store management and data analysis. The Senior Lab Consultant of the PMU came to Nigeria in August for a follow up visit on the GeneXpert Pilot Project. The following action list came out of the visit: (1) Need to develop a basic computer module (with help from MSH IT Department), (2) Finalization National MDR TB Guidelines, (3) Follow up meeting to finalize the curriculum and development of a logistics plan, (4) Finalization of the site selection, (5) Training should only start after the earlier mentioned issues are addressed. In order to improve TB case detection, the project continued to support community volunteers (CVs) under the four umbrella Community-based Organizations (CBOs) - Catholic Action committee on AIDS, (CACA), Forward In Action For Education, Poverty and Malnutrition (FACE-PAM), Federation of Moslem Women Association of Nigeria (FOMWAN) and National Union of Road Transport Workers (NURTW) in AMAC, Bauchi, Kachia and Udi LGAs respectively. A one day refresher training was organized for the CVs on the basics of TB disease and the crucial role of effective referral and referral linkages in the community approach to TB management and control. It made use of the referral tools as the basic training aids for the role plays. A total of 130 CV were trained (21 in Udi, 45 in Kachia, 32 in AMAC and 32 in Bauchi LGAs). In order to acquaint laboratory personnel especially at MDR TB diagnostic sites with all aspects of bio-safety measures required to work in a BSL3 TB culture Laboratory or BSL2 with BSL3 practices, a 3-day training was organized for 42 personnel selected from FHI-supported sites. Furthermore, a 3-day capacity building activity was conducted for 64 laboratory personnel on good clinical practice required to work in a TB laboratory. Eighteen biomedical engineers were also trained on care of medical equipment and infrastructure services in line with Planned Preventive Maintenance (PPM) standard operating procedures (SOP). The NTP with the support from TB CARE I organized an expert meeting to review the National ACSM guidelines and develop ACSM toolkits as well as IEC materials. The key outcomes of the meeting included linking up effectively ACSM activities with the national program, involvement of the program managers in all ACSM activities by the partners, incorporating ACSM capacity building programs for relevant stakeholders across all levels and ensuring access of the harmonized and updated ACSM tools and materials, through the NTP. A visit was conducted to assess the feasibility of introducing e-TB manager for the management of MDR-TB. It was concluded that most of the resources required for the implementation of e-TB manager are available in Nigeria, and if the key challenges of power, funding and internet connectivity were addressed, e-TB manager implementation would be possible. The NTP agreed to implement e-TB manager as a pilot in the MDR-TB centers in the country.

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TB/HIV (COP) Workplan: The TB/HIV workplan focuses on IC, PMDT, TB/HIV, HSS and M&E. A 2-day training was organized for nurses working in the MDR TB ward at the University College Hospital (UCH) Ibadan in September. The purpose of the training was to introduce the nurses to current updates in clinical management of MDR TB and re-emphasize infection control measures. It was recommended that refresher trainings to be done quarterly. In total, 18 nurses were trained (M=1; F=17). Interactive training on the management of MDR TB and infection control was also conducted for five resident doctors (M=1, F=4) working in the chest unit at UCH. Recommendations from the training include increasing the number of doctors trained.

4.16 Pakistan KNCV is the lead and sole implementer of TB CARE I activities in Pakistan. The Pakistan workplan focuses solely on the National Prevalence Survey (M&E, OR and surveillance). As of the end of September 2011, 79 clusters have been completed, indicating that only 16 more clusters need to be completed, which should be accomplished by the end of 2011. Data entry of all clusters is projected to be carried out by the end of the year, although data validation will take longer. The Prevalence Survey is planned to be completed by the end of March 2012, including all field activities, data entry, data validation and preparation of the draft report.

4.17 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 universal access, laboratories, TB/HIV and HSS. Several documents developed during the reporting period. The SOPs for the Bio-safety of the CRL and Peripheral Laboratory were developed. The process involved conducting a risk assessment to the CRL and peripheral TB laboratories from which the most important SOPs were identified. The draft has been distributed for comments before piloting and scaling up in the coming quarter. Training manuals for the laboratory staff on smear microscopy were developed. The manual will be piloted and distributed during laboratory trainings. Training was conducted for 20 (M=19, F=1) laboratory staff on sputum smear microscopy and 21 (M=14, F=7) clinicians on TB management. The participants were drawn from Primary Healthcare Centers (PHCCs) to improve knowledge and raise the index of suspicion among the health care providers to think about TB as a diagnosis. The SOPs for improving case detection were distributed during these trainings. Follow up and mentorship will follow in the coming quarter. A workshop was carried out for 23 (M=20, F=3) management staff from NTP and the HIV Directorate at central and state level on the Management and Organizational Sustainability Tool for TB/HIV Collaboration (MOST for TB/HIV). The participants developed action plans to address key challenges indentified in the MOST training. A TB CARE I-supported quarterly review meeting was conducted for the state TB and HIV coordinators from 10 states. The meeting was facilitated by the NTP and a 3-month workplan was developed for each state. Three laboratories are undergoing refurbishment to accommodate TB/HIV services. This will improve access of services to the community and integrate TB/HIV services into the general health system. TB CARE I has been supporting NTP with Global Fund (GF) TB Round 11 proposal development. A gap analysis was conducted and the consultant was able to lead the team in identifying the objectives, SDAs and activities to be address in Round 11. The process will continue within the Year 2 workplan.

4.18 Vietnam KNCV is the lead and sole implementer for TB CARE I activities in Vietnam. Activities are implemented in universal access, laboratories, IC, PMDT, TB/HIV, HSS and M&E. The NTP guidelines on management of TB in children were reviewed by the NTP and TB CARE I. Training curriculum and materials have been developed.

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In five MDR-TB treatment centers, laboratory and MDR TB treatment ward renovation proposals to upgrade the bio-safety status were developed by local staff and designers with technical support from TB CARE I. Renovations are expected to begin before the end of 2011 once approval is obtained. The final decision on the GeneXpert implementation plan (a stepwise approach), quantification (17) and site selection (11 MDR treatment centers (provinces, districts), four HIV clinics (provincial general hospitals), and two Pediatric Hospitals) has been made by the USAID country Mission and stakeholders. Two GeneXpert machines and 2,700 cartridges for Phase I have been purchased through the WHO procurement mechanism; the remaining 15 machines will be procured in Phase II and III. The first workshop on TB investment awareness for members of parliament of nine North-East provinces was conducted. A quarterly technical working group meeting and a workshop on laboratory network development were organized.

4.19 Zambia FHI is the lead partner in Zambia and works closely with collaborating partners KNCV and WHO. Activities are implemented in all eight technical areas. TB CARE I provided technical and financial support for the finalization of the National TB Strategic Plan by the NTP and partners. TB CARE I also provided financial support for a national level TB/HIV coordinating body meeting held in August 2011 and participated in six district level TB/HIV meetings in the Copperbelt province. TB CARE I received one consultant in ACSM to assess the country's ACSM needs in preparation for an ACSM planning workshop in early 2012 and to provide input to the TB Strategic Plan and to the Year 2 TB CARE I work plan. Two consultants in TB infection control also provided technical support with the in-country consultants for facility level planning at three facilities targeted for MDR-TB management. Fifty-eight health care workers from the three facilities received orientation training in TB IC and participated in the development of plans for their facilities. Laboratory activities were also reviewed at all three reference laboratories and three other laboratories in three provinces by a consultant. Fifteen laboratory staff members from the four none-TB CARE I target sites were trained with project support to provide equity in LED based microscopy training. TB CARE I also procured a GeneXpert machine and accessories that were placed at the National Reference Laboratory’s Chest Diseases Laboratory, with plans to move it to a point of care facility in the future. EQA visits were made to 44 district level diagnostic centers in the five target provinces by staff members from the Chest Diseases Laboratory, the Tropical Diseases Research Centre and the Provincial Hospital laboratory. The project also printed 272 copies of the laboratory SOPs. Fifty health care workers at facility level from Northern and Central Provinces were trained using revised community volunteer training modules. The TB CARE I board member also provided technical support to the country on operational research scale up.

4.20 Zimbabwe Zimbabwe is led by The Union and has KNCV and WHO as collaborating partners. The project implements activities in universal access, PMDT, TB/HIV, HSS and M&E. The 25 trainers trained in the 3rd quarter were active in all five provinces, with training a focus on the three "new" provinces (Manicaland, Matebeleland North and Matebeleland South provinces). A total of 204 (M=68, F=136) health workers from the five provinces were trained in TB and TB/HIV management and 29 (M=20, F=9) in pediatric TB management with the financial and technical support of TB CARE I. All five provinces successfully conducted support supervision visits to all 37 districts, and all the districts in turn conducted support supervision visits to selected peripheral primary health care centers.

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The draft Drug Resistance Survey (DRS) protocol was prepared by TB CARE I and submitted to the NTP. It is now awaiting finalization and submission to the Zimbabwe Medical Research Council by the NTP. The actual DRS has not begun because proficiency testing of the National Reference Laboratory will not be completed until December 2011. Data collected between January-September 2011 indicates that 1% of sputum positive pulmonary TB patients have DR-TB (25/2463). A key uncompleted activity was the development of PMDT training materials, which awaited completion of the MDR-TB guidelines. The guidelines have since been developed and training material development is now planned for the first quarter of Year 2. An international TB/HIV training course was conducted with 29 participants (M=20, F=9) from all eight rural provinces and Chitungwiza City. Infection control training of 148 health workers (M=31, F=117) was also carried out. An HR assessment was carried out as a foundation for the development of HR strategic and implementation plans to be done in Year 2. Findings included: 1) TB control is fully integrated in the health system and the National TB program has no control over the Human Resources, 2) The national TB program suffers from lack of clarity in the organizational structure affecting staff and program performance, 3) The current HR strategy of the MOHCW is in line with NTP’s HR ambitions and could support these ambitions, 4) NTP is strongly donor dependent for funding of salaries, training and supervision, 5) Innovative learning approaches are needed to enhance training effectiveness and limit staff absence from work stations, 6) HRM systems need to be developed or strengthened (i.e. job descriptions, work planning and performance appraisal systems). Performance reviews were conducted at all three levels of the system: at national level, in four out of five supported provinces; and in 20 review meetings involving 26 districts. Overall data indicated general improvement in performance indicators such as notification rates and pulmonary TB diagnoses with no sputum result. Development of the data analysis and use guidelines was completed; the document is due to be piloted in the first quarter of Year 2. The first ever OR orientation course was conducted over 3 days for 11 provincial health workers. Participants were trained on how to conduct operations research and develop a research protocol. All attendees (11) developed an OR topic to be implemented in Year 2 of TB CARE I (one topic per province and main city).

5. Regional Projects

In addition to the aforementioned country and core programs, TB CARE I also manages three regional projects which are all follow-ons from TB CAP.

5.1 Center of Excellence (CoE) for PMDT The CoE for PMDT project is implemented by KNCV. During Quarter 4, the CoE moved into the renovated classroom where courses will now be conducted. The classroom is situated within the School of Public Health at the National University of Rwanda. The CoE held the second international course on PMDT in September at the renovated CoE classroom in the School of Public Health. The course was attended by 11 international participants (Ethiopia (2), Kenya (2), Malawi (1), Tanzania (1), Uganda (2), Zimbabwe (2), Burundi (1)) and eight national participants from Rwanda (in total, M=14, F=5). The first international training on laboratory diagnostics was also held in September at the School of Public Health. It was attended by 13 representatives of national and regional laboratory technologists, three of whom were from Somalia. The launching of the business plan has been delayed, thus the CoE is still wholly dependent on USAID funding.

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5.2 East Africa Supranational Reference Laboratory (SNRL)

The Union, the lead partner, works closely with KNCV/KIT on the SNRL project. The lab order was executed and the shipments arrived, staff contracts were renewed, and funds were transferred to support the SNRL. Technical assistance was provided by a Consultant, which concentrated on further improvements of management and quality issues at the NRL. A laboratory strategic plan began to be developed for the country. Current financial needs are substantial; it appears that there has been overreliance on bilateral donors, while also the NTP has not sufficiently taken up its responsibility for the lab network, and while other government services such as Medical Stores Department remain deficient. A start was made with meeting the minimum requirements for SRL certification, such as organization and conduct of proficiency testing for DST and linking up with neighboring countries. S. Sudan and Zambia were chosen as the best candidates.

5.3 ECSA (East, Central and Southern Africa) The ECSA project is conducted by KNCV. During this period one mission was done to the ECSA secretariat for capacity strengthening and to participate in the Regional Advisory Panel (RAP) of the East Africa Public Health Laboratory (World Bank) project that focuses in strengthening disease surveillance in the region including TB. The next Health Ministers Conference will be held November 21st-25th in Kenya. The member states have been asked to report on the progress made in implementing the resolutions from the 52nd HMC including those on TB/PMDT. The ECSA Manager and Officer for HIV/AIDS & Infectious Diseases posts have been vacant since March. The post of officer was filled in August but they would not manage to do monitoring missions to member states. One mission is planned in October to Swaziland to document best practices, which will be shared during the HMC.

tb care i year 1 qmr 4 december 7 2011 nf...• rapid scale up of genexpert should continue, but...

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