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TB CARE IPROGRAM YEAR 2

First Quarter Performance Monitoring ReportOctober 1, 2011 – December 31, 2011

February 15, 2012

TB CARE

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TB CARE I Partners

American Thoracic Society (ATS)FHI 360

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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Contents

List of Abbreviations ............................................................................................................................51. Introduction ................................................................................................................................72. Project Management Unit (PMU) .....................................................................................................82.1 Knowledge Exchange ....................................................................................................................83. Core projects ...............................................................................................................................94. Country projects ..........................................................................................................................16PMDT .................................................................................................................................................17GeneXpert ..........................................................................................................................................184.1 Afghanistan .................................................................................................................................184.2 Botswana ....................................................................................................................................194.3 Cambodia ...................................................................................................................................204.4 CAR-Kazakhstan ...........................................................................................................................204.5 CAR-Kyrgyzstan ...........................................................................................................................214.6 CAR-Uzbekistan ...........................................................................................................................214.7 Djibouti ......................................................................................................................................214.8 Dominican Republic ......................................................................................................................214.9 Ethiopia ......................................................................................................................................224.10 Ghana .......................................................................................................................................234.11 Indonesia ...................................................................................................................................234.12 Kenya ........................................................................................................................................244.13 Mozambique ...............................................................................................................................254.14 Namibia .....................................................................................................................................264.15 Nigeria ......................................................................................................................................264.16 Pakistan .....................................................................................................................................274.17 South Sudan ..............................................................................................................................284.18 Vietnam .....................................................................................................................................284.19 Zambia ......................................................................................................................................294.20 Zimbabwe ..................................................................................................................................295. Regional Projects .........................................................................................................................305.1 Center of Excellence (CoE) for PMDT ...............................................................................................305.2 East Africa Supranational Reference Laboratory (SNRL) .....................................................................305.3 ECSA (East, Central and Southern Africa) ........................................................................................305.4 Central Asian Republic (CAR) Regional Funding ................................................................................30

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Table

Table 1: Summary of visitors to the TB CARE I website, October-December 2011 .......................................... 8Table 2: Completed Year 1 Core Projects and Deliverables, through December 2011 ..................................... 9Table 3: Overview of Extended Year 1 Core Projects, October 2011 to December 2011 ................................... 11Table 4: Overview of Approved Year 2 Core Projects, October 2011 to December 2011................................... 13Table 5: MDR-TB cases diagnosed by DST and put on second-line drug treatment ......................................... 17Table 6: TB CARE I-funded procurements of GeneXpert instruments and cartridges ....................................... 18

Figures

Figure 1: Map of TB CARE I countries, as of December 2011 ....................................................................... 16Figure 2: Role of the community in TB suspect identification, 2008-2011 ...................................................... 19

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List of Abbreviations

ACSM Advocacy Communication Social MobilizationAHRI Armauer Hansen Research InstituteAFB Acid Fast BacilliCAR Central Asian RepublicsCATA Cambodia Anti-TB AssociationCDC Center for Disease Control and PreventionCENAT National Center for Tuberculosis and Leprosy ControlCoE Center of ExcellenceCDR Case Detection RateCSO Civil Society OrganizationDOT 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 DiagnosticsFLD First Line DrugGDF Global Drug FacilityGFATM Global Fund for Aids, Tuberculosis and MalariaGLC Green Light CommitteeGLI Global Laboratory InitiativeGSN Gold Star NetworkHBC High Burden CountryHRD Human Resource DevelopmentHSS Health System StrengtheningIC Infection ControlIEC Information, Education and CommunicationILEP International Federation of Anti-Leprosy AssociationsIMCI Integrated Management of Childhood IllnessesInSTEDD Innovative Support to Emergencies Diseases and DisastersJATA Japan Anti Tuberculosis AssociationKANCO Kenya AIDS NGOs ConsortiumKAPTLD Kenya Association for the Prevention of TB and Lung DiseasesKIT Royal Tropical Institute KNCV KNCV Tuberculosis FoundationMDR Multi Drug ResistanceMDR-TB Multi Drug Resistant Tuberculosis M&E Monitoring and EvaluationMOA Memorandum of AgreementMOH Ministry of HealthMoLHR Ministry of Law and Human RightsMOST Management & Organizational Sustainability ToolMSF Médecins sans Frontières (Doctors without Borders)MSH Management Sciences for HealthNAP National AIDS ProgramNGO Non Governmental OrganizationNIHE National Institute of Health and Epidemics (Vietnam)NMCP National Malaria Control ProgramNTP National TB ProgramNRL National Reference LaboratoryNTRL National Tuberculosis Reference Laboratory (Uganda)OD Operational DistrictOR Operations ResearchPMDT Programmatic Management of Drug-resistant TuberculosisPMU Program Management UnitPPM Private Public MixPPP Public Private PartnershipRIF RifampacinQMR Quarterly Monitoring ReportSLD Second Line DrugSRL Supra-national Reference LaboratorySRLN Supra-national Reference Laboratory NetworkSOP Standard Operating ProceduresSS+ Sputum Smear positiveSS- Sputum Smear negativeSTAR Situation, Task, Action, Result

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TA Technical AssistanceTB TuberculosisTB CAP Tuberculosis Control Assistance ProgramTBCTA Tuberculosis Coalition for Technical AssistanceTWG Technical Working GroupUSAID United States Agency for International DevelopmentUSG United States GovernmentWHO World Health Organization

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1. Introduction TB CARE I is pleased to present USAID with a report for the October-December 2011 quarter of the TB CARE I program. This report straddles both Year 1 and Year 2 workplans as some projects have an approved extension for Year 1 workplans and others have begun Year 2 workplans during this time period. Seventeen country projects continued Year 1 activities while three commenced new Year 2 workplans. Nineteen Year 1 core projects continued and 22 new Year 2 core projects were launched this quarter. Two new regional projects began this quarter, bringing the total number of regional projects to five (both Year 1 and Year 2 funding). This report provides a technical and financial update on progress made during the quarter for these core, regional and country projects. Below is a brief summary of TB CARE I’s main achievements to date and challenges for the next quarter.

Main Achievements: • In light of varying start dates of Year 1 workplans, considerable progress has been made at wrapping up Year

1 projects. On average 78% of country workplans, 87% of regional workplans and 87% of core projects have been successfully completed.

• WHO has now accepted the Benin NRL and Uganda NRL as designated SRLs and granted permission to include them in the group delivering the final judicial result for the annual rounds of panel testing. The Benin NRL is also mentioned as one of the new candidate SRLs in the annual Global Laboratory Initiative (GLI) report.

• Routine use of GeneXpert has started in three countries: Cambodia, Kenya and Nigeria. So far, more than 300 tests have been performed in these three countries.

• The laboratory accreditation roadmap and toolbox (found at www.GLIquality.org) was launched at the Union Conference in Lille, France.

• Two regional workshops were implemented where the five tools of the patient-centered approach package were introduced. Cambodia, Indonesia, Mozambique and Nigeria selected 2-3 tools each to implement in Year 2.

• The “TB Infection Control at the Community Level” training handbook was finalized and the “Simplified Checklist for TB Infection Control” was printed and disseminated.

• Civil society organizations (CSOs) in Nigeria (4) and Indonesia (4) have developed and are implementing their workplans, using the monitoring and evaluation (M&E) framework to monitor their performance. Collaboration has improved at the regional level between CSO’s and the TB network in Nigeria.

• Significant progress has been made with the expansion of DOTS to new public/private health facilities in Kabul City, Afghanistan. Three new public health facilities are now covered by DOTS. In total, 56 (50%) private and public health facilities are now involved in DOTS in Kabul City compared to only 22 (21%) in 2009.

• Botswana National TB Reference Laboratory (NTRL) was successfully ISO15189 accredited by the South Africa Accreditation Systems (SANAS). TB CARE I will continue to support the continuation of NTRL activities.

• A two-day regional Central Asian Republic (CAR) workshop on GeneXpert was conducted in November to introduce the new technology and to help NTPs and partners plan the implementation of GeneXpert in Central Asian countries.

• TB CARE I supported both technically and financially the 2nd International Scientific Lung Health Conference, which was held in Kenya in October. The theme of the conference was “Towards Universal Access to TB/HIV and Comprehensive Lung Health Service”. The conference registered a total of 530 participants including 50 international participants; TB CARE I supported 331 local participants to attend the conference.

• In Mozambique, laboratory technicians were trained in malaria diagnosis including identification of species, biosafety, laboratory management, quality assurance and supervision using provincial trainers. Overall, 1,072 laboratory technicians were trained, which corresponds to 95% of the 1,200 laboratory staff existing in the country.

Main Challenges and Next Steps: • The cancellation of Global Fund Round 11 and the replacement with a transitional funding mechanism is

affecting almost every TB CARE I country. TB CARE I will need to work closely with the NTP and USAID to find short and long-term alternatives to this funding source.

• Year 1 and 2 workplan implementation must be accelerated to ensure the timely completion of activities/deliverables. Increased obligations and a decreased rate of expenditure this quarter has resulted in a growing pipeline. Pipelines are particularly high in countries like Mozambique, Indonesia, Vietnam and Zambia. Considerable efforts will need to be made in the coming quarters to ramp up workplan implementation and spending to decrease the size of this pipeline.

• The scale up of the programmatic management of drug-resistant TB (PMDT) continues to be a complex struggle in many countries. Drug shortages persist in some countries and there are serious difficulties with collecting accurate and timely data on MDR-TB diagnosis and treatment in most countries.

• In Nigeria, the unstable environment is impacting all TB CARE I-supported projects – the country OP and COP workplans, the Zaria Regional Training Center and the core implementation of GeneXpert. Services must be expanded and scaled up in light of this insecure environment.

• The implementation of the Vietnam workplan continues to be a challenge; significant progress will hopefully be seen next quarter.

• A savings of about $700,000 is anticipated from the Year 1 management budget; a plan for reallocating these funds must be developed and implemented rapidly.

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2. Project Management Unit (PMU)

During the reporting period the PMU took two steps to strengthen operational, management and technical services within the program. Given the linkages between M&E and program management, the functions of ‘Team Leader of M&E and Knowledge Exchange’ and the original Deputy Director position were merged into a new position: “Deputy M&E and Operations”. Ersin Topcuoglu has taken on this role. Also, a “Deputy of Technical Services” position was created to strengthen the technical services of the PMU. Jeroen van Gorkom was selected for this new position.

Technical assistance visits by PMU staff this quarter included:

Country: Purpose:

Cambodia GeneXpert & Laboratory Strategic Plan

CAR-Kazakhstan GeneXpert & workplanning/program management

Indonesia Workplanning

Kenya ECSA Health Minister’s Conference

Nigeria Patient-centered approach workshop & GeneXpert

Vietnam GeneXpert & workplanning

Zambia Ndole TB-IC project

Zimbabwe WHO/AFRO Advisory Board meeting & TB TEAM meeting

2.1 Knowledge Exchange

This quarter’s activities have mainly been devoted to the completion of the TB CARE I website (http://www.tbcare1.org) which launched on the 29th of September 2011. The site contains all of the tools published by the TBCTA coalition under TB CAP as well as those now being published under TB CARE I.

There are up-to-date country sections with current information about TB CARE I work in the country, as well as general news and information across all TB CARE I projects.

Table 1: Summary of visitors to the TB CARE I website, October-December 2011

Number of visitorsTotal: 2,700

October: 679 November: 832 December: 1189

Percent that were new visits 67%

Number of countries visitors came from 100

Total downloads 679

Most Popular Downloads 1. Rapid Implementation of Xpert MTB-RIF Diagnostic Test (27)2. A Guide for Integrating HIV Testing in MDR surveillance (25)3. TB-IC at Community Level - Training Handbook (22)4. The Platform (18)5. A Guide to Monitoring and Evaluation for Collaborative TB/HIV

Activities (15)

The TB CARE I Year 1 Annual Report was also prepared and submitted this quarter.

New TB CARE I Tools:A number of new TB CARE I tools have been published this quarter:

TB-ICFacilitator’s Guide: Refresher (Advanced) Training Course & Workshop on TB-IC for ConsultantsThis guide is meant for trainers and facilitators involved in the “Refresher Advanced Training Course and Workshop on Tuberculosis Infection Control for Consultants”. This training aims to train-up (inter)national TB Infection Control (TB-IC) consultants, a number of which will be available to perform TB-IC missions with limited scope or independent missions within one year. http://www.tbcare1.org/publications/toolbox/tools/recent/fac_guide.pdf

TB-IC at Community Level - Training HandbookThis handbook is designed to facilitate the understanding and use of the Simplified Checklist for TB Infection Control, with a particular emphasis on settings where TB, HIV and TB with HIV are prevalent.http://www.tbcare1.org/publications/toolbox/tools/recent/TB_IC_at_Community_Level_Training_Handbook.pdf

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Simplified Checklist for TB Infection ControlThe three-part Simplified Checklist for TB Infection Control (TB-IC) has been translated into French and Portuguese.French - http://www.tbcare1.org/publications/toolbox/tools/ic/TB_IC_Liste_de_controle_simplifiee.pdfPortuguese - http://www.tbcare1.org/publications/toolbox/tools/ic/TB_IC_Lista_de_Verificacao_Simplificada.pdf

LaboratoryLaboratory Accreditation Roadmap and Toolbox GLI (under WHO guidance) has developed a ‘Laboratory toolbox’ to standardize laboratory methods. This toolbox provides many SOP templates for TB-specific equipment and examinations.www.GLIquality.org

3. Core projects

As of December 31, 2011, eighteen of the 29 Year 1 core projects (62%) have been completed and tangible deliverables are published on the website. Eleven projects require extensions: six of these projects have approved 3-month no-cost extensions through March 2012, three others have approved 6-month extensions and the remaining two projects are awaiting approval of another 3-month extension. Table 2 lists all completed Year 1 core projects and their respective deliverables as of December 2011. Table 2: Completed Year 1 Core Projects and Deliverables, through December 2011 (all tangible deliverables are available on the TB CARE I website unless otherwise indicated)

Technical Areas

Code Lead Project Title Type of Deliverable

Outcome/Deliverables

Universal and Early Access

C1.1.5 KNCV Adapt and pilot patient centered package

Workshops Two regional workshops were implemented where the five tools of the patient-centered approach package were introduced. Cambodia, Indonesia, Mozambique, Nigeria and Zambia selected 2-3 tools each to implement in Year 2.

Laboratories

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

Handbook A practical handbook for the development of a national laboratory strategy was developed.

C6.1.2 Union Tool for laboratory network assessment

Tool A draft tool for conducting lab network assessments was developed; piloting and training will take place in Year 2.

C6.2.1 KNCV Laboratory accreditation tools and roadmap

Toolbox Laboratory accreditation roadmap and toolbox have been developed (available on the GLI website: www.GLIquality.org).

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

Guide The document Rapid Implementation of the Xpert MTB/RIF diagnostic test - Technical and Operational ‘How-to’ Practical considerations has been developed.

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

Tool The GLI assessment tool has been revised and is available on the GLI and TB CARE I websites.

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

SRL candidate status

WHO has accepted the Benin NRL as a candidate SRL.

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Infection Control

C3.1.1 WHO Develop a tool to measure TB incidence in HCWs

Guide Guides on monitoring active TB incidence among health care workers (HCWs) and conducting TB prevalence surveys among HCWs were drafted and will be finalized in Year 2.

C3.2.1 PMU Core Package of IC Interventions

Strategy A core TB-IC package was agreed to and finalized (TB CARE I and II collaboration).

C3.3.2 KNCV Training and mentoring on TB-IC

Training & mentored field

visits

Twelve participants were trained and nine (target) completed mentored field visits; three became TB-IC consultants and were registered on the TB TEAM website.

PMDT

C2.1.1 PMU Strengthening of regional and local technical collaboration centers (TCC) for PMDT

Assessment report

An inventory of strengths, weaknesses and challenges of existing TCCs was conducted. Technical assistance needs and possible scale-up approaches of TCCs were identified through discussion with current TCCs and other stakeholders.

TB/HIV

C4.1.1 FHI 360 TB Infection Control at Community Level

Curriculum and guide

The TB Infection Control at the Community Level training handbook and the Simplified Checklist for TB Infection Control were developed.

Health Systems

Strengthening

C7.4.1 MSH Training national leaders on HRD Tools

Action plans Action plans on HRD are in place for six NTPs that participated in a virtual HRD training program (Afghanistan (2), Ghana, Indonesia, Pakistan, and Uganda).

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

Workplans Civil society organizations (CSOs) in Nigeria (4) and Indonesia (4) have developed and are implementing their TB control activity plans (continuing in Year 2).

M&E, OR and Surveillance

C5.2.1 MSH Develop M&E COP for NTPs

Training A workshop "Using TB Information for Decision Making" was attended by 31 participants from 16 countries. Participants developed mini M&E plans for their countries, which will be implemented in Year 2.

Overarching elements

C0.0.2 KNCV Support to CSHGP and CORE Group

Evaluation reports

Two evaluation missions for CORE Group (a coordinating body of US-borne private voluntary organizations) were implemented in India and Malawi.

C6.1.4 WHO Training for Global Fund Round 11 Consultants

Training 42 consultants (36 TB CARE I-funded) were trained to provide quality technical assistance for Global Fund Round 11 proposal development.

Table 3 provides detailed information on the progress of the Year 1 core projects that are not yet complete. Table 4 summarizes progress on the Year 2 core projects that have been approved before or during the quarter (22 in total). Twelve Year 2 core projects are either still under review for approval or were approved after this reporting period.

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Table 3: Overview of Extended Year 1 Core Projects, October 2011 to December 2011

Technical Area Code Lead Title Expected Year 1 Deliverables Progress to date %

completeLevel of

spending

Universal Access C1.1.1 KNCV

Tool to identify TB most at risk and vulnerable populations

• Framework format developed

Draft tool materials currently under review by 26 Risk-Group Experts. Website development process beginning. Deliverables to be completed by the approved March 2012 extension.

90% 64%

TB/HIV

C4.2.2 ATS

Guidelines for evaluations of contacts to infectious cases of tuberculosis

• WHO-approved set of guidelines developed

The draft document is being finalized and will be submitted to the WHO Guideline Review Committee in February. Editing & printing will take place in March. A workshop with selected countries to outline and prepare national guidelines based on the WHO/ATS guidelines is then planned. A no-cost extension through June 2012 is being requested (March no-cost extension (NCE) already approved).

75% 84%

C4.3.1 KNCV

Assessment of TB/HIV mortality data

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

4/5 assessments completed. Data analysis ongoing. Delays due to data entry, cleaning, & harmonization of protocols. Revised Death Audit tool for PCA Package being finalized. Activities will be completed by March.

80% 48%

M&E, OR and surveillance

C5.1.1 WHO

Guide on electronic recording and reporting for TB care and control

• Guide on ERR developed

The document has been reviewed & copy edited. The final PDF will be posted on the WHO website by the end of March. NCE through March has been requested.

75% 76%

C5.1.2 WHO

Guide on inventory studies to assess the level of TB under-reporting

• Guide on inventory studies developed

Draft guidelines were written by a core group of 13 authors from six institutions. A peer-review process will be conducted in January. A final electronic version will be available in March.

85% 60%

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Laboratories C6.4.3 WHO

Meeting of the SRLN

• Meeting of SRLN convened and consensus workplan and strategy developed

This meeting will be held in April 2012 as part of a large three-day meeting (with one day each devoted to the SRL network, the laboratory strengthening activities of the GLI partners and to review GeneXpert implementation progress) in France. NCE granted through June.

50% 5%

Health System 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.

40% of national health/TB plan synergy analyses have been completed. The 60% remaining will be completed in February and field visits will take place in March. The planned workshop with partners & several national counterparts is delayed until April and the final lessons learnt document will be delivered in May. A NCE until June is being requested.

25% 37%

C7.1.2 ATS

Create political commitment and financing database

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

Progress and next steps for this project will be discussed during the Joint Strategic Meeting in Washington DC in February.

25% 1%

C7.1.3 WHO

Enhancement of the planning and budgeting tool

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

22/41 countries (a reasonable sample) have answered the questionnaire about the use of the tool at country level. Responses will be analyzed in January and changes to the tool will then be discussed.

50% 11%

C7.4.1 MSH

Training national leaders on HRD Tools

• Action Plan on HRD in place in NTPs

6/8 participating teams successfully completed the program and submitted action plans. Action plan follow-up will be done in March.

95% 103%

Overarching elements C0.0.1 WHO

Support to the Sub Working Groups of the Stop TB Partnership

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

The DEWG HRD TB Sub Group Expanded Core Group Meeting took place in Lille, France in October. The GLI meeting will take place in April as a part of a large three-day meeting (see activity 6.4.3).

75% 76%

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Table 4: Overview of Approved Year 2 Core Projects, October 2011 to December 2011

Technical Areas Code Lead Title Expected Year 2 Deliverables Progress to date %

completeLevel of

spending

Universal and Early Access

C1.2 WHO

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

WHO is in the process of selecting a consultant to undertake the review and conduct site visits to document working models of pharmacist engagement.

0% 1%

C1.4 WHOPPM Toolkit workshop

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

The project is selecting a venue and countries that will be invited to the workshop. The content of the workshop is being developed.

0% 0%

C1.9 The Union

Childhood TB training

- ToT for 10 people - Training in 4 Districts in both countries

Training tools have been developed. ToT and evaluation of implementation in two high-burden countries planned for Q1 2012. 10% 5%

C1.12 WHO

Guidelines on screening for active TB

Guidelines on TB screening Liverpool School has sent first report with protocol for analysis. Johns Hopkins University started the additional analyses. Re-analysis of prevalence survey datasets is underway. Meeting planned for June 2012.

0% 24%

C1.15 KNCV

Adapt and pilot PCA package

- Complete regional workshops from Year 1- Final report of pilot with results & recommendations for next steps, scale up and adaptation.

Cambodia & Mozambique have received ethical approval for the research component of the project and have begun data collection. Nigeria is delayed due to civil unrest in country and Indonesia is awaiting Year 2 approval. The coordination team will support Indonesia to coordinate the start-up of planned activities.

10% 0%

C1.16 ATS

Develop contact investigation guidelines*

Development of WHO approved set of guidelines for evaluations of contacts to infectious cases of TB and enhanced existing intensified active TB case finding strategies in PLHIV and children.

No updated provided this quarter

0% 40%

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Laboratories

C2.3 KNCV

Lab management training of NRL staff

A 2-week laboratory training of 12 NRL lab staff from sub-Saharan Africa in Nairobi, Kenya

A meeting in The Hague for curriculum development and a training venue in Nairobi (including dates) have been agreed upon. The Union partner has started revising the training files because of the incompatibility of newer Excel versions with the original tool version made under TB CAP.

5% 8%

C2.4 KNCV

Lab accreditation tools and roadmap

Improved, functional implementation guide (version 2.0) available for use by NTRLs for the implementation of a total quality management system leading to ISO 15189 accreditation

A workshop has been organized (January 2012) in Amsterdam on performance indicators for evaluating the implementation of laboratory quality management systems.

5% 2%

C2.7 The Union

Develop Benin NRL to SNRL

- A functional supra-national TB reference laboratory (SNRL) in Benin

The draft guide for monitoring active TB disease incidence among health workers was completed. The countries for field-testing of the draft guide were selected and visits are tentatively scheduled for April. The guide on measuring TB prevalence among health workers (Year 1) will be disseminated in March.

10% 1%

Infection Control

C3.1 PMU

Testing of guide for TB among HCWs

field-tested guideline The draft guide for monitoring active TB disease incidence among health workers was completed. The countries for field-testing of the draft guide were selected and visits are tentatively scheduled for April. The guide on measuring TB prevalence among health workers (Year 1) will be disseminated in March.

10% 1%

C3.2 PMU

TB-IC Core package

TB-IC 'core package' strategy has been adapted and adopted in 15 health facilities of Ndola district (Zambia)

TB CARE II (PIH) is the lead partner in this joint project. The first TB CARE I activity, a joint TA mission to Zambia, is scheduled for April 2012.

0% 1%

C3.3 KNCV

TB-IC training - Organize and conduct training and workshop in TB-IC for 12-20 participants from EMRO & Asia, in Indonesia participants from EMRO & Asia, in Indonesia Provide mentored field visits to 8 consultants from the workshop Provide distance support to consultants

A training venue has been identified and facilitators, mentors and trainees were selected for the February training in Jakarta. Trainees for the mentorship program are still to be selected. 10% 0%

C3.5 PMU-PEPFAR

TB-IC demonstration Ndola district

End-evaluation study reports to describe approaches and demonstrate results

The project has been approved by the MoH Zambia and a detailed project protocol has been developed. The baseline survey is planned for January, followed by training activities in February.

10% 0%

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PMDT

C4.3 MSH

Cost effectiveness modeling for MDR-TB treatment

- Tool completed- Advocacy materials

Tool design under development.

25% 1%

C4.4 KNCV

Assessing the costs faced by MDR -TB patients

- Development and validation of tool Working group has been established and tool is being developed. Tool will be validated in one country once developed. 10% 3%

C4.6TB

CARE II-4.3

DR TB Learning site

On-line PMDT training program for clinicians and program managers

A teleconference was organized with PHI where expectations and roles were discussed. 5% 19%

C4.7TB

CARE II-4.1

PMDT management training course

A training of three days around the WHO Guide, Management of MDR-TB: A field guide

TB CARE I activities have not started.0% 0%

C4.8TB

CARE II-4.6

Tools for tracking DR-TB suspects

Review of existing tools No review was undertaken during the quarter.0% 4%

Health Systems

Strengthening

C6.8 ATSImproved domestic financing

Technical assistance and mentoring will be provided to selected workshop participants

No updated provided this quarter.0% 0%

C6.11 PMUSupport to CSHGP and CORE group

Evaluation report for mid-term or final evaluations of selected CORE Group field projects

As of December 2011 no requests have been made. 0% 0%

M&E, OR and Surveillance

C7.3 WHO

Handbook on analysis of TB surveillance data

Handbook on "Analysis of TB surveillance data"

The project activities will start in January 2012.

0% 0%

C7.5 MSH

Support M&E efforts of NTPs

-A community of practice (CoP) will be established -Test and pilot in 2 TB CARE countries (one each in Asia and Africa) virtual and in-person training materials on TB data management

The eRoom CoP has been set up and access granted to participants. The first trainings are planned for February and March. Following the workshop in The Hague (Year 1), 13 country teams finalized mini-M&E workplans, which are being implemented. The data management training materials outline has been developed.

20% 5%

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4. Country projects

All 20 country projects showed progress this quarter. Based on approved extensions or the timing of Year 2 workplan approvals, some countries are reporting on Year 1, Year 2 or both workplans. Figure 1 displays the geographic distribution of TB CARE I countries.

Figure 1: Map of TB CARE I countries, as of December 2011

Afghanistan

KazakhstanKyrgyzstan

Uzbekistan

Nigeria

Botswana

Pakistan

Ghana

Dominican Republic

Senegal

Cambodia

Djibouti

Ethiopia

IndonesiaNamibia

KenyaUgandaMozambique

South Sudan

Vietnam

Zambia

Zimbabwe

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PMDT

As PMDT scale-up at country level is a priority for TB CARE I, national data on MDR-TB cases that were diagnosed and put on treatment are collected each quarter. Table 5 summarizes the available information for 2010 and 2011 by country. In total, 10,145 MDR-TB cases were diagnosed in TB CARE I-supported countries in 2010, and 8,032 were put on treatment. Preliminary data for 2011 show a declining trend that 8,970 MDR-TB cases were diagnosed and 7,443 were put on treatment; however several countries do not yet have data for Quarter 3 and/or 4 of 2011 (July-December or October-December). These data will be updated and analyzed further next quarter once more year-end 2011 data becomes available.

Table 5: MDR-TB cases diagnosed by drug sensitivity testing (DST) and put on second-line drug treatment during 2010 or 2011 by country, as of December 2011

Countries

Jan - Dec 2010 Jan - Dec 2011

CommentsNumber Diagnosed

Number put on

Treament

Number Diagnosed

Number put on

Treament

Afghanistan 31 15 U U

Botswana 106 92 30 TBD Data only available through Sept 2011

Cambodia 31 50 31 83

Data only available through Sept 2011. # put on treatment includes confirmed and suspected cases (31 and 51) cases put on treatment in 2010 and 2011 respectively).

CAR - Kazakhstan 7,336 5,740 7,386 5,311

CAR - Kyrgyzstan 441 441 423 423

Only MDR-TB cases on treatment are registered. About 700 MDR-TB cases are not on treatment and are not registered. Complete country data will be available next quarter.

CAR - Uzbekistan 1,023 628 U U The NTP will only provide 2011 data once registration is complete

Djibouti 8 8 73 12

Dominican Republic 108 108 85 85

Ethiopia 140 85 136 214

Ghana 14 2 10 1

Indonesia 182 142 326 238

Kenya 112 67 59 59Data only available through June 2011. All diagnosed MDT-TB cases on treatment according to NTP

Mozambique 165 86 U U

Namibia U 214 U 95

Unable to provide number of MDT-TB cases diagnosed due to electronic system which captures the number of samples tested rather than cases. TB CARE I is working with NTP and CDC to modify the R&R system. Data only available through June 2011.

Nigeria - OP U 23 U 43 Data only available through Sept 2011.

Pakistan 203 203 344 344

South Sudan 3 0 0 0

Vietnam 202 101 U 495

Zambia U U U U

R&R tools for PMDT are not yet available. The NTP has finalized the tools and TB CARE I plans to make them available to the teo PMDT treatment sites in the next quarter.

Zimbabwe 40 27 67 40

Total 10,145 8,032 8,970 7,443

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GeneXpert

GeneXpert is used in the routine diagnosis of HIV positive TB suspects and MDR-TB suspects. TB CARE I is helping to introduce and scale-up GeneXpert use in several countries. More than 300 tests have been performed to date in Cambodia, Kenya and Nigeria. Another five countries are starting operations soon (Djibouti, Indonesia, Mozambique, Vietnam and Zambia). More detail can be found in each respective country section. Below is a summary of GeneXpert instruments and cartridges procured through December and planned for Year 2 with TB CARE I funds.

Table 6: TB CARE I-funded procurements of GeneXpert instruments and cartridges (completed and planned in Year 2) as of December 2011

Countries # Instruments Procured

# Cartridges Procured

# Instruments Planned

# Cartridges Planned

Afghanistan 0 0 0

Botswana 0 0 0

Cambodia 2 2000 1 3,000

CAR - Kazakhstan 0 0 4 6,000

CAR - Kyrgyzstan 0 0 0 0

CAR - Uzbekistan 0 0 0 0

Djibouti 0 0 1 2,060

Dominican Republic 0 0 1 TBD

Ethiopia 0 0 0 0

Ghana 0 0 0 0

Indonesia 17 1,700 0 0

Kenya 3 3,000 0 1,450

Mozambique 3 1,500 0 0

Namibia 0 0 0 0

Nigeria - OP 9 7,600 5 7,500

Pakistan 0 0 0 0

South Sudan 0 0 0 0

Vietnam 2 2,700 10 10,000

Zambia 1 400 2 560

Zimbabwe 0 0 1 0

Total 37 18,900 25 30, 570

Each TB CARE I 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 (UA), laboratories, infection control (IC), health system strengthening (HSS) and M&E. The project received a NCE for the period Oct-Dec 2011 during which the pending activities from Year 1 were completed; the workplan for Year 2 was approved by USAID in late Dec 2011. TB CARE I Afghanistan will be intensifying its efforts to catch up on Year 2 implementation during the coming quarters.

Significant progress has been made with the expansion of DOTS to new public/private health facilities in Kabul City. Three new public health facilities are now covered by DOTS. In total, 56 (50%) private and public health facilities are now involved in DOTS in Kabul City compared to only 22 (21%) in 2009. All of the staff from these health facilities were trained on SOPs for case detection, diagnosis and treatment, as well as SOPs for TB-IC.

The first ever TB electronic reporting system was introduced to the NTP with four NTP staff and six TB CARE I staff were trained on system utilization in December. This system will be expanded to all 34 provinces in Afghanistan in January 2012. TB CARE I will provide technical and financial support to the NTP to conduct trainings and provide computer equipment for the smooth utilization of electronic reporting. This will assist the NTP in overcoming the challenge of delayed reporting and data analysis at various levels.

In TB CARE I-supported provinces, 64 health facility staff from newly covered health facilities were trained on

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SOPs for TB case detection, diagnosis, and treatment. Also during this period, 85 managers from public and private sectors participated in a DOTS coordination workshop. In total, TB-IC expanded to 36 health facilities and each of these has TB-IC committee meetings each month (36 meetings in total with ~10 participants per meeting). TB-IC assessment tool orientation workshops were conducted in Kandahar for 27 participants from BPHS implementers and the NTP. The participants, from five insecure provinces in the South Western region (Kandahar, Uruzgan, Helmand, Zabul and Nimroze provinces) assessed the Kandahar TB Center using the TB-IC assessment tool. Later, this was replicated with four other health facilities in Kandahar Province.

There was an increase in the proportion of TB suspects identified in USAID supported provinces compared to non-USAID provinces, from 47% in the second quarter of 2011 to 50% in the third quarter of the same year. In total, suspects identified in TB CARE I intervention areas reached 20,671, which is an increase of 4,000 suspects identified compared to the similar quarter of 2010. The figure below shows that the project has maintained momentum and achieved yearly targets of increasing TB suspect identification from the community.

Figure 2: Role of the community in TB suspect identification, 2008-2011

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10

15

20

25

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35

40

2008 2009 2010 2011

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4.2 Botswana

KNCV is the lead partner and sole implementer in Botswana. In Year 2 the project focuses on universal and early access and laboratories. The project began implementing the Year 2 workplan in October 2011. Dr Diriba, the new Technical Advisor to the NTP, began in December.

Botswana NTRL was successfully recommended for accreditation by the South Africa Accreditation Systems (SANAS). TB CARE I will continue to support the continuation of accreditation activities for the NTRL.

Thirty laboratory technicians were trained in performance and quality assurance of AFB smear microscopy. Follow-up will take place through supervisory visits; periodic panel tests by the NTRL External Quality Assurance team will follow to monitor performance of lab technicians.

Botswana hosted a core project laboratory strategic planning workshop, which was attended by 12 staff from the NTP, partner organizations and the NTRL. PMDTA draft National Laboratory Strategic Plan was developed, which is to be finalized in a second workshop in 2012.

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4.3 Cambodia

JATA is the lead partner in Cambodia, with collaboration from FHI 360, KNCV, MSH, and WHO. The project in Year 2 has activities in seven TB CARE I technical areas (UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E). The Year 2 workplan was approved in mid-December so the majority of the quarter was spent completing Year 1 activities.

TB CARE I procured two Xpert MTB/Rif instruments in August 2011. They were used for the first time this quarter for mass screening of prisoners (for those with symptoms and abnormal chest x-rays) and as a primary test for MDR-TB suspects. Thirty-three (14%) of the 244 prisoners eligible for Xpert were MTB positive with no cases of Rif resistance. Among the 57 MDR-TB suspects tested using Xpert, 25 cases (43%) were detected as MTB positive. Four (16%) of the 25 MTB positive were also Rif positive and initiated second line anti-TB drugs. All Rif positive cases are being confirmed for MDR-TB with DST.

Preparatory activities for public-private mix (PPM) implementation in TB CARE I supported sites were started in earnest during the quarter. Workplans and budgets for most PPM sites were finalized and a series of orientation workshops were organized to clarify the new arrangement for PPM under TB CARE I. 613 private providers signed MoUs with PHD/OD to continue PPM activities.

WHO/TB CARE I conducted a detailed review and training for PMDT in December. Members of the regional GLC (rGLC) also participated.

Quality improvement (QI) activities began in five selected health centers this quarter. QI measurement tools were finalized to aid monitoring and for use in the monthly learning sessions, the first of which were held in December. Reporting on the data collected from these learning sessions will begin next quarter. (Photo: QI team conducts system analysis at Daunthy Health Centre.)

A regional kick-off workshop for the Patient-Centered Approach (PCA) package was conducted in Phnom Penh with participants from Cambodia and Indonesia. In addition, most of preparatory activities for implementation of the PCA package were completed during the quarter to facilitate a quick start to the Year 2 workplan; ethical clearance was received, the PCA workplan was designed, and survey instruments and protocols have been prepared.

4.4 CAR-Kazakhstan

KNCV is the lead and sole implementer of TB CARE I activities in all three Central Asian Republic (CAR) countries: Kazakhstan, Kyrgyzstan and Uzbekistan. There is also a small CAR regionally-funded project which is discussed on page 34. All three CAR country projects have activities in the eight technical areas (UA, laboratories, IC, PMDT, TB/HIV, HSS, M&E and drug supply and management). Each of these countries also has an approved NCE through March 31, 2012 for the Year 1 workplans.

Clinical protocol recording and reporting forms have been revised for Xpert implementation by the Xpert implementation working group with TA from the PMU. An assessment of facilities for selection of Xpert sites was

conducted in Eastern Kazakhstan and North Kazakhstan oblasts by the Regional Laboratory Technical Officer. In addition, maintenance guidelines and draft SOPs for laboratory equipment were developed.

A two-day regional workshop on GeneXpert was conducted in November with technical assistance from WHO and in collaboration with the Quality Health Care Project to introduce new technology and help NTPs and partners to plan implementation of GeneXpert in Central Asian countries. Country teams discussed placement of GeneXpert in each country and draft diagnostic algorithms have been developed by the country teams. (Photo: Aigul Tursynbayeva, TB CARE I M&E Officer, working with the Kazakhstan NTP during the sub-regional GeneXpert workshop.)

TA was provided by a Regional TB-IC consultant for finalization of the National TB-IC plan and adaptation of the TB-IC assessment tool. The national TB-IC plan was finalized and submitted to the MoH. The assessment TB-IC tool was adjusted to the Kazakhstan setting and was sent to partners for comments. It will be a part of the national TB-IC guidelines. The TB-IC national order was drafted by the IC thematic working group and sent to the prison system for comments.

PMDT action plans were developed in new project sites (Akmola, South Kazakhstan and North Kazakhstan) and submitted to the oblasts healthcare authorities for approval. MDR-TB protocols were revised by the MDR-TB thematic working group. A protocol on TB in children for Kazakhstan was drafted in accordance with the latest WHO recommendations.

Progress was also made with patient support; 243 TB/MDR-TB patients have been enrolled in a patient support program in East Kazakhstan oblast (EKO). Agreement was achieved with key partners (Oblast Akimat, the NTP, the prison system, Department of Social Affairs, Department of Labor, the migration police and others) to establish oblast working groups to develop a patient support system in two new project sites - North Kazakhstan and South

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Kazakhstan. Lastly, a tool for monitoring patient support programs was tested in EKO and finalized.

Other achievements include the following: The national TB-HIV plan and prikaz (legal order for implementation) were finalized and submitted to the MoH for approval. Recording & reporting forms have been revised, specifically the laboratory and drug management sections because of new diagnostic and treatment algorithms that are being implemented. An OR protocol on effectiveness of patient support in EKO was drafted. And in regards to drug management, a draft tool for first and second-line drug forecasting has been developed and specialists from project sites have been trained on basic forecasting skills. Implementation of project activities in the prison system are postponed until the MoU with the Ministry of Internal Affairs is signed. Also, cancellation of Global Fund for Aids, Tuberculosis and Malaria (GFATM) Round 11 and the reduction of funds for Round 8 Phase 2 required the plan for GeneXpert implementation to be revised. The Year 2 workplan will focus strategically on vulnerable populations, the introduction of ambulatory treatment and the roll out of GeneXpert.

4.5 CAR-Kyrgyzstan

Roundtables on strengthening TB control in migrants and patient support systems were conducted and it was agreed to establish a technical working group (TWG) on TB in migrants. A technical working group on TB-IC has been established and the content of the TB-IC guidelines was agreed to by the TWG. Guidelines on TB in children were drafted by the TWG on TB in children. The National TB strategy 2011-2016 was drafted and February 2012 is the deadline for finalization. A national laboratory plan was developed with technical assistance from a laboratory consultant from SNRL Gauting. Laboratory services for the prison system is now part of the national laboratory plan.

Several activites have been postponed to Year 2 due to the late start of some project staff and the need for more technical project staff. The election of a new president resulted in changes at the Ministry level. A new Minister of Health Care was appointed, which might result in management changes within the NTP.

4.6 CAR-Uzbekistan

The regional GeneXpert workshop (see Kazakhstan section) was the only activity implemented during this period. Without registration it is impossible to implement activities. Registration documents have been submitted to the Ministry of Justice at the beginning of November 2011. An official response about registration status is expected at the beginning of February. The TB CARE I Country Representative is responsible for following up on the registration process. Activities from the Year 1 plan will move to Year 2 and will be submitted for approval to the USAID mission.

4.7 Djibouti

WHO is the lead and sole implementer of activities in Djibouti. The Year 2 workplan, which was approved in mid-December, focuses on UA, laboratories, PMDT, HSS, M&E and drug management.

Due to the late start to the Year 2 workplan, some activities were conducted with other financial sources, however, activities still relied on the local technical assistance provided and financed by TB CARE I.

An algorithm covering TB and MDR-TB diagnosis and the management of MDR-TB using GeneXpert was developed and submitted for technical advice. Discussions were held with FIND experts on the practical modalities of introducing GeneXpert in the National Reference Laboratory.

The treatment regimens have been updated to be in line with the new WHO guidelines; notably the reliance on DST for treating retreatment cases and the establishment of an MDR standard regimen have been addressed in the new regimen guidelines.

A one-week training on M&E and the recording and reporting system (including quarterly drug order forms and the GDF drug calculation sheet) was held with the participation of DOTS personnel and doctors.

Supervision in the capital was regularly conducted as scheduled. The NTP unit was unable to conduct regular supervision to the districts because of lack of financial resources. (The Global Fund froze funds dedicated to supervision including fuel and fees until the vehicle purchased by the GF for the NTP was given back to the NTP by the MoH for supervision activities). Only one visit out of 5 was conducted.

4.8 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 continues to implement the Year 1 workplan, which will run through March 2012. A new Country Director, Dr. Luis Alberto Rodriguez Reyes, began in January 2012.

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With high-level health authorities and representatives of USAID, WHO and KNCV in attendance, the photo exhibition “INVISIBLES, Naked Tuberculosis” was formally opened (an online photo gallery can be found at http://www.tbcare1.org/voices/). Pictures were taken by 10 participants and a total of 32 pictures were selected for the exhibit. More than a photographic exhibition, it was a process of personal transformation for all participants who took photographs to show the situation of TB from their personal perspective (patients, former patients and healthcare personnel). It promotes critical dialogue through group discussions and the use of photographs, based on the premise that each one of us “observes” reality very differently from each other, offering a new space for dialogue on and understanding of TB in the Dominican Republic.

The Health Minister asked that the exhibition tour through all 32 provinces in the country with the support of the Provincial Offices of the Ministry of Health to continue to raise awareness about TB. A survey is under development to measure observer opinion of the exhibition in the different locations. (Photo: The Minister of Health, together with the Vice Ministers, visited the photo exhibition accompanied by the NTP Director and the KNCV Country Manager.)

Area V and VII of Santo Domingo have joined the initiative to involve pharmacies with 98 and 97 pharmacies respectively joining to date from those areas. A total of 295 pharmacies have currently been trained and provided with IEC materials and referral forms.

During this quarter four Stop TB committees were established: two in urban neighborhoods, two in municipalities in Monte Plata Province (Yamasa and Bayaguana). A new modality has been established - the hospital based committee – and is starting in the biggest maternity hospital in Santo Domingo. To date there have been a total of 17 workshops (1,465 participants) realized to establish Stop TB committees through which the community involvement model is implemented. 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 Year 2 workplan, which has activities in all eight technical areas, began in October.

The third MDR-TB Treatment Unit started service at the ALERT Center. USAID through TB CAP/TB CARE I Ethiopia has covered the cost of renovation, medical supplies, furnishing equipment and capacity building activities. As of the end of December, a total of 13 MDR-TB patients, who had been on the waiting list, had been admitted for treatment. This 28 bed MDR unit has the capacity to provide in-patient service for about 300 MDR-TB patients annually.

TB CARE I in collaboration with the Ethiopian Health & Nutrition Research Institute (EHNRI) organized and conducted a 15-day training on tuberculosis culture to strengthen the five Regional laboratories. A total of 14 laboratory experts attended the training. The training will enable the regional laboratories to start long awaited TB culture services, in turn strengthening the diagnostic capacity of MDR in the country. In effect, it will upgrade the rate of MDR-TB patient enrolment improving access to second line treatment. (Photo: Practical exercises in TB culture and identification during a regional laboratory training.)

A panel discussion was held in December on TB prevention under the theme of “simple precaution saves lives”. It was organized by the TB Media forum in collaboration with TB CARE I. The discussion was attended by 80 participants from faith-based organizations, educational institutes, prisons and government & private media organizations. Participants are expected to use their communication skills to convey the intended messages regarding TB to

the community using mini Medias at the school and public /religious gathering places. TB CARE I will continue supporting the organizations by providing the necessary technical assistance and educational materials.

A three-day training on TB-IC was conducted for 34 health care providers working in 13 health centers in Addis Ababa. A follow up visit, which was conducted three months after the training, has shown that 95% of the health centers established or strengthened their TB-IC committee. Nearly all of the health centers also developed a TB-IC plan with a budget and also assigned a focal person to oversee the overall TB-IC activity. Additionally, 90% of the health centers strengthened the triage system, including cough triage, and almost all of them significantly reduced TB suspect waiting time in the out-patient department (OPD). Notably, eight of the 13 health centers underwent visible renovations (both minor & major) in the TB room, waiting area, maternity ward and ART units using their own budget, which will undoubtedly assist in reducing nosocomial TB transmission. After the performance assessment during a one-day follow up workshop in December, TB CARE I in collaboration with the Health Bureau gave an award to the three best performing health centers that had demonstrated major improvements in TB-IC.

A ten-day training on methods of epidemiology for operations research (OR) and ethics was provided for 15

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participants from the regions and the Federal Ministry of Health. The main objective of the training was to capacitate TB program managers, health professionals and academics with proposal development skills for research in the area of TB, HIV, TB/HIV and other related health issues. TB CARE I-Ethiopia provided TA and fully sponsored this training for which it was awarded a certificate of appreciation. This is the fourth round of OR training supported by TB CARE I/TB CAP since 2009.

There was an intention to apply for Global Fund Round 11. However, the recent decision of GFATM to cancel Round 11 will have a significant impact on the continuity of sensitive programs like PMDT, apart from its major consequence on the overall TB program.

4.10 Ghana

MSH is the lead partner in Ghana with support from KNCV and WHO as collaborating partners. The Year 2 workplan, which focuses on UA, laboratories, IC, TB/HIV, HSS and M&E, received approval in late November.

As a part of scaling up TB case detection activities, TB CARE I in collaboration with the NTP conducted a TB situation analysis throughout the 10 Regions in Ghana to determine the true DOTS coverage with particular focus on the public sector. Preliminary results show that out of all 3,663 health facilities (public, private and faith-based), 1,432 facilities provide some form of TB DOTS services representing 39% health facility DOTS coverage. Out of the 2,918 health facilities in the public sector and faith-based health sector, 1,300 (45%) provide DOTS services. Furthermore, out of the 670 laboratories in the public and private sector 282 (42%) provide smear microscopy services, representing one TB microscopy center for every 85,106 people. There are 332 medical laboratories in the public sector and 229 (70%) provide smear microscopy services. Three labs have the capacity to perform culture and DST and two of these laboratories are in Accra.

To fully understand how TB case detection activities are organized in the Eastern Region, TB CARE I conducted monitoring visits to six hospitals that report higher numbers of TB cases in the region. The results show that in 2010 a total of 809,711 OPD clients accessed care in these facilities and as low as 3,260 (0.40%) TB suspects had their sputum samples examined of which 422 (13%) were smear positive cases. Since all six hospitals were not using TB suspect registers, it was impossible to determine the number of the OPD attendees that met TB suspect criteria. Out of the 422 documented smear positive cases, 241 (57%) had their 5-month follow up smears done and 10 (4%) did not convert. A total of 922 HIV positive individuals were registered with the HIV clinics in these six hospitals; 616 (67%) were screened for TB and 218 (35%) were diagnosed with active TB. This means that not all people living with HIV (PLHIV) are screened for TB. The TB screening algorithm that was printed and handed over to the National AIDS Control Program to be distributed to all Anti-retroviral Therapy (ART) clinics is aimed at improving TB case finding among PLHIVs. None of the six hospitals had a TB-IC plan. The identified short falls are being addressed in the Year 2 workplan. Furthermore, TB CARE I has supported the updating of the TB screening tool that will be used in all health facilities across the country.

Quarterly TB review meetings are essential elements of a well-functioning NTP. The TB CARE I Country Director, TB CARE I M&E Officer and the NTP Head of M&E participated in the quarterly review meeting for Eastern Region for the purpose of assessing how the region conducts its review meetings. The TB CARE I team found that the review meeting mainly focused on PowerPoint presentations by district TB coordinators and no practical sessions were held to permit for validation of data presented. The NTP Manager tasked TB CARE I to draft a memo to be circulated to all the regions instructing them on how the TB review meetings should be conducted. One of the key features in the memo is ensuring TB coordinators bring key documents with them to each quarterly TB review meeting (i.e. TB Registers and quarterly case finding report forms and TB treatment outcome report forms to permit for data validation through register swaps). The review meetings will be used to build capacity in data management at the peripheral level.

TB CARE I played a vital role in supporting the NTP in reviewing and updating TB prevalence survey forms. The Ghana TB prevalence survey is scheduled to be launched in April 2012. The project also assisted with review of the new MDR-TB surveillance forms.

TB CARE I complements the resources that the NTP receives from GFATM and the delay in signing the Global Fund Round 10 Grant equally affected TB CARE I activities. The Round 10 was finally signed at the end of December 2011 and the first tranche of funds are awaited.

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 360, JATA (as of Year 2), MSH, The Union and WHO. TB CARE-Indonesia works in all eight technical areas. The project continued implementation of the Year 1 workplan during this quarter while awaiting Year 2 workplan approval (not yet approved).

During this quarter, 341 MDR-TB suspects were examined, 71 were confirmed as MDR-TB cases and 67 MDR-TB patients were put on treatment. Treatment support was provided to 296 new and existing patients within the quarter. Four new PMDT sites (Medan, Denpasar, Yogyakarta, and Bandung) were assessed and will be ready to start in the first quarter of 2012. The PMDT TWG met in Bogor to develop MDR-TB counseling and case management guidelines. A total of 46 participants from four provinces (West Java, North Sumatra, Bali and DIY)

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were trained on PMDT and they will be involved at the provincial and referral hospital level. A GeneXpert implementation plan was drafted. Initially, the machines will be placed in six sites. Training was conducted for 5 sites (Microbiology FM UI, RS Persahabatan Jakarta, RS Pengayoman Cipinang Jakarta, RS Hasan Sadikin Bandung, BLK Bandung) and attended by NTP, the Directorate of Medical Services (BPPM), and TB CARE I (22 participants). In a coordination meeting attended by NTP, BPPM, TB CARE I and other stakeholders, the GeneXpert algorithm for MDR-TB and TB-HIV suspects and the reporting and recording system were finalized. A geneXpert MoU between MoH and six GeneXpert sites was drafted for legal review.

Drug management stakeholder organizations for both public and private sector were mapped. New working partnerships were established with the GF coordinator, PMU & USAID. Linkages to be used for partnering on upcoming activities were created with related programs especially related to warehousing.

A meeting between the Indonesian Pharmacist Association (IPA) and NTP was conducted. This meeting resulted in (1) an agreement among IPA, NTP, and the Directorate General of Pharmaceutical and Medical Devices (Binfar) in TB control, (2) an action plan for IPA regarding the TB control program, and (3) the establishment of a network among stakeholders.

The sampling method and amount of TB drugs that will be used in quality assurance (QA) testing were defined. Drug sampling was done in seven sites and will be tested by the FDA in January 2012.

TB CARE I provided clinical and programmatic mentoring to prisons, narcotics prisons, and detention centers in DKI Jakarta, West Java, and East Java province. The mentoring conducted by FHI 360 (a local NGO, supports DKI Jakarta) involved the Provincial Office of Law and Human Rights, head of the prisons and prison health staff. Clinical mentoring was also conducted in Central Java, West Papua and Papua, and involved hospitals and health centers, which are designated as referral hospital for prisons in those provinces. (Photo: Clinical mentoring for prison staff in DKI Jakarta.)

An assessment was carried out in two provinces for PPM to identify challenges for PPM implementation and stakeholder involvement in priority areas. The assessment results were fundamental to the development of a PPM action plan and the establishment of a provincial PPM team as a basic management unit at the provincial level.

PMDT and PPM implementation were hampered due to several technical positions within TB CARE I being vacant. Efforts to speed up the recruitment process have been made. Timelines, deadlines and targets were set for human resource issues, including

hiring an experienced HR specialist.

The development of the Year 2 workplan and budget was very challenging, especially to coordinate with all partners in the absence of certain key project staff. More frequent partnership meetings, leadership and communication improvements between partners and the Mission were essential to address the challenges; all lesson learnt will be incorporated during Year 3 workplan development.

4.12 Kenya

KNCV is the lead partner in Kenya; the collaborating partners are ATS, FHI 360 and MSH, and subcontracts 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 UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E. As the Year 2 workplan was not approved until January 2012, the Year 1 workplan continued to a limited extent until December.

The Kenya Ministry of Public Health & Sanitation through the NTP and in collaboration with partners organized and hosted the Second International Scientific Lung Health Conference in Kenya in October. USAID and TB CARE I took part in the planning as members 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. USAID/TB CARE I-Kenya supported 313 local participants to attend the conference. In addition, 18 participants from Rwanda, Tanzania Uganda and Burundi (mainly from NTPs) were also able to attend thanks to core support from USAID-East Africa. During the conference other lung health diseases including non-communicable diseases and pneumonia were discussed within the platform of TB control.

A workshop on guideline development for poverty and gender was held and draft guidelines were developed. Three focus group discussions with patients, health workers and opinion leaders were conducted to provide more input to the guideline development.

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4.13 Mozambique

FHI 360, the lead partner for Mozambique, managed two separate TB CARE I workplans in Year 1: one for malaria activities, and one for TB activities. The TB workplan focuses on UA, laboratories, IC, PMDT, TB/HIV, HSS and drug management. FHI 360 works with collaborating partners KNCV, MSH and WHO on the TB workplan. The Year 1 workplans had a NCE through December.

TB workplan:During the reporting period, the final four sub-agreements for CB-DOTS implementation were signed with local implementing agencies. All 36 districts are covered with at least one local implementing partner responsible for providing CB-DOTS in one or more districts, reaching the target for Year 1. As a part of the start-up of TB CARE I, partners were oriented on the strategy and implementation of CB-DOTS management and participated in a series of trainings to improve early case detection, treatment, follow-up and contact tracing. A total of 1,821 volunteers, 48 health practitioners, 83 field officers and 107 traditional practitioners were trained in CB-DOTS management. In addition, 78 health staff were trained on slide fixation. (Photo: CB-DOTS volunteer supervising treatment in the community, Mafambisse, Sofala Province.) The project also provided technical assistance to implementing agencies in Gaza (AMODEFA and World Relief), Zambézia (AMODEFA) and in Niassa (ESTAMOS, AMIREMO, CISLAMO and ADC) to establish or improve their management systems, with particular emphasis on improving referral mechanisms between community volunteers and health facilities. Planning for Year 2 activities commenced with the identification of new districts to be covered and completion of baseline assessments. Nine new districts were selected; five of these districts are within Tete Province which is a new province to be covered by the TB CARE I program in Year 2. The remaining four are in Nampula and Zambezia Provinces. During the reporting period, two laboratory supervision visits were carried out in Gaza and Sofala provinces. Five districts were visited in each province by a joint TB CARE I and NTP team. The common problems identified included lack of a maintenance plan for laboratory equipment, lack of training in good laboratory practices and a need for a separate room dedicated to TB smear microscopy. A working group is compiling all findings from the supervision visits in order to suggest specific actions to address them, including improvement of supervision guidelines. This document will be discussed during a national laboratory meeting scheduled to take place between April-June 2012. A three-day PMDT Workshop was conducted in Namaacha where 40 health staff from the MoH, Maputo Central Hospital, Machava Hospital, TB CARE I, USAID and CDC participated; a draft PMDT national strategy was produced. Targets for key indicators were also defined. The contents of this document will be incorporated in the new TB national strategy to be developed in 2012 with TB CARE I support. In order to strengthen the development of the PMDT country strategies and to strengthen the capacity of the national team on PMDT related issues, an exchange visit to Namibia was conducted in November. The NTP from Mozambique, TB CARE I, National Reference Laboratory (NRL), CDC and Machava Hospital staff participated. During the visit, the team had the opportunity to interact and learn with their Namibian NTP counterparts and TB CARE I-Namibia as well as to make several site visits. The project also provided technical assistance for the revision of a training curricula for clinicians, which included issues related to TB, TB/HIV and MDR-TB. This curricula was used to train 67 health staff in Manica, Gaza and Zambézia Provinces. The project organized a workshop for the development of an ACSM expansion plan. The workshop was attended by MoH staff, civil society organizations, public health institutions, community and faith-based organizations and private institutions. At the end of the workshop, a logical framework was developed, which will be used during the development of the new TB strategic plan. Finally the project also made some progress with research activities. A review team composed of TB CARE I, NTP and the National Institutes of Health-Mozambique has been set up to review TB articles related to Mozambique published in the international literature. The review report will be completed during the next quarter. Renovation of health infrastructures (laboratories and TB corners) has proven to be a major challenge as the needs are huge compared to the available resources. Construction company selection and the need to ensure adequate supervision of renovation activities have also been time-consuming challenges. Malaria workplan:Data collection for the Antimalarial drug efficacy study started in June 2011 and the study included two arms: Arm

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1 (artemether-lumefantrine) and Arm 2 (artesunate-amodiaquine). For Arm 1, data collection has been completed in all sites. From the 2,587 children pre-selected, 364 children were successfully included. Due to logistical constraints, it was agreed that only three of the five sentinel sites would continue with recruitment of children for Arm 2. Data collection has been completed in two of the three sentinel sites. From the 2,154 pre-selected children, 214 completed the study and 28 are still in follow up. Data analysis will start next quarter and the report is due to be completed by June 2012. A dissemination workshop will be organized in July and publication of the results in a scientific journal will follow. The major challenge of implementing malaria drug efficacy studies is to choose the right timing to implement the study. A longer than expected recruitment period was observed in this study due to loss to follow-up during the economically busy rainy season and fewer malaria cases/recruits in the dry season.

Laboratory technicians were trained in malaria diagnosis including identification of species, biosafety, laboratory management, quality assurance and supervision. After a ToT (previous quarter), cascade training of provincial laboratory technicians was conducted between August and November. It was difficult to obtain accurate data on the number of laboratory technicians to be trained. The data sent by the Provincial Directorates of Health were consistently lower than the number of lab technicians found on the ground. In addition, there were insufficient laboratory materials (cell counters) and malaria reagents and consumables for the practical sessions. Overall, 1,072 laboratory technicians were trained. The total number of people trained (laboratory technicians and 65 trainers) corresponds to 94.7% of the 1200 laboratory staff existing in the country. (Photo: Lab technicians participating in a training post test.)

During this period, the three key NMCP documents (Malaria policy, Strategic Plan and M&E plan) were submitted to the MoH for approval. The printing and distribution of these documents will be carried out using Year 2 funds. 4.14 Namibia

KNCV is the lead partner and sole implementer in Namibia under TB CARE I. Activities are implemented in UA, IC, PMDT, TB/HIV, HSS and M&E. A NCE allowed the project to continued Year 1 activities through the end of December.

Due to unforeseen delays in disbursement of Global Fund 10 money, TB CARE I provided gap-filling financial support to three major community-based TB organizations (CoHeNa, Penduka and Health Unlimited).

A workshop to train national level staff as well as representatives from three regions of Oshana, Khomas and Erongo on the use of e-TB Manager software for the management of DR-TB patients was conducted in collaboration with MSH and the NTP. The initiative was funded by TB CARE I. MSH (non-TB CARE I funding) covered costs for the first training on the tool and a Technical Advisor’s visit to Namibia to set up the system at three pilot DR-TB sites. e-TB manager has proved to be a useful tool in capturing necessary DR-TB patient information and tracking patient care. In conjunction with I-TECH, TB CARE I supported and participated in the development of DR-TB curriculum for health care workers, as well as reviewed the existing TB training curriculum.

TB CARE I supported and participated in the quarterly TB National Steering Committee meeting (38 participants). TB CARE I also supported installation of project-procured UVGI lamps and equipment in the Oshakati and Rundu Hospital TB wards.

An Office of the U.S. Global AIDS Coordinator TB/HIV proposal, on which TB CARE I provided technical and financial support, was approved for funding. A team from OGAC visited Namibia during this quarter for further consultations and to refine the proposal/plan of action. The once-off, three-year, centrally funded OGAC project is planned to be allocated to USG implementing agencies, USAID and CDC. Based on the concept paper of the project, the fund will be used to consolidate TB/HIV collaborative activities in selected districts, focusing on the 3 I’s (Intensified Case Finding, IPT and IC), with the aim to serve as a demonstration project that can be replicated in other countries.

The project is working to improve the sub-optimal working relationship between the MoH and Ministry of Safety and Security (MoSS) on TB control in prisons and police detention centers. TB CARE I aims to strengthen the link between the public and private health care systems, including the referral of TB patients and the lack of coordination in training community health workers hired through local and international NGOs. The uncertainty over continued funding has resulted in low staff morale at the NTP (central and regional level) and some seasoned technical officers have resigned, thus the quality of services provided has been affected.

4.15 Nigeria

KNCV, the lead partner for Nigeria, works closely with collaborating partners, FHI 360, MSH and WHO. These partners are implementing two workplans: one for TB and the other for TB/HIV-funded activities through PEPFAR.

TB Workplan:The TB workplan focuses on UA, laboratories, PMDT, HSS and M&E. The Year 1 workplan was given a NCE through the end of December. An important achievement was that seven out of nine GeneXpert machines (including inverter systems) were installed in the selected health facilities. The health facilities were given 120 cartridges

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each to start testing. In addition all earlier developed training materials, SOPs and recording and reporting forms were printed and distributed to the facilities. The first data are currently being reported. During the quarter the USG Department of Defense (DoD) contacted TB CARE I to be briefed on the ongoing activities. The materials as developed under TB CARE I were shared for further use in the field. In addition the DoD will be invited to the next Country GeneXpert Advisory Team Meeting.

The Regional Kick-off Workshop for a Year 1 core project on Patient Centered Approach (PCA) was organized. Nineteen participants from Nigeria and Mozambique were in attendance. The Nigerian Country Team selected three tools from the PCA Package: the Quote Light Tool, the Patient Charter and the TB Costing Tool. A workplan and budget were prepared by the Country Teams. The next steps are finalizing the workplan and budget (to be included in Year 2 Country Plans), establishing a baseline analysis, submitting a proposal for ethical clearance and planning the follow up activities.

TB CARE I participated in the end term evaluation of the National TB & Leprosy Training Institute in Zaria in December. The team (consisting of staff from NTBLTC, Netherlands Leprosy Relief, KNCV and Ahmadu Bello University Zaria) visited the Training Institute and did a desk review, hospital/training institute tour and conducted a field visit to the Kaduna State TB Control Programme before a ‘Strategic Thinking Session’ was organized with different stakeholders. The end-term evaluation precedes the development of a new strategic plan for the training institute. The report is currently being finalized.

During the quarter, community TB care (CTBC) meetings were held in Udi, AMAC and Bauchi Local Government Areas. Major issues discussed during these meetings included the review of the CTBC activities for the month of October, the need for more advocacy and sensitization of the communities/stakeholders by the CVs/CBOs to create demand for and increase access to CTBC services, and motivation of the community volunteers. In addition, mentoring and supervisory visits held in the month of October in Udi and Bauchi LGAs where an emphasis was put on the need for up-to-date documentation in the CBO/CV registers by the engaged CBOs, and the CV/facility registers by facility staff in supported sites.

Significant progress was been made towards expansion of access to MDR-TB diagnosis and treatment as the Phase 1 for upgrade of the MDR-TB treatment centers at IDH, Kano was completed. The completed sections include the waiting room, consulting rooms, bathrooms, nurses’ station, pediatric ward, male ward, audiometer room, pharmacy, and the praying ground. In the same vein, contractors mobilized to the NIMR lab to commence renovation and upgrade to a BSL-3 lab. Sub-structure and framework demolition were completed, and external walls, casting, electrical installation, and plumbing works were also done. The 3-day advocacy, sensitization and orientation training for community and religious leaders as well as training of general health workers was conducted in 16 out of the 18 WHO USAID focus states during the quarter under reporting. A total of 388 community and religious leaders and 364 GHWs were orientated from 17 LGAs in 62 communities. The community and religious leaders who participated in the sensitization and orientation training include the pastors, Imams, market women, and the youth leaders.

The challenges Nigeria has faced during the quarter are of social unrest (including bombings), imposed state of emergencies and curfews. The project will discuss the pending activities with the NTP and ensure implementation of the outstanding activities in the coming quarter.

TB/HIV (COP) Workplan: The Year 1 TB/HIV workplan, which runs through June 2012, focuses on IC, PMDT, TB/HIV, HSS and M&E. The in-country ILEP partners have started renovating the remaining clinics to which they will expand TB/HIV collaborative activities. A budget was allocated within the OP workplan for the printing of the participants modules and facilitators guides for both the training on TB/HIV collaborative activities as well as training on HIV counseling and testing for DOTS staff. The printed documents were handed over to the NTP as well as ILEP partners.

There is a need for close collaboration with the National HIV/AIDS Program to ensure availability of HIV test kits. For future workplans (COP12) a back-up plan for the procurement of additional HIV test kits must be included. This back-up can ensure a continuous supply of test kits also to TB DOTS clinics. The USAID team is also looking at the shortage of test kits and the National TB/HIV Working Group will look into this recurrent problem again in January.

4.16 Pakistan

KNCV is the lead and sole implementer of TB CARE I activities in Pakistan. The Pakistan Year 1 workplan, which runs through March 2012, focuses solely on the National Prevalence Survey (M&E, OR and surveillance).

Completion of the survey field work in 95 country wide clusters by mid-December was the most significant achievement of the project. The field work was started in December 2010. This success is the result of a strong team effort and has been achieved despite challenges such as the security situation, floods, staff turnover, maintenance of equipment and ensuring functionality in difficult geographic terrain.

Timely completion of the data entry and its validation is a priority as well as a challenge. The survey management needs to keep to a strict timeline so that the files are ready for data analysis by the end of February 2012. This will

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enable the preparation of the first draft of the report, which is expected to be shared with the stakeholders in a national workshop by the end of March 2012. (Photo: The survey data management unit with TB CARE I data consultant, Nico Kalivaart.)

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 UA, laboratories, PMDT, TB/HIV and HSS. The Year 2 workplan was approved in mid-December so the quarter was spent completing Year 1 activities; Year 2 activities will begin in January 2012.

During the quarter, TB CARE I supported NTP in the printing of key documents developed in the previous quarters. Among the documents printed are 1,000 training manuals for clinicians, 500 SOPs for improving case detection and 500 copies of the 2010 annual report. The documents have been handed over to the NTP and distribution is in process. Training manuals will be used as resource material during the training of health workers. SOPs and posters for improving case detection will be distributed to the facilities during and after the piloting of the documents. The annual report has been distributed to key government departments and implementing partners. Development of Patient Centered Treatment Approach guidelines will be developed through a consultative process with key stakeholders and a consensus workshop to agree on the approach. TB CARE I has worked very closely with the NTP to identify facilities that required support to improve TB diagnosis in an integrated approach. Renovation of one laboratory was completed and handed over to the management of Torit Hospital. The laboratory was furnished with a table, a chair and two stools. TB lab services in Torit hospitals have been integrated in the refurbished laboratory. Follow up supervision by laboratory personnel at the NTP has been planned and this will be an opportunity to include the newly recruited Laboratory Specialist in the visit. Recruitment of the Lab Specialist was completed during the quarter and she will be starting working in January 2012. In addition, 20 laboratory personnel were trained as supervisors. Weak health systems and a lack of standardized laboratories have hindered the integration of services in South Sudan. TB CARE I supported NTP to refurbish three laboratories at primary health care centers (PHCCs) during the reporting period. Refurbishment has improved the general laboratory services in the PHCCs and TB lab services are provided in an integrated approach.TB/HIV services are limited in South Sudan due to lack of adequately trained staff on PITC. A five-day PITC training was organized and supported by TB CARE I to improve the testing and counseling skills of 17 health workers in the PHCCs. TB CARE I supported the NTP in the development of the Global Fund Round 11 proposal. The process was interrupted by the cancellation of R11 applications and the introduction of the transitional funding mechanism (TFM) for TB control. Cancellation of Global Fund R11 will have an impact because of lack of adequate funding to scale up TB services which can only be solicited from the Global Fund. TB CARE I and other donors are still committed to ensure that NTP develop a high-quality TFM proposal to be submitted to the Global Fund.

4.18 Vietnam

KNCV is the lead and sole implementer for TB CARE I activities in Vietnam. Year 1, which ran through December 2011, has activities in UA, laboratories, IC, PMDT, TB/HIV, HSS and M&E.

The Vietnamese NTP guidelines on the management of TB in children were reviewed by the NTP and a TB CARE I consultant. A proposal was made for the adjustment of the guidelines in line with the latest WHO recommendations to bring diagnosis from the provincial to the district level to be as close to the children’s home as possible. Training materials were developed and presented at a workshop in October that included representatives from NTP and four provinces for discussion and feedback. In November the scientific council of the NTP adopted the revised guideline for piloting in 2012. External consultants (laboratory bio-safety and microbiology) have provided technical support to the development of renovation proposals for five MDR-TB laboratories. Renovation proposals (designs and estimated costs) for the five MDR-TB laboratories were approved by local authorities/MoH according to Vietnamese construction regulations. Renovations began on three MDR-TB laboratories and MDR-TB treatment wards in late December and will be finished in the first quarter of 2012. Maintenance work for the laboratories and laboratory equipment has been carried out in six laboratories (NRL, K74, Hanoi, Da nang, PNTH and Can tho).

Two GeneXpert machines and 2,700 cartridges for Phase 1 were purchased with core funds through the WHO procurement mechanism in late December. Site assessments were conducted in six sites in K74 Hospital (1) and HCMC (5) in October. A workshop was organized in November to discuss and finalize the implementation plan, diagnostic algorithms, indicators for follow-up and operations research protocol.

Two additional workshops were organized on TB and TB investment awareness for parliament members from three social-economical regions (Red River Delta, Central High land and Central coast). Challenges and solutions for TB control activities in this area were discussed.

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A Cooperative Agreement was signed in September between the NTP and KNCV headquarters, formalizing the collaboration and implementation of the TB CARE I project. MoH still needs to endorse the TB CARE I MoU.

4.19 ZambiaFHI 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. Implementation of Year 1 activities continued through the quarter as the Year 2 workplan was approved in January 2012.

TB CARE I-Zambia prepared the Year 2 workplan to be in line with the National TB Strategic Plan 2011-2015, which was also being finalized during the quarter with technical input from TB CARE I. The project finalized plans for operationalization of the OR studies including developing activity timelines and budgets.

TB CARE I also provided funding support and participated in EQA support to 63 health facilities in the five target provinces. The project has included a plan for follow-up/feedback visits to be made to facilities that will require support to improve the quality of their microscopy services. A local architectural company was contracted to support the preparation of renovation drawings for the MDR-TB sites. (Photo: Ndola Central Hospital Nutritional Specialist, Mr. Nyati, inspecting stacks of peanut butter; food supplements procured for MDR-TB patients.)

TB CARE I has been awarded additional PEPFAR funds (core) to support a one year TB-IC demonstration site project in Ndola district, Copperbelt Province. The project is being coordinated by the PMU TB-IC Technical Advisor and the FHI 360 in-country team. TB CARE I has expanded its focus with additional

activities in the TB-IC Demonstration Project in Ndola District and planned implementation of the 3 Is. The project is also preparing a proposal for submission to the USAID mission for another funding opportunity to implement TB/HIV activities with PEPFAR funding under the 3Is initiative. The project plans to hire additional staff to support the new additional activities under the two new funding opportunities.

Zambia is currently not receiving Global Funds because of the cancellation of Round 11. The NTP is receiving most of the supplementary funding support from USAID and CDC partners.

4.20 Zimbabwe

Zimbabwe is led by The Union and has KNCV and WHO as collaborating partners. In Year 1, the project implemented activities in UA, PMDT, TB/HIV, HSS and M&E. The Year 2 workplan, which was approved in January 2012, has two new technical areas: laboratories and IC. In response to the January start for Year 2, a compressed annual schedule for the remaining nine months has been drafted after consultation with the NTP.

The Human Resources for Health Implementation Plan for TB Control (2012-2014) was developed this quarter. This followed a situation analysis and a three-day stakeholder’s workshop to discuss vision, strategies and main activities for HR strategy and the implementation plan.

Data verification was conducted in one district in each of the five provinces using funding from Year 1. The results showed that the quality of data varied extensively across the districts visited. A follow up meeting was held with all District TB Coordinators to discuss data collection, analysis and utilization at local level. Regular verification exercises will continue.

To improve TB patient treatment and support, 849 DOTS supporters in four of the five target provinces were mobilized to participate in community DOT and TB/HIV care work.

Two health workers were trained in advanced infection control in South Africa and two health workers underwent training in pediatric TB.

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5. Regional ProjectsIn addition to the aforementioned country and core programs, TB CARE I also manages five regional projects, three of which are continuations from work started under TB CAP; the other two are new projects: CAR (Year 1 funding) and the Kenya Lung Health Conference (Year 2 funding).

5.1 Center of Excellence (CoE) for PMDTThe CoE for PMDT project is implemented by KNCV. No major activities were done during the quarter; activities will begin once the Year 2 workplan is approved. The administration of CoE will be moved to the School of Public Health (SPH) once KNCV signs an MoU with SPH in Year 2.

5.2 East Africa Supranational Reference Laboratory (SNRL)The Union, the lead partner, works closely with KNCV/KIT on the SNRL project. The Year 2 workplan was not yet approved during the reporting period so activities were limited. The project discussed country links with the SNRL, other SNRLs, PMU and WHO Geneva. The South Africa SRL prefers to maintain their link with Zambia, while Rwanda prefers to continue with Antwerp as its SRL. Distance support was given for the preparation of a test and equipment validation guide and for an SRL business plan that will help the SRL to obtain a semi-autonomous status from the Uganda Government, which seems essential for financial sustainability. Remote support continued to be provided by KNCV/KIT.

5.3 ECSA (East, Central and Southern Africa)The ECSA project is conducted by KNCV. The Year 1 workplan continued implementation during the reporting period; the Year 2 workplan has not yet been approved. An ECSA team comprised of the Manager for M&E and Program Officer for HIV/AIDS & Infectious Diseases conducted a monitoring mission to Swaziland in October. The team documented the progress that has been made by Swaziland in implementing the ECSA Health Ministers Conference (HMC) resolutions. The team was also able to document some of the best practices Swaziland has employed in PMDT. The program officer presented these practices during the HMC that was held in November in Kenya. One country mission is pending, which will be carried forward to Year 2.

5.4 Central Asian Republic (CAR) Regional FundingIn addition to the three CAR country workplans, KNCV is the lead implementer of two regional CAR activities: a CAR/PMDT Workshop and a high level meeting on cross border TB control. There is currently only Year 1 funding for these small projects.

PMDT Workshop: The regional workshop was postponed until April 2012 to ensure facilitator and trainee participation. The draft agenda for the workshop was developed.

Cross border TB control meeting: The regional high level meeting on cross border TB control was conducted in Almaty in November. The Eurasian Economical Society and representatives of Ministries of Health, Internal Affairs, Labor and Social Affairs, Migration Police, NTPs, NGOs and international partners (USAID, IOM, Project HOPE, Project Quality, Dialogue, IFRC, UNDP) from Kazakhstan, Tajikistan, Uzbekistan and Kyrgyzstan participated in the meeting. Representatives of the migration service of the Russian Federation and a local NGO also took part. In total, 60 people participated. The meeting was conducted with technical assistance from WHO European Office experts. As a result of the meeting, participants worked out a Consensus Paper with suggestions on further steps related to TB in migrants in the CA region and the Russian Federation. The consensus paper will be finalized with a cover letter to send to CAR countries and the Russian Federation.