GABE BIENCZYCKI FOR PATH
USAID ERADICATE TB PROJECT QUARTERLY PROGRESS REPORT Reporting period: January 1 to March 31, 2019
Submission date: May 3, 2019
Submitted to: Submitted by: Dr. Nancy Kasese-Chanda Dr. Joseph Nikisi Contracting Officer Representative Chief of Party USAID Zambia USAID ETB Project Email: [email protected] Email: [email protected]
PROJECT SUMMARY
Program Name: Eradicate TB
Activity Start Date and May 26, 2017 to May 25, 2022 End Date:
Name of Prime PATH Implementing Partner:
Contract Number: Eradicate TB Activity _AID-611-C-17-00003
CITAM+, Afya Mzuri, African Society for Laboratory Medicines Names of Sub-partners (ASLM), Initiatives Inc., Zambart
Major Counterpart Ministry of Health/National Tuberculosis and Leprosy Program Organizations:
Copperbelt, Central, Northern, North-Western, Luapula, Geographic Coverage: Muchinga
Reporting Period: January 1, 2019 to March 31, 2019
TABLE OF CONTENTS
PROJECT SUMMARY 1 ABBREVIATIONS 4 EXECUTIVE SUMMARY 6 KEY ACHIEVEMENTS 6 INTRODUCTION 12 PROJECT OPERATION 12 PROJECT PARTNERSHIP ROLES AND RESPONSIBILITIES 12 TASK 1: PURSUE HIGH-QUALITY DIRECTLY OBSERVED THERAPY, SHORT- COURSE (DOTS) EXPANSION AND ENHANCEMENT. 13 SUB-TASK 1.1: PROVIDE AN ENABLING ENVIRONMENT FOR TB CONTROL EFFORTS. 15 1.1.3. CONVENE AN ORIENTATION MEETING FOR THE ZAMBIA PARLIAMENTARY CAUCUS ON TB. 15 1.1.5. ENGAGE PRIVATE MEDICAL PRACTITIONERS AND PHARMACIES. ERROR! BOOKMARK NOT DEFINED. 1.1.6. STRENGTHEN TB LEADERSHIP AND MANAGEMENT TO IMPROVE COORDINATION OF TB SERVICES AND INTERVENTIONS. 16 1.1.7. BUILD CAPACITY FOR INCREASED TB AWARENESS AND COMMUNITY-BASED FINDING AND TREATMENT SUPPORT IN COMMUNITIES. 16 SUB-TASK 1.2: INCREASE TB CASE DETECTION THROUGH IMPROVED DIAGNOSTICS. 17 1.2.1. QUALITY-ASSURE DIAGNOSTIC SERVICES THROUGH GENEXPERT®. 17 1.2.3. PROVIDE TECHNICAL ASSISTANCE FOR QUALITY ASSURANCE. 18 1.2.4. IMPLEMENT INNOVATIVE LABORATORY MENTORING PROGRAM. 18 1.2.5. STRENGTHEN THE LABORATORY SPECIMEN COURIER SYSTEM. 19 1.2.6. PROVIDE TECHNICAL ASSISTANCE TO THE NTRL TO STRENGTHEN ITS CAPACITY TO PROCESS SPECIMENS (ESPECIALLY TO DIAGNOSE DR-TB). 21 1.2.7. PROCURE LABORATORY SUPPLIES AND EQUIMENT. 21 SUB-TASK 1.3. STANDARDIZE TB TREATMENT, SUPPORT, AND CARE. 21 1.3.1. SUPPORT THE UPDATING, PRINTING, AND DISSEMINATION OF TB TREATMENT GUIDELINES. 21 1.3.3. TRAIN CBVS TO SUPPORT PATIENTS RECEIVING TREATMENT. 21 1.3.4. INCREASE TB CASE DETECTION THROUGH ACTIVE TB CASE FINDING. 22 SUB-TASK 1.4. SUPPORT THE EXISTING NTLP MONITORING AND EVALUATION (M&E) SYSTEMS. 22 1.4.2. COLLECT AND REPORT TB, DR-TB, TB/HIV, AND COMMUNITY DATA. 22 1.4.3. STRENGTHEN THE HEALTH MANAGEMENT INFORMATION SYSTEM. 24 ETB’S PROJECT DATABASE 24 ETB’S DATA COLLECTION INSTRUMENT 24 MOH SHIFT TO DHIS2 24 NATIONAL TRAINING DATABASE 24 1.4.5. PARTICIPATE IN ACTIVITIES THAT SHARE PROJECT EXPERIENCES AND FACILITATE LEARNING. 25 TASK 2. INCREASE ACCESS TO TB/HIV AND DR-TB SERVICES FOR POOR AND VULNERABLE POPULATIONS IN TARGET PROVINCES. 25 SUB-TASK 2.1. REDUCE THE BURDEN OF TB/HIV COMORBIDITY. 25 2.1.1. SUPPORT PROVISION OF TPT. 25 2.1.2. SUPPORT ICF IN PLHIV AND HIV SCREENING IN TB PATIENTS. 25
USAID.GOV USAID ERADICATE TB PROJECT | 2 2.1.4. PROVIDE TECHNICAL AND ADMINISTRATIVE SUPPORT. 26 SUB-TASK 2.2. STRENGTHEN SYSTEMS TO HALT DR-TB EXPANSION. 26 2.2.1. BUILD HCW CAPACITY IN DIAGNOSIS AND CLINICAL MANAGEMENT OF MDR-TB.26 SUB-TASK 2.3. INCREASE TB DETECTION AND TREATMENT AMONG CHILDREN AND PREGNANT WOMEN. 27 2.3.1. STRENGTHEN CHILDHOOD TB MANAGEMENT. 27 2.3.2. CONDUCT CHILDHOOD TB SCREENING. 27 SUB-TASK 2.4. PROVIDE SUPPORT TO INCREASE TB DETECTION AND TREATMENT AMONG PRISONERS. 27 2.4.1. SUPPORT CAPACITY-BUILDING. 27 2.4.2. SUPPORT TB SCREENING AMONG INMATES. 28 2.4.3. COORDINATE PARTNERS WORKING WITH ZCS. 32 TASK 3. ENGAGE ALL CATEGORIES OF CARE PROVIDERS. 33 SUB-TASK 3.1. ENGAGE TRADITIONAL PROVIDERS. 33 SUB-TASK 3.2. IMPROVE CBV ENGAGEMENT IN TB CASE FINDING AND TREATMENT SUPPORT. 33 TASK 4. INTENSIFIED RESEARCH AND INNOVATION. 33 SUB-TASK 4.1. BUILD CAPACITY IN OR AND ESTABLISH NATIONAL TB OR PRIORITIES. 33 4.1.5. DISSEMINATE OR FINDINGS. 34 4.1.6. SUPPORT QUARTERLY MEETINGS FOR THE OR SUBCOMMITTEE OF THE TB TWG. ERROR! BOOKMARK NOT DEFINED. 4.2. DEVELOP STRATEGIC PARTNERSHIPS FOR OR. 34 FINANCE AND ADMINISTRATION 35 CHALLENGES 35 LESSONS LEARNED 35 PLANNED ACTIVITIES FOR FY19 Q3. 36 TASK 1. PURSUE HIGH-QUALITY DOTS EXPANSION AND ENHANCEMENT. ERROR! BOOKMARK NOT DEFINED. SUB-TASK 1.1. PROVIDE AN ENABLING ENVIRONMENT FOR TB CONTROL EFFORTS. ERROR! BOOKMARK NOT DEFINED. SUB-TASK 1.2: SCALE UP QUALITY-ASSURED DIAGNOSTIC SERVICES THROUGH GENEXPERT®. ERROR! BOOKMARK NOT DEFINED. SUB-TASK 1.3. STANDARDIZE TB TREATMENT, SUPPORT, AND CARE. ERROR! BOOKMARK NOT DEFINED. SUB-TASK 1.4. SUPPORT THE EXISTING NTLP M&E SYSTEMS. ERROR! BOOKMARK NOT DEFINED. TASK 2. INCREASE ACCESS TO TB–HIV AND MDR-TB SERVICES FOR POOR AND VULNERABLE POPULATIONS IN TARGET PROVINCES.ERROR! BOOKMARK NOT DEFINED. SUB -TASK 2.3. INCREASE TB DETECTED AND TREATED AMONG CHILDREN AND OTHER VULNERABLE GROUPS. ERROR! BOOKMARK NOT DEFINED. TASK 3. ENGAGE ALL CATEGORIES OF CARE PROVIDERS. ERROR! BOOKMARK NOT DEFINED. SUB-TASK 3.4. IMPROVE CBV ENGAGEMENT. ERROR! BOOKMARK NOT DEFINED. TASK 4. INTENSIFIED RESEARCH AND INNOVATION ERROR! BOOKMARK NOT DEFINED.
3 | USAID ERADICATE TB PROJECT USAID.GOV
USAID.GOV USAID ERADICATE TB PROJECT | 4 ABBREVIATIONS AIDS acquired immune deficiency syndrome ART antiretroviral therapy ASLM African Society for Laboratory Medicine CBV community-based volunteer CDL Chest Diseases Laboratory CIDRZ Centre for Infectious Disease Research in Zambia CITAM+ Community Initiative for Tuberculosis, HIV/AIDS, Malaria plus related diseases DATIM Data for Accountability, Transparency, and Impact Monitoring DHIS2 District Health Information System 2 DHO district health office DISCOVER-Health District Coverage of Health Services Project DOT directly observed therapy DOTS directly observed therapy, short course DQA data quality assessment DR-TB drug-resistant tuberculosis DTLC district tuberculosis and leprosy coordinator EQA external quality assessment ETB Eradicate Tuberculosis Project FM fluorescent microscopy FY Fiscal Year GRZ Government of the Republic of Zambia HCW health care worker HIV human immunodeficiency virus ICF intensified case finding IPT isoniazid preventive therapy M&E monitoring and evaluation MCH maternal and child health MDR-TB multidrug-resistant tuberculosis MOH Ministry of Health MP Member of Parliament MPH Master of Public Health NHRA National Health Research Authority NSP National Strategic Plan for Tuberculosis Prevention, Care, and Control, 2017–2021 NTLP National Tuberculosis and Leprosy Program NTRL National Tuberculosis Reference Laboratory OPD outpatient department
5 | USAID ERADICATE TB PROJECT USAID.GOV OR operational research PEPFAR United States President’s Emergency Plan for AIDS Relief PLTFU primary loss to follow-up PY project year Q quarter RIF rifampicin RR rifampicin-resistant RR-TB rifampicin-resistant tuberculosis SAFE Supporting an AIDS-Free Era SOP standard operating procedure TB tuberculosis TSS technical supportive supervision TWG technical working group UNZA University of Zambia UNZA-SPH University of Zambia School of Public Health USAID United States Agency for International Development ZAMBART Zambia AIDS Related Tuberculosis Project ZCS Zambia Correctional Service ZPA Zambia Pediatric Association
USAID.GOV USAID ERADICATE TB PROJECT | 6 EXECUTIVE SUMMARY The United States Agency for International Development (USAID) Eradicate Tuberculosis (ETB) Project is pleased to share the Fiscal Year (FY) 2019 Quarter (Q) 2 Performance Report covering the period January 1 through March 31, 2019. Data presented in this report were collected from all facilities in 60 districts from the six project-supported provinces. This includes data from three additional new districts which originated from the 60 districts noted above; the data from the three new districts are reported under the districts from where they originated. Key achievements for this reporting quarter are highlighted below; these and additional achievements are described in further detail in the body of the report.
KEY ACHIEVEMENTS During FY19 Q2, ETB-supported provinces notified 3,753 tuberculosis (TB) patients, constituting a 74% achievement against the quarterly target of 5,103 (Figure 1Error! Reference source not found.). This includes 3,331 TB notifications from 35 directly-supported districts. Of the 3,331 TB patients notified by ETB-supported districts, 2,201 (66%) were male and 1,130 (34%) were female. This marked improvement of 12 percentage points against the quarterly notification target between FY19 Q1 and Q2 may be attributed to improved diagnostic support (GeneXpert® machines and cartridges), enhanced health care worker (HCW) training in TB management, technical support and mentorship provided by ETB to the project-supported provinces, and the focused intensified case finding (ICF) activities that the project supported at facility and community levels.
Figure 1. TB notifications by quarter from 60 ETB-supported districts, January 2018 to March 2019.
6,000
5,000 5,103 5,103
4,603 4,603 4,603 4,000
3,753 3,000 (74%) 3,110 3,184 2,854 2,863 (68%) (62%) (62%) (62%) 2,000
1,000
0 (Jan 18—March 18) (Apr 18—Jun 18) (Jul 18—Sep 18) (Oct 18—Dec 18) (Jan 19—March 19)
Target No. of cases notified
During the reporting period, Copperbelt province notified the highest number of TB patients (1,729 notifications), and Central province notified the second-highest number of TB patients (510 notifications). These two provinces account for 60% of the total TB notifications from ETB- supported provinces. The National Tuberculosis and Leprosy Program (NTLP) declared the month of March 2019 as a period to intensify case finding activities; ETB played an active role in TB awareness-raising campaigns and TB screening activities in order to find the missing patients.
ETB continues to monitor closely the proportion of TB patients notified who are children. During the reporting period, 227 TB notifications were among children, an increase from 184 in the previous quarter (Figure 2Figure 2). ETB continues to engage the Zambia Pediatric Association
7 | USAID ERADICATE TB PROJECT USAID.GOV (ZPA) to train and provide mentorship to clinicians in order to improve their skills in childhood TB diagnosis and management. To further improve childhood TB detection, ETB will support facilities to conduct TB screening in outpatient and maternal and child health (MCH) departments, which will also include TB screening during MCH outreach activities.
Figure 2. TB case notifications among children from 60 districts in the ETB-supported provinces, January to March 2019. 4,000
3,500
3,000
2,500
2,000
1,500
1,000
500 6% 5% 6% 6% 0 (Apr 18—Jun 18) (Jul 18—Sep 18) (Oct 18—Dec 18) (Jan 19—March 19) No. of cases notified 2,863 3,110 3,184 3,753 No. of children notified 174 148 184 227 No. of cases notified No. of children notified
In January 2019, ETB introduced monitoring tools that track TB notifications by TB type. Figure 3 depicts the breakdown of the 3,753 TB patients notified by TB type. In FY19 Q2, of the 3,753 total TB patients notified, 60% (2,258) were bacteriologically confirmed pulmonary TB patients, 3% (94) were bacteriologically confirmed extra pulmonary TB patients, 9% (341) were clinically diagnosed extra pulmonary TB patients, and 28% (1,060) were clinically diagnosed pulmonary TB patients.
Figure 3. TB notifications by type, January to March 2019.
EPTB patients EPTB patients clinically diagnosed, bacteriologically 341 , 9% confirmed, 94 , 3%
PTB patients PTB patients clinically diagnosed, bacteriologically 1,060 , 28% confirmed, 2,258 , 60%
During the reporting period, 31,564 individuals were tested in the laboratory (Error! Reference source not found.). Of the 31,564 patients tested in the laboratory, 9% (2,458) were bacteriologically confirmed. Of key significance is the improvement in the proportion of bacteriologically confirmed patients initiated on treatment, from 75% in FY19 Q1 to 91% in FY19 Q2. This improvement is linked to the ETB-driven mop-up exercise conducted in February 2019, which focused on identifying and linking to care all confirmed TB patients. Of important note is that although 31,564 patients were tested for TB in the laboratory, only 20,834 presumptive TB patients
USAID.GOV USAID ERADICATE TB PROJECT | 8 were recorded in the presumptive TB registers. Based on findings from field work and data quality assessments (DQAs), this discrepancy between the number of presumptive TB patients recorded and the number of individuals tested in the laboratory is due to poor documentation in the presumptive TB registers. To address the poor patient documentation in the presumptive registers, ETB continues to orient and mentor facility staff on the importance of documenting patient details in the presumptive registers. ETB is also facilitating the provision of presumptive registers in every consultation room at project-supported facilities.
Figure 4. Laboratory TB testing cascade, January to March 2019. 30,000 27,409
25,000
20,000
14,985 15,000
10,000
5,000 9%, 91%, 2,458 2,458 2,245
- No. of individuals tested for TB in No. of individuals bacteriologiclly No. of bacteriologically confirmed the lab confirmed initiated on treatment Target (Jan —March 2019) 14,985 2,458 Performance (Jan—March 2019) 27,409 2,458 2,245
The project recorded a low positivity rate, 9%, among presumptive TB patients tested in the laboratory. This may be attributed to poor selection of presumptive TB patients by HCWs and community-based volunteers (CBVs) during ICF activities and poor quality of sputum specimens collected. Moving forward, ETB will re-orient HCWs and CBVs on the use of the screening tool and effective selection strategies for presumptive TB patients, as well as to employ correct sputum- collection techniques.
ETB observed an increase of 569 TB notifications from the 60 districts in the six project-supported provinces, from 3,184 notifications in FY19 Q1 to 3,753 notifications in FY19 Q2 (Figure 5). ETB also recorded a slight increase in the number of bacteriologically confirmed TB patients, from 2,208 in the previous quarter to 2,245 during the reporting period. However, the proportion of TB notifications that were bacteriologically confirmed has decreased, from 69% in FY19 Q1 to 60% in Q2. To address this, ETB will continue to mentor CBVs and HCWs on selection of presumptive TB patients.
9 | USAID ERADICATE TB PROJECT USAID.GOV Figure 5. TB notifications versus bacteriologically confirmed patients, January to March 2019.
4,000 3,753 3,500 3,110 3,184 3,000 2,863 2,592 2,500 2,337 2,208 2,245 2,000
1,500
1,000
500
- (Apr 18—Jun 18) (Jul 18—Sep 18) (Oct 18—Dec 18) (Jan 19—March 19)
No. of notified TB cases (All forms) Bacteriologically confirmed cases
ETB-supported provinces recorded an increase in treatment success rates from 81% in FY19 Q1 to 85.3% in FY19 Q2 (Figure 6Error! Reference source not found.). To improve treatment success across project-supported provinces, ETB is supporting systematic implementation of directly observed therapy (DOT) through CBVs (community DOT) and HCWs (facility-based DOT). Through technical supportive supervision (TSS) and mentorship, ETB will support HCWs to monitor closely all patients due for periodic sputum examination.
Figure 6. TB treatment success rates (%), April 2018 to March 2019.
95
90 90 90 90 90 85 85.3 80 81 79 75 77
70 (Apr 18—Jun 18) (Jul 18—Sep 18) (Oct 18—Dec 18) (Jan 19—March 19) Target Treatment success rate
Figure 7 depicts treatment success performance by province. Northern Province surpassed the set target of 90% and achieved 93% treatment success, while North-Western province saw the lowest treatment success rate of the six provinces (79%). The higher treatment outcomes in Northern province could be attributed to the fact that the province has been consistently tracking the bacteriologically confirmed patients such that they have managed to significantly reduce unfavorable outcomes to as low as 7%. Following the mop-up exercise ETB conducted in FY19 Q2 and moving forward, ETB is tracking all patients detected and initiated on treatment in all project-supported provinces.
USAID.GOV USAID ERADICATE TB PROJECT | 10 Figure 7. TB treatment success rates by province, January to March 2019.
100 90 9 80 16 13 15 70 21 21 60 50 40 84 71 66 74 30 59 58 20 10 0 North- Central Copperbelt Luapula Muchinga Northern Western Completed % 16 15 13 21 9 21 Cured % 71 66 74 59 84 58 Target % 90 90 90 90 90 90
Generally, the project has noticed a decline in most of the unfavorable TB treatment outcomes, namely treatment failure, lost to follow-up, and not evaluated (Figure 8Error! Reference source not found.). However, the mortality rate among TB patients increased from 3.8% in FY19 Q1 to 4.4% in FY19 Q2 (The highest contributor is Muchinga at 10.7% followed by Central province at 6.9%). In FY19 Q3, ETB will increase community awareness of TB to facilitate early presentation of patients at health facility points for early diagnosis and treatment to reduce TB-related mortality. Additionally, the project will support the NTLP to increase linkage to community care and support for identified TB patients. ETB will support activities including treatment monitoring and counseling for patients and their immediate families.
Figure 8. Unfavorable TB outcomes, April 2018 to March 2019.
10 9 8 7 6 5 4 3 2 1 0 (Apr 18—Jun 18) (Jul 18—Sep 18) (Oct 18—Dec 18) (Jan 19—March 19) Treatment failure % 0.6 1.6 2.9 1.35 Lost to follow-up % 7.5 6.2 6 4.85 Not evaluated % 9.2 8 7.5 4.20 Died % 3.9 4.5 3.8 4.40
ETB has maintained HIV testing rates among TB patients of 90% and higher in the last two reporting quarters (Figure 9Error! Reference source not found.). These results may be attributed to the positive synergies that the project has forged with other USAID-supported implementing partners such as EQUIP and Supporting an AIDS-Free Era (SAFE). However, ETB noted a slight decrease in antiretroviral therapy (ART) uptake among TB/HIV co-infected patients, from 100% in FY19 Q1 to 98% in FY19 Q2. ETB will continue to support TSS and mentorship activities in all project-supported facilities in partnership with other USAID implementing partners for improved HIV documentation.
11 | USAID ERADICATE TB PROJECT USAID.GOV Figure 9. TB/HIV coinfection indicators, April 2018 to March 2019.
4,000 3,753 90%, 3,500 3,184 3,389 3,110 92%, 2,863 95% 2,918 3,000 2,723 82%, 2,537 2,500 45%, 47%, 2,000 51%, 50%, 1,517 93%, 1,381 100% 98% 1,379 1,281 1,280 99%, 1,386 1,481 1,500 1,270
1,000
500
0 (Apr 18—Jun 18) (Jul 18—Sep 18) (Oct 18—Dec 18) (Jan 19—March 19) No. of notified TB cases (All forms) No. of registered TB patients (All forms) tested for HIV
No. of TB/HIV co-infected patients No. of TB/HIV co-infected patients on ART
Note: ART, antiretroviral therapy; TB, tuberculosis. In FY19 Q2, ETB-supported provinces reported 40 rifampicin-resistant (RR) TB patients, and 37 (93%) were initiated on second-line TB treatment (Figure 10). The three individuals not initiated on treatment during Q2 are from North-Western province. Two of these patients have been identified as DR-TB treatment defaulters who had started second-line treatment in Lusaka but stopped taking their treatment; their samples have been sent for culture and drug-susceptibility testing. The remaining patient was traced and found that he died. This performance of 93% treatment initiation rate is a significant improvement compared to last quarter’s rate of 70%. This improved performance may be attributed to strategies ETB employed, including weekly, monthly, and quarterly reporting of RR detection and treatment initiation. With the exception of the 12 individuals with drug-resistant tuberculosis (DR-TB) from Copperbelt who were not initiated on treatment and are still being traced, the remainder of the DR-TB patients diagnosed in Q1 were found and linked to treatment.
Figure 10. Drug-resistant TB patients detected and initiated on second-line treatment. 100 91 90
80
70 64
60
50 40 40 37
30
20
10
0 (Oct 18—Dec 18) (Jan 19—March 19) No. RR detected 91 40 No. RR initiated on treatment 64 37
Note:USAID.GOV RR, rifampicin -resistant. USAID ERADICATE TB PROJECT | 12 INTRODUCTION USAID’s ETB project works in partnership with the Government of the Republic of Zambia (GRZ), the NTLP, the private sector, and other partners at the community, facility, district, provincial, and national levels to strengthen the implementation of key components of the GRZ’s response to control TB across Zambia. This report outlines activities conducted from January 1, 2019 through March 31, 2019. The project’s goal is to reduce TB-related mortality by 50% (from 2016 figures as baseline) in the intervention provinces by 2022. Specifically, the activity aims to achieve the following two objectives:
1. Increase the number of individuals screened for TB in the target provinces by 50% (from 2016 figures), thereby increasing the number of people diagnosed with TB. 2. Increase the TB treatment success rate to 85% and beyond in the target provinces.
PROJECT OPERATION ETB works in six provinces: Central, Copperbelt, Luapula, Muchinga, Northern, and North-Western, as well as at the national level to strengthen components of the GRZ’s response toward TB elimination by 2030. The project’s support is aligned with the global End TB Strategy and Zambia’s National Strategic Plan for Tuberculosis Prevention, Care, and Control, 2017–2021 (NSP).
At the national level, ETB supports financial and technical capacities to strengthen the following key focus areas: laboratory supervision, national surveillance systems, TB/HIV coinfection activities, and development of TB guidelines. At the provincial, district, facility, and community levels, the project focuses on joint strategic planning, laboratory strengthening, HCW training, infection control promotion, supply procurement and provision, TB specimen transportation, HCW supervision, community based volunteers (CBVs) training, awareness creation and treatment support.
PROJECT PARTNERSHIP ROLES AND RESPONSIBILITIES The ETB consortium consists of six organizations, led by PATH. PATH’s subcontracting partners are Afya Mzuri; African Society for Laboratory Medicine (ASLM); Community Initiative for Tuberculosis, HIV/AIDS, and Malaria plus related diseases (CITAM+); Initiatives, Inc., and the Zambia AIDS Related Tuberculosis Project (ZAMBART). The roles and responsibilities of each organization are summarized in TABLE 1 below.
TABLE 1. ETB PARTNERS AND ROLES.
PARTNER ROLE
Provides overall management, financial, and technical oversight in addition to M&E and strategic PATH information support. Moreover, PATH leads corporate engagement, gender-related, public-private mix, DR-TB, TB/HIV coinfection, and pediatric TB capacity-building activities.
Afya Mzuri Responsible for community TB training, mobilization, and awareness-raising activities, and community- level case finding and treatment support.
Responsible for increasing TB case detection through quality-assured microscopy and other diagnostic ASLM methods. ASLM also provides technical assistance to the NTRL to strengthen its capacity to process specimens and improve turnaround time.
Responsible for advocacy and activities aimed at increasing financing for TB control efforts from the CITAM+ GRZ, private sector, and international organizations. CITAM+ also implements capacity-building activities for community organizations and groups for treatment literacy and awareness.
Responsible for supporting the NTLP at all levels to strengthen human resources management and Initiatives, Inc. performance through improved coordination of training and strengthened supportive supervision.
13 | USAID ERADICATE TB PROJECT USAID.GOV Promotes research to optimize implementation, impact, and innovation through training and ZAMBART mentoring staff in operational research. ZAMBART also leverages TB research for strategic partnerships with the private sector, the GRZ, and Zambian research institutions.
Abbreviations: ASLM, African Society for Laboratory Medicine; CITAM+, Community Initiative for Tuberculosis, HIV/AIDS, and Malaria plus related diseases; DR-TB, drug resistant tuberculosis; GRZ, Government of the Republic of Zambia; M&E, monitoring and evaluation; NTLP, National Tuberculosis and Leprosy Program; NTRL, National Tuberculosis Research Laboratory; TB, tuberculosis; ZAMBART, Zambia AIDS Related Tuberculosis Project.
TASK 1: PURSUE HIGH-QUALITY DIRECTLY OBSERVED THERAPY, SHORT-COURSE (DOTS) EXPANSION AND ENHANCEMENT. MOP-UP EXERCISE ON PRIMARY LOST-TO-FOLLOW-UP INDVIDUALS CONFIRMED BUT NOT INITIATED ON TB TREATMENT Following the FY19 Q1 report that showed 25% pretreatment loss to follow-up, ETB conducted a patient-tracking and linkage-to-care exercise to verify, track, and link to treatment the reported primary loss to follow-up (PLTFU) individuals. This exercise took place in 75 facilities which, according to the report, had shown 818 PLTFU patients out of the 1,626 bacteriologically confirmed patients and the 808 patients initiated on treatment during the same period, representing a 50% treatment-initiation rate. The exercise was implemented using a mixed-design approach involving document reviews, phone calls, and discussions with facility staff, TB treatment supporters, and village leaders to locate missing patients using their details documented in the facility registers.
Exercise findings revealed two major discrepancies that caused the rate of pretreatment loss to follow-up to appear higher than the true rate. First, ETB verified the actual number of bacteriologically confirmed patients to be 1,446 (180 fewer than originally reported). Second, ETB verified the actual number of bacteriologically confirmed patients to be 1,101 (345 higher than originally reported). The verified number of PLTFU patients was therefore 293 (significantly fewer than the 818 originally reported). ETB subsequently followed up with the verified PLTFU individuals in the health facilities and communities. Through the follow-up process, ETB found that 13 patients had died, and the remaining 280 patients are still being traced. This exercise revealed the following contributing factors to the issues related to tracking PLTFU patients:
• Incomplete patient information on the presumptive registers, laboratory registers, and request forms. • Patients providing incorrect addresses to HCWs. • Facility staff not indicating patients’ phone numbers in the presumptive registers to facilitate active follow-up in the event that patients are bacteriologically confirmed with TB • Facility staff not conducting routine tracking and follow-up with confirmed TB patients in the community • Poor linkages between inpatient wards and TB clinics, between inpatient wards and referring peripheral health facilities, and between referring peripheral health facilities and laboratory hubs. • Poor filing systems for patients in outpatient departments (OPDs) and wards at three major hospitals: Kabwe, Ndola, and Kitwe.
TABLE 2 summarizes quantitative findings from the mop-up exercise.
USAID.GOV USAID ERADICATE TB PROJECT | 14
TABLE 2. SUMMARY OF MOP-UP EXERCISE RESULTS. REPORTED IN VERIFIED USING STATUS OF DIFFERENCE: VERIFIED MINUS REPORTED FACILITIES DATABASE SOURCE DOCUMENTS PLTFU DISTRICT SAMPLED Still being Confirmed Initiated PLTFU Confirmed Initiated PLTFU Dead Confirmed Initiated PLTFU traced Kapiri-Mposhi 1 51 39 12 30 27 3 1 2 -21 -12 -9 Serenje 1 28 22 6 24 23 1 1 -4 1 -5 Kabwe 11 219 121 98 155 136 19 19 -64 15 -79 Kitwe 9 286 79 207 280 210 70 8 62 -6 131 -137 Kalulushi 3 60 34 26 53 48 5 1 4 -7 14 -21 Lufwanyama 2 8 7 1 8 8 0 0 1 -1 Ndola 10 346 137 209 346 258 88 88 0 121 -121 Samfya 1 3 1 2 3 3 0 0 2 -2 Mbala 1 16 12 4 16 15 1 1 0 3 -3 Chingola 4 126 69 57 143 118 25 25 17 49 -32 Chilibombwe 2 46 29 17 46 39 7 7 0 10 -10 Mufulira 2 69 30 39 55 46 9 9 -14 16 -30 Nakonde 2 56 28 28 28 19 9 9 -28 -9 -19 Mpika 2 46 19 27 27 19 8 8 -19 0 -19 Mpulungu 1 22 4 18 20 16 4 4 -2 12 -14 Chinsali 3 26 18 8 16 16 0 -10 -2 -8 Isoka 1 25 17 8 8 8 0 -17 -9 -8 Kalumbila 4 24 14 10 21 14 7 1 6 -3 0 -3 Mushindamo 1 9 9 0 7 7 0 -2 -2 0 Mwinilunga 3 18 12 6 20 16 4 4 2 4 -2 Solwezi 11 142 107 35 140 107 33 2 31 -2 0 -2 TOTAL 75 1626 808 818 1,446 1,153 293 13 280 -180 345 -525 Note: PLTFU, primary loss to follow-up.
15 | USAID ERADICATE TB PROJECT USAID.GOV To address challenges identified during the mop-up exercise, the Ministry of Health (MOH) and its implementing partners—including ETB—will embark on the following immediate remedial activities:
• Provide immediate, intensive, on-site, focused technical support and mentorship to clinicians, laboratory staff, and nursing staff on TB management, recording, and reporting • Develop data flow charts, standard operating procedure manuals, and mentorship sessions that guide how communication systems can be strengthened among hospital OPDs, wards, laboratory hubs, and referring peripheral health facilities • The MOH will re-establish TB-focused service delivery points at hospitals and appoint dedicated hospital TB focal point persons to routinely coordinate with the districts and referring peripheral facilities. In hospitals that do not have a dedicated TB focal point person, in Q3 of FY19, ETB will support the NTLP to identify and orient these focal point persons. • Improve filing system of patient records by mentoring and orienting facility staff and ensuring that health facilities secure patient records in the provided box files and lockable cabinets. • Place presumptive TB registers in all key service-delivery points, such as OPDs, maternal and child health wards, and medical wards, and provide on-site orientation to HCWs. • Integration of HIV viral load/ early infant diagnosis and TB sample courier systems
SUB-TASK 1.1: PROVIDE AN ENABLING ENVIRONMENT FOR TB CONTROL EFFORTS.
1.1.3. CONVENE AN ORIENTATION MEETING FOR THE ZAMBIA PARLIAMENTARY CAUCUS ON TB. On February 21, 2019, ETB and the NTLP convened and participated in a TB orientation meeting for 120 Members of Parliament (MPs). The meeting’s main objective was to ensure that MPs have an enhanced TB knowledge base to enable them to engage in government, donor, and private-sector resource-mobilization activities to increase funding for TB prevention, care, and control activities. The meeting also served as a buy-in platform for MPs to support and participate in community-level TB control efforts. Influential political leaders and key stakeholders—the First Deputy Speaker of the National Assembly, the Deputy Clerk for Administration, the Minister of Health, the TB Caucus Interim Chairperson, 120 MPs, the Permanent Secretary of Technical Services under the MOH, and representatives from the NTLP, ETB, USAID, and the media—attended the meeting. Notably, the MPs committed to support the national strategy to eliminate TB, champion the fight against TB, and help reduce stigma associated with TB and HIV. All MPs pledged to play a key role in building partnerships and mobilizing resources for the fight against TB at constituency and community levels.
Moving forward, MPs are expected to actively support TB prevention, care, and control activities at all levels. In partnership with stakeholders working on TB, the MPs are also expected to advocate to the government, the private sector, and international organizations for increased investment of resources for TB. Zambian MPs are expected to prioritize TB in their budgetary allocation debates. This orientation meeting is also expected to encourage increased participation of Zambian MPs in the actualization of declarations made at the United Nations High-Level Meeting held in September 2018. As a follow up to this there will be a meeting organized in collaboration with MOH for the TB the caucus members to develop a roadmap for the next steps and implementation
USAID.GOV USAID ERADICATE TB PROJECT | 16 1.1.6. STRENGTHEN TB LEADERSHIP AND MANAGEMENT TO IMPROVE COORDINATION OF TB SERVICES AND INTERVENTIONS. To improve the coordination of TB control interventions and promote shared priorities among partners, ETB supports the NTLP to host monthly TB technical working group (TWG) meetings. The NTLP postponed both the February and March 2019 meetings due to competing priorities. To address this issue, ETB is further engaging the TWG chair and the NTLP to find a way to ensure that TWG meetings take place in future months.
1.1.7. BUILD CAPACITY FOR INCREASED TB AWARENESS AND COMMUNITY-BASED FINDING AND TREATMENT SUPPORT IN COMMUNITIES. ETB national and provincial units actively participated in preparation, commemoration, and post- commemoration World TB Day activities at both national and provincial levels. As part of pre– World TB Day activities, ETB hosted all national planning meetings. The project supported TB awareness–creation through appearing on both private and public radio and television stations to provide TB information on talk shows, on both live and recorded programs. Additionally, the project supported live drama performances and school debates. ETB also printed materials to support these activities, including 16,000 posters, 12,000 brochures, and 8 banners to support awareness-raising, as well as 100 correctional facility TB screening forms and 1,000 community TB screening forms for use during ICF activities. ETB also procured and provided 700 T-shirts, 50 corporate shirts, and 160 caps for participants at national and provincial levels to raise TB awareness during the World TB Day commemoration activities.
As part of the project’s support toward World TB Day commemorations, from March 11 to 31, ETB conducted ICF activities in eight selected hot-spot districts across the six supported provinces (three in Copperbelt and one in each of the remaining five provinces). Within the districts, the ICF activities were concentrated in TB hot-spot catchment areas mapped by the districts with support from ETB. TABLE 3 summarizes the results of the activity.
17 | USAID ERADICATE TB PROJECT USAID.GOV TABLE 3. SUMMARY OF ICF ACTIVITIES IN EIGHT ETB-SUPPORTED DISTRICTS.
Individuals Presumptive Patients Individuals Patients RR-TB reached individuals Positivit started on Province screened diagnosed patients with TB tested in the y rate TB for TB with TB detected messages lab treatment
Copperbelt 15,302 5,778 2,257 128 6% 128 12
Central 4,995 4,995 731 14 2% 14 0
Luapula 2,143 517 346 13 4% 13 0
Muchinga 3,922 2,482 254 13 5% 13 1
Northern 2,935 484 136 7 5% 7 0
North-Western 2,363 1,758 567 31 5% 28 1
TOTAL 31,660 16,014 4,291 206 5% 203 14
Note: ETB, Eradicate Tuberculosis; ICF, intensified case finding; RR-TB, rifampicin-resistant tuberculosis; TB, tuberculosis.
A total of 31,660 people were reached with TB messages through drama as well as door-to-door and group health education. From the total number reached with TB messages, 16,014 (51%) were symptomatically screened for TB. Of those screened for TB, 4,291 (27%) were presumed to have TB, and their sputum was tested in the laboratory. A total of 206 were bacteriologically confirmed, representing a 5% positivity rate; Copperbelt reported the highest positivity rate (6%), and Central reported the lowest (2%). The 206 bacteriologically confirmed patients included 14 RR-TB patients.
SUB-TASK 1.2: INCREASE TB CASE DETECTION THROUGH IMPROVED DIAGNOSTICS.
1.2.1. QUALITY-ASSURE DIAGNOSTIC SERVICES THROUGH GENEXPERT®. During the reporting period, the project procured and distributed 10,000 GeneXpert cartridges to supplement MOH efforts to ensure consistent supply of laboratory reagents. USAID officially handed over the cartridges to the Permanent Secretary on February 7, 2019. The cartridges were distributed to all ETB-supported provinces except North-Western and Central Provinces: North- Western Province already had sufficient stock, and Central Province had just received 9,000 cartridges from Medical Stores Limited. Additionally, ETB provided the NTLP with 1,000 cartridges to distribute to the four non-ETB-supported provinces.
During the period under review, ETB worked with the provincial health office to conduct an assessment of GeneXpert functionality in Copperbelt, Central, and Northwestern provinces. In six out of the 63 laboratories assessed, the machines were found to be faulty (in Copperbelt and Central provinces), and all machines were fully functional in North-Western province. Four out of
USAID.GOV USAID ERADICATE TB PROJECT | 18 the six faulty machines have been repaired, and two are still awaiting repair by Cepheid Inc.’s local agent.
ETB, with the Ndola and Solwezi district health offices (DHOs) in Copperbelt and North-Western provinces, respectively, conducted activities in support of the DataToCare software. In Ndola district, ETB supported the district laboratory focal point person to disable automatic updates on the GeneXpert computers to prevent GeneXpert machines from crashing after installation of DataToCare software. ETB also provided technical support on GeneXpert testing and data management. In Solwezi district, the ETB provincial laboratory specialist and the provincial information technology officer installed the DataToCare system on Zambia clinic’s GeneXpert machine and oriented facility staff to use the system. The USAID Zambia District Coverage of Health Services Project (DISCOVER-Health) procured the GeneXpert machine and also provides internet modem bundles to support internet connectivity.
In Kabwe and Mansa districts (Central and Luapula provinces, respectively), ETB conducted laboratory mentorship in nine GeneXpert facilities for 13 laboratory staff. The mentorship focused on routine GeneXpert equipment maintenance, recording results in the new laboratory registers, using positive and negative controls in fluorescence microscopy (FM), laboratory safety, and disinfection procedures.
1.2.3. PROVIDE TECHNICAL ASSISTANCE FOR QUALITY ASSURANCE. In North-Western province, ETB investigated errors identified during an external quality assessment (blinded rechecking) at Lumwana District Hospital—the facility performed poorly on the 2018 Q3 assessment (57%). To strengthen the capacity of facility staff, ETB provided on-site mentorship on reagent preparation, smear preparation, and reading, reporting, and interpreting results. Additionally, laboratory staff were subjected to panel testing, and all staff passed, with one scoring 100% and the rest 83%.
In Ngabwe (Central province) and Lavushi Manda (Muchinga province) districts, ETB supported the assessment of rooms at Mumba Chala Health Center and Tazama’s company clinic, respectively, for suitability to operate as a laboratory, because the districts do not currently have a laboratory. ETB staff provided the necessary technical specifications to the relevant provincial health offices (Muchinga and Central) for the laboratories to be fully operational.
1.2.4. IMPLEMENT LABORATORY MENTORING PROGRAM. ETB provided TSS to Chalabesa Laboratory (Muchinga province), which was newly opened after placement of an FM microscope procured by the project. The objective of the visit was to support the newly recruited laboratory staff and assess implementation progress.
In Mansa district (Luapula province), the ETB laboratory specialist worked with the biomedical scientist from Mansa General Hospital to conduct on-site mentorship of two laboratory staff from Mansa Central Clinic in FM smear preparation, staining, and examination.
In Kalumbila district (North-Western province), on March 11, the ETB laboratory strengthening specialist and staff from Solwezi General Hospital conducted laboratory TSS at Mutanda Mission Rural Health Center for the new staff who had just been posted to the facility. During the visit, the TSS support team found two specimens that were false negatives. The Mutanda Mission Rural Health Center staff were attached to Solwezi General Hospital for a two-week on-the-job training exercise.
19 | USAID ERADICATE TB PROJECT USAID.GOV Also in March, ETB provincial staff provided TSS to the Solwezi General Hospital laboratory staff to re-orient them on how to perform skin slit smear for leprosy diagnosis.
1.2.5. STRENGTHEN THE LABORATORY SPECIMEN COURIER SYSTEM. During the reporting period, ETB began the process of procuring packaging materials to support the laboratory specimen courier system.
In March 2019, laboratory advisors from ETB and SAFE continued to meet to discuss further the strengthening of the TB and HIV specimen courier integration in Central, Copperbelt, and North- Western provinces. In particular, the laboratory advisors discussed the integration of HIV viral load and early infant diagnosis samples with the TB specimen courier system in the three provinces, as well as how to improve the documentation required to track specimens and results.
The courier systems supported by the partners use motorbikes for transportation. However, SAFE uses an electronic sample-tracking system, eLABInventory, while ETB uses a paper-based system. To track specimens and results, SAFE and ETB resolved that it would be more efficient and cost- effective if both projects could jointly use eLABInventory to track specimens. However, because DataToCare is embedded on GeneXpert instruments, ETB needed to engage Savics, the developer of DataToCare, to discuss interoperability of eLABInventory and DataToCare. Communication has commenced between the two companies to discuss the technicalities of connecting the two systems. To further reinforce the collaborative efforts, ETB and SAFE resolved that the eLABInventory training for TB focal point persons will be conducted jointly with ART staff.
ETB and SAFE provincial staff are further strengthening the integration of the courier system at the provincial level. ETB’s laboratory specialist, SAFE’s provincial laboratory coordinator, and the MOH district health planner in Central province identified facilities to be serviced by both partners and developed schedules. All provinces have set targets on the expected number of samples to be referred for testing and number of TB notifications per month.
In Kitwe and Ndola districts, ETB began providing fuel and airtime support toward the operation of the integrated sample referral system as of March 1, 2019. For Kitwe district, ETB is co-sharing the fuel support with SAFE (each partner supports two motorbikes). In both Kitwe and Ndola, the executive officers in charge of transport, district laboratory focal point persons, three motorbike riders, district TB and leprosy coordinators (DTLCs), and drivers were oriented on refueling using the fuel card at the filling station and completing the mileage log and other documents for retirement. TABLE 4 summarizes the TB samples couriered in Kitwe and Ndola in March 2019. Before ETB started supporting the courier system, there was no system for tracking the samples. Going forward, samples being referred for testing will be monitored and reported.
TABLE 4. TB SAMPLES COURIERED FROM MARCH 1 TO 31, 2019 IN KITWE AND NDOLA DISTRICTS.
DISTRICT NUMBER OF NUMBER OF REFERRING SAMPLES COURIERED TO GENEXPERT HUBS FACILITIES GENEXPERT HUBS
Kitwe 6 27 581
Ndola 5 19 243
Total 11 46 824
USAID.GOV USAID ERADICATE TB PROJECT | 20 In Chinsali district, ETB held a meeting with EQUIP’s provincial team to discuss integration of the intra-district courier system for viral load and TB sputum samples in Muchinga province. The provincial biomedical scientist, ETB’s laboratory specialist, and EQUIP’s coordinator for Muchinga attended the meeting. EQUIP’s provincial coordinator was receptive to the prospect of an integrated courier system; however, he emphasized the need to have a memorandum of understanding in place before sharing the actual facilities and EQUIP courier system routes in the province. This has been resolved through intervention by EQUIP management.
In Luapula province, ETB held meetings with EQUIP staff, MOH motorbike riders, and laboratory in- charges to discuss further strengthening of TB and HIV courier system integration. As a result of the meeting, satellite centers have been aligned to district hubs for sputum sample analysis, and the EQUIP courier system has started transporting TB sputum samples jointly with viral load samples. However, there is need for ETB to introduce the specimen-tracking form and orient the riders on its use. ETB will conduct this activity by mid-April 2019.
In Kasama district, EQUIP’s deputy chief of party, EQUIP’s supply chain manager, the MOH TB focal point person, ETB’s laboratory specialist, and ETB’s technical specialist held a meeting to review progress made on integrating the TB specimen referral system into the HIV viral load system. Meeting participants resolved that ETB should start contribute to the cost of fuel to cover the additional facilities not supported by EQUIP. The ETB expected percentage contribution towards the cost of fuel had not been worked out by the end of March.
In order to improve the referral of TB samples, ETB conducted clinical mentorship visits to five facilities (Mulenga Hills, Musa, Army, Tazara, and Lukashya health facilities) in February 2019 in order for these facilities increase their referral numbers for GeneXpert testing. The project further conducted a follow-up visit to the two GeneXpert testing hubs (Location clinic and Kasama General Hospital) that service the five facilities mentioned above in March 2019. The purpose of this exercise was to monitor the referral of sputum samples from the five facilities after the clinical mentorship visit. Figure 11 depicts increased sample referrals from the all five health facilities in March compared to January and February 2019, except for Mulenga Hills, which shows a drop from four samples each in January and February to one sample in March. Tazara increased its sample referrals significantly, from 1 referred sample in January and 2 referred samples in February to 23 referred samples in March, indicating a positive response to mentorship that ETB conducted in the facility.
21 | USAID ERADICATE TB PROJECT USAID.GOV Figure 11. Sample referrals before and after mentorship in Kasama, January to March 2019.
25
20
15
10
5
0 Tazara Musa Mulenga Hills Lukashya Army Clinic No. of Samples — Jan 2019 1 0 4 0 0 No. of Samples — Feb 2019 2 2 4 1 0 No. of samples — March 2019 23 5 1 4 3
1.2.6. PROVIDE TECHNICAL ASSISTANCE TO THE NTRL TO STRENGTHEN ITS CAPACITY TO PROCESS SPECIMENS (ESPECIALLY TO DIAGNOSE DR-TB). During the period under review, ETB conducted one monthly visit to the National Tuberculosis Reference Laboratory (NTRL) to offer technical support to the quality management system. However, subsequent monthly visits could not take place due to the presence of other mentors from the United States Centers for Disease Control and Prevention and the MOH.
1.2.7. PROCURE LABORATORY SUPPLIES AND EQUIMENT. The Global Health Supply Chain–Procurement Supply Management project provided feedback on the draft report from the national forecast and quantification for TB lab commodities meeting that was held in November 2018. ETB has addressed the comments and is waiting for information from the NTLP on the funding available for 2019 to procure laboratory commodities.
SUB-TASK 1.3. STANDARDIZE TB TREATMENT, SUPPORT, AND CARE.
1.3.1. SUPPORT THE UPDATING, PRINTING, AND DISSEMINATION OF TB TREATMENT GUIDELINES. The project supported the finalization of the latent TB infection control guidelines and printed 20 copies for the national launch during the 2019 World TB Day commemoration. After the launch, a small team comprising HIV and TB experts reviewed the guidelines again and made some edits; printing of the final product (4,980 copies) is under way.
1.3.2. STRENGTHEN TB SUPPORTIVE SUPERVISION AND COORDINATION SYSTEMS. To support DTLCs in their work, ETB’s Human Resources for Health Advisor worked with NTLP counterparts and ETB technical staff to draft the DLTC diary. The purpose of the diary is to help the DTLC document what they find and take note of action points for follow up. The NTLP approved the design; subsequently, ETB and the NTLP field-tested the diary in Chongwe and Lusaka districts.
USAID.GOV USAID ERADICATE TB PROJECT | 22 ETB and the NTLP are now making final adjustments to the diary based on the feedback received from Chongwe and Lusaka DTLCs. The diary will be rolled out in FY19 Q3.
1.3.3. TRAIN CBVS TO SUPPORT PATIENTS RECEIVING TREATMENT. ETB-trained treatment supporters (CBVs) have continued providing treatment adherence support to TB patients in all target districts.
1.3.4. INCREASE TB CASE DETECTION THROUGH ACTIVE TB CASE FINDING. To increase TB notifications, all ETB-supported provinces conducted community-based ICF activities in high-burden districts and hotspot communities prior to and during World TB Day commemoration activities (see section 1.1.7. above). ETB has also been strengthening facility-based ICF activities by screening patients for TB in the OPD and inpatient wards.
The ETB monitoring and evaluation (M&E) team developed a standardized Microsoft Excel–based data-capturing system to facilitate data capture related to ICF activities across the six ETB-supported provinces. ETB selected an Excel-based system because it is an easier data-management system (compared to internet-based systems such as ODK), and it overcomes internet connectivity challenges that internet-based tools normally face in remote areas.
Enhanced supportive supervision has been shown to improve staff performance and results. In FY19 Q1, ETB and the NTLP completed revisions of the supportive supervision checklists for provincial, district, and facility levels. The new checklists guide a participatory process to evaluate TB patient services, infection control, recording and reporting, staffing, and commodity management. They also guide service delivery observations and include more robust processes for problem identification and joint action-planning than the previous NTLP checklists. ETB shared the final revised checklist with the NTLP for final approvals in January 2019. The NTLP approved the provincial and district checklists but requested an approach for data assessment and data-based decision-making be added to the facility supervision checklist. ETB has completed these refinements to the facility checklist and will orient provincial TB and leprosy control officers on the checklists in April 2019. Subsequently, the provincial TB and leprosy control officers will cascade the orientation down to DLTCs through integration with routine provincial and district meetings starting in May 2019.
SUB-TASK 1.4. SUPPORT THE EXISTING NTLP MONITORING AND EVALUATION (M&E) SYSTEMS.
1.4.2. COLLECT AND REPORT TB, DR-TB, TB/HIV, AND COMMUNITY DATA. To demonstrate impact and accountability, ETB continues to strengthen systems for high-quality data collection, analysis, and reporting in the 35 directly supported districts. During the period under review, ETB collected monthly monitoring data from 228 project-supported notification and diagnostic facilities in all six ETB-supported provinces and entered the data into both USAID’s Data for Accountability, Transparency, and Impact Monitoring (DATIM) database and ETB’s District Health Information System 2 (DHIS2) instance. ETB will analyze and use data entered into ETB’s DHIS2 database to meet internal and external reporting requirements.
Further, ETB has shifted from a passive quarterly data collection system to an active approach that enables monitoring of key indicators on a monthly basis. This revised approach has allowed the
23 | USAID ERADICATE TB PROJECT USAID.GOV project to make prompt decisions based on timely submission of data: for example, the project was able to carry out a mop-up exercise based on monthly data collected.
ETB also initiated a WhatsApp group that allows the team to share data and provide updates on data collection and quality on a daily basis. ETB also uses this platform to share ideas and request prompt support on program-related issues. The WhatsApp group has facilitated peer review of data and created a healthy competitive spirit among the team members. It has also resulted in timely submission of high-quality data by ETB provincial teams.
After a careful assessment of the current status of provincial staffing and expected deliverables (onsite TSS and mentorship to all diagnostic centers at least once per month and monthly collection of data from all reporting sites), ETB drafted a concept note that illustrates various options for monthly data collection, including costs, pros, and cons of each option. The concept note also highlight the project’s recommended method, which is to allow the monthly data collection to be driven by TB focal persons and DTLCs with active ETB provincial staff involvement in the verification of monthly data and the quarterly data collection exercise. ETB will share the final version of the concept note with both USAID and the NTLP for buy-in and approval.
ETB’s M&E team supported the strengthening of the tool used to track referrals between the community and health facilities. Key indicators added to the tool include contact tracing and PLTFU activities (patients diagnosed with TB and not initiated on treatment). Additionally, this tool will play a pivotal role in ensuring that individuals reached during community awareness activities are linked systematically to services. The revised monitoring tools will also track ICF activities at the community level.
To strengthen daily and weekly monitoring and reporting of TB data from facilities, which is critical for operational decision-making, ETB finalized collaboration modalities with USAID HIV partners to begin collecting and reporting data from facilities using a common daily data-collection platform. The project developed synergies with EQUIP and SAFE in data-collection and data-sharing activities. Continued collaboration with EQUIP has facilitated weekly reporting of TB data from six facilities (two in Muchinga province, two in Northern province, and two in Luapula province). To operationalize this monitoring system, ETB provided on-site training and mentorship to 30 EQUIP staff from six EQUIP/ETB–supported facilities (two facilities per province).
The project further engaged with SAFE in three ETB-supported provinces (Copperbelt, Central, and North-Western) to develop data collection and sharing synergies. To forge a partnership similar to that established with EQUIP, on March 27, ETB’s M&E team convened a meeting with SAFE’s M&E team and agreed to share data in facilities where both parties are present, conduct joint DQA exercises informed by data discrepancies in facilities supported by both partners, and participate in data review meetings at district and provincial levels. Capitalizing on the wide M&E human resource base that SAFE has at facility level, ETB agreed to share three or four indicators that SAFE could track on a daily basis in high-volume facilites and weekly in low-volume facilities. This synergy that allows sharing of real-time data will allow ETB staff to make prompt data-driven programmatic and operational decisions. Additionally, this initiative will validate data submitted by ETB field teams on a monthly basis.
These collaborative efforts provide a platform for data-sharing and comparison on common indicators such as isoniazid uptake, HIV testing of TB patients, and ART uptake among TB/HIV co- infected patients in facilities where the USAID implementing partners are present. Moving forward, these collaborative efforts will also allow the USAID implementing partners to conduct joint DQA
USAID.GOV USAID ERADICATE TB PROJECT | 24 activities and quarterly data review meetings, thereby applying cost-effective and efficient strategies to TB/HIV programming.
1.4.3. STRENGTHEN THE HEALTH MANAGEMENT INFORMATION SYSTEM.
ETB’S PROJECT DATABASE During FY19 Q2, ETB’s M&E team upgraded the project database from a Microsoft Excel–based system to an online DHIS2 platform, which is compatible with other systems built on DHIS2, such as USAID’s DATIM and the MOH’s health management information system. Additionally, ETB’s M&E team modified the DHIS2 structure to incorporate additional data elements to meet both the project’s and government stakeholders’ reporting requirements, including alignment with the revised monthly data collection tool. The new system is now fully operational and enables project staff to access real-time data that informs timely decision-making. In FY19 Q3, the project plans to add a feature that allows exportation of data from the ETB database to DATIM and the MOH system.
Following the database upgrade, on March 20, 2019, ETB’s data manager conducted an on-site orientation on the use of the ETB DHIS2 database for the ETB Lusaka team. The orientation focused on data collection and capture; most importantly, the orientation session addressed output reports (standard, pivot, and graphical reports) that can be generated from the system. The data storage platform is web-based and therefore will allow quick access to data entered off-site.
ETB’S DATA COLLECTION INSTRUMENT Following the data collection exercise that took place from October to December 2018, the project revised its data collection instrument in January 2019 to include additional indicators to monitor complete cascades of TB service provision and outcomes. This involved expansion of the diagnosis indicators to include components of clinical diagnosis that were missing in the previous version: specifying TB forms (i.e., extra pulmonary TB and pulmonary TB), tracking TB screening among HIV- positive clients, and monitoring isoniazid preventive therapy (IPT) uptake among HIV clients (new patients and those continuing on ART). Also during the reporting period, ETB integrated data validations into the project’s Excel-based data-collection tool and modified the tool to enable automatic import into DHIS2, which has drastically reduced transcription errors and discrepancies.
MOH SHIFT TO DHIS2 In an effort to support the MOH’s shift to DHIS2, ETB supported six two-day training sessions (one in each project-supported province) for 126 total DTLCs and district information officers (one each per district) on data collection, analysis, and reporting using the DHIS2 tool. This training is expected to increase reporting efficiency and improve the collection and submission of high-quality data from ETB-supported facilities to provincial and national levels.
NATIONAL TRAINING DATABASE To date, the NTLP has lacked a system to track or monitor TB training implementation against plans and targets outlined in the NSP. As a result, there are persistent concerns that the same staff undergo repeat training. To address this issue, ETB worked with the NTLP and the Centre for Infectious Diseases Research in Zambia (CIDRZ) to design a national training database, which can be integrated with the MOH’s existing data system. The NTLP has reviewed and approved the database; however, processes for integration with the MOH system are still underway. The NTLP advised that the handover of the database will occur in April 2019 and will be followed by
25 | USAID ERADICATE TB PROJECT USAID.GOV orientation of the NLTP, MOH, and partners to input data and use the database for planning and coordination.
1.4.5. PARTICIPATE IN ACTIVITIES THAT SHARE PROJECT EXPERIENCES AND FACILITATE LEARNING. During the period under review, ETB developed the following abstracts from project experiences and submmitted them to the Union World Conference on Lung Health:
1. Designing a TB Operational Research Training Program: Experience from the USAID Eradicate TB Project in Zambia 2. Investigation of Staff and Structural Related Factors Contributing to Low Sputum Sample Referrals in Mpulungu District, Northern Province, Zambia 3. Identification of Risk Factors for Unfavorable Tuberculosis Treatment Outcomes among Patients in Chingola District, Zambia 4. Estimating Losses in the Pediatric TB Care Cascade from Point of Entry to TB notification: A Case Study of Ndola District, Zambia 5. Enhancing Demand for and Use of Data through DHIS2 Deployment: A Case of the USAID Eradicate TB Project in Zambia 6. Improving Tuberculosis Diagnosis using an Integrated TB/HIV Intra-District Courier System in Kasama District, Zambia
TASK 2. INCREASE ACCESS TO TB/HIV AND DR-TB SERVICES FOR POOR AND VULNERABLE POPULATIONS IN TARGET PROVINCES.
SUB-TASK 2.1. REDUCE THE BURDEN OF TB/HIV COMORBIDITY.
2.1.1. SUPPORT PROVISION OF TPT. As described in section 1.3.1. above, ETB participated and supported the NTLP in finalization of the latent TB infection control guidelines and printed 20 copies for the national launch. After the launch, a small team of HIV and TB experts made further edits to the guidelines; printing of the final product (4,980 copies) is under way.
2.1.2. SUPPORT ICF IN PLHIV AND HIV SCREENING IN TB PATIENTS. In Lusaka, ETB met with SAFE to discuss collaborative activities in Copperbelt, Central, and North- Western provinces. The teams agreed to explore capacity-building opportunities related to TB/HIV screening, mass community screenings for TB/HIV, and TB/HIV coordination meetings.
ETB continued to provide logistical and technical support to ongoing joint TB/HIV clinic meetings in health facilities in ETB-supported provinces; the meetings enable coordinated support and care of co-infected patients.
USAID.GOV USAID ERADICATE TB PROJECT | 26 2.1.4. PROVIDE TECHNICAL AND ADMINISTRATIVE SUPPORT. During the reporting period, ETB provided technical support and mentorship to all diagnostic and notification centers in six project-supported provinces using the NTLP’s supportive supervision tool. Positive findings included availability of the new registers (TB register, presumptive TB register, IPT register, etc.), designated health facility TB focal point persons, strong collaboration between USAID implementing partners on TB and HIV activities, and linkage between TB and HIV entry points within the health facilities. Areas that needed improvement included presumptive TB patient-selection strategies, use of the TB presumptive registers in all service delivery points, communication between GeneXpert hubs and referring facilities, documentation practices in source registers, and IPT uptake.
ETB immediately provided on-site orientation and mentorship on the use of the presumptive TB registers and shared good case-selection strategies with HCWs. ETB also mentored HCWs to complete registers correctly and, where available, seek support from CBVs to update registers. ETB also recommended diagnostic and referring facilities to use the available communication platforms— such as WhatsApp groups, SMS, and e-mail—to promptly share results with referring facilities to facilitate patients’ linkage to treatment and care.
ETB also continues to raise the issue of isoniazid and pyridoxine (vitamin B6) commodity stock outs with the NTLP, other implementing partners, and the HIV program at the MOH in every technical meeting in which the project participates.
SUB-TASK 2.2. STRENGTHEN SYSTEMS TO HALT DR-TB EXPANSION.
2.2.1. BUILD HCW CAPACITY IN DIAGNOSIS AND CLINICAL MANAGEMENT OF MDR-TB. During the reporting period, ETB-supported facilities reported 40 new RR-TB patients: 7 in central, 20 in Copperbelt, 5 in Luapula, 2 in Muchinga, 5 in North-Western, and 1 in Northern. Of the 40 new RR-TB patients, 37 were initiated on second-line TB treatment. The three patients not yet initiated are from North-Western province. Two of these patients have been identified as defaulters who had started second-line treatment in Lusaka but stopped taking their treatment; their samples have been sent for culture and drug-susceptibility testing. The other one was traced and found to have died.
Additionally, ETB’s central technical team participated in the Copperbelt provincial clinical expert committee meeting on DR-TB, the objective of which was to determine how to strengthen DR-TB outreach services and mentorship to districts within the province. The committee resolved that ETB will support the outreach services using the existing platform comprising two teams, each headed by a consultant: one team will cover Chingola, Chililabombwe, Masaiti, and Mpongwe, and the other team will cover Mufulira, Luanshya, Kalulushi, and Lufwanyama. The committee also agreed that the head of internal medicine at Ndola Teaching Hospital would lead the identification of clinicians to be trained in DR-TB mentorship and share all monthly DR-TB reports with ETB. ETB also engaged the Copperbelt DR-TB clinical expert committee lead person to develop a budget and schedule for monthly DR-TB clinical outreach reviews in the districts. The monthly outreach activities have begun in Ndola.
ETB also procured 32 blankets and 32 pairs of bed sheets and participated in the official handover of the 16-bed-capacity DR-TB ward at Mansa General Hospital, which was renovated by USAID through the Challenge TB project.
27 | USAID ERADICATE TB PROJECT USAID.GOV SUB-TASK 2.3. INCREASE TB DETECTION AND TREATMENT AMONG CHILDREN AND PREGNANT WOMEN.
2.3.1. STRENGTHEN CHILDHOOD TB MANAGEMENT. In Lusaka, ETB convened a meeting with a representative from the ZPA on January 25, 2019 to identify and agree upon areas of collaboration to increase pediatric TB notifications from the six ETB-supported provinces. Identified areas of collaboration included the need for the two partners to jointly develop health care worker job aids, review the score card for clinical diagnosis of childhood TB, jointly conduct zonal trainings, and provide joint on-site mentorship to supported health facilities after training. ETB and the ZPA also prioritized the integration of childhood TB services with MCH and nutrition programs. It was agreed that ETB’s M&E team will document baseline values (using routine data) prior to the development of HCW materials and training. ETB will continuously monitor TB data by age groups to assess the effectiveness of implemented strategies.
ETB also initiated and participated in the zoning of districts in preparation for the systematic implementation of childhood TB capacity-building activities (TSS and mentorship). The zoning model divides the district into geographic clusters of health facilities so that supervisors can manage facilities located near each other; this allows for cost-effective implementation and closer, continuous supervision of TSS and mentorship activities. By the end of the meeting, all Copperbelt districts had been zoned.
2.3.2. CONDUCT CHILDHOOD TB SCREENING. ETB actively provides contact tracing support for children exposed to TB through CBVs in all ETB- supported facilities. ETB monitors IPT uptake in children on a monthly basis, and the monthly ETB- driven ICF activities in Copperbelt and Central include pediatric TB screening. In FY19 Q2, 87 children were initiated on IPT. The project engaged the MOH, the Ministries of General and Higher Education, and other stakeholders to determine the best approach to conduct TB screening in educational facilities.
SUB-TASK 2.4. PROVIDE SUPPORT TO INCREASE TB DETECTION AND TREATMENT AMONG PRISONERS.
2.4.1. SUPPORT CAPACITY-BUILDING. From March 11 to 15, 2019, ETB supported the training of 12 inmates and 11 correctional staff (prison wardens, gatekeepers, receptionists, and health facility staff) as TB treatment supporters at Kamfinsa correctional facility. The training modules included basic facts about TB and HIV; signs and symptoms; TB transmission; types of TB; complications of TB; TB prevention and control; TB/HIV coinfection; DOT; principles of home visits; basic counseling; nutrition; communication; health education partnership in TB control; volunteerism; stigma and discrimination; gender in TB control; patients’ rights; reporting forms and registers; monitoring and supervision; and basic facts about leprosy. Two MOH TB officers and one ETB officer facilitated the training. Methodologies used included group discussions, PowerPoint presentations/lectures, and role plays. The trained cadres will supplement the efforts of the Zambia Correctional Service (ZCS) in ensuring that correctional facilities adhere to TB infection control measures and routinely screen inmates for TB.
USAID.GOV USAID ERADICATE TB PROJECT | 28 2.4.2. SUPPORT TB SCREENING AMONG INMATES. ETB continues to support TB screening activities in correctional facilities. During FY19 Q2, ETB finalized the design, development, and printing of registers for use during screening of inmates for TB at entry and exit.
TABLE 5 depicts TB screening at entry and during stay (mass screening) during the reporting period. The proportion of inmates screened at entry was 97%, an improvement from 73% in the previous quarter. Of the 142 samples examined in the laboratory, only 3 (2%) were bacteriologically confirmed, and all were put on TB treatment.
29 | USAID ERADICATE TB PROJECT USAID.GOV TABLE 5. TB SCREENING OF INMATES AT ENTRY AND DURING MASS SCREENING IN ETB-SUPPORTED CORRECTIONAL FACILITIES.
Total admitted in Sputum ETB-supported Screened % screened samples Sputum samples Total screened Number tested Bacteriologically Initiated on TB FACILITY correctional for TB at for TB at examined in bacteriologically during mass in laboratory confirmed treatment facilities entry entry the lab confirmed screening
Mukobeko Medium 167 167 100% 21 1 1,568 332 1 1
Mukobeko 113 113 100% 40 1 1,907 331 4 5 Maximum
Isoka 75 75 100% 17 0 143 17 0 0
Mpika 69 69 100% 4 0 0 0 0 0
Kanseshi 102 102 100% 16 0 0 0 0 0
Mansa 86 65 76% 7 0 0 0 0 0
Milima 100 100 100% 37 1 0 0 0 1
TOTAL 712 691 97 142 3 3,618 680 5* 7*
Note: ETB, Eradicate Tuberculosis; TB, tuberculosis. *Includes one rifampicin-resistant TB patient.
USAID.GOV USAID ERADICATE TB PROJECT | 30 During mass TB screenings, 3,618 inmates were symptomatically screened for TB, of whom 680 (19%) were presumed to have TB and had their sputum examined in the laboratory. A total number of 5 patients were bacteriologically confirmed, including 1 RR-TB patient. All bacteriologically confirmed patients came from Mukobeko Medium (one RR-TB patient) and Mukobeko Maximum (four drug-susceptible TB patients). All of these patients were initiated on treatment.
TABLE 6 below summarizes TB screening activities at exit point in ETB-supported ZCS facilities.
31 | USAID ERADICATE TB PROJECT USAID.GOV TABLE 6. TB SCREENING OF INMATES AT EXIT IN ETB-SUPPORTED CORRECTIONAL FACILITIES.
Total inmates that Screened for % screened Sputum samples Sputum samples % bacteriologically Initiated on % initiated on FACILITY exited ETB-supported TB at exit for TB at examined in the bacteriologically confirmed TB TB treatment correctional facilities exit lab confirmed treatment
Mukobeko Medium 159 101 64% 3 0 0 0 0
Mukobeko Maximum 7 4 57% 0 0 0 0 0
Isoka 67 22 33% 0 0 0 0 0
Mpika 69 51 74% 0 0 0 0 0
Kansenshi 96 66 69% 0 0 0 0 0
Solwezi 59 19 32% 0 0 0 0 0
Milima 75 42 55% 0 0 0 0 0
Mansa 56 26 46% 0 0 0 0 0
TOTAL 588 331 56% 3 0 0 0 0 Note: ETB, Eradicate Tuberculosis; TB, tuberculosis.
USAID.GOV USAID ERADICATE TB PROJECT | 32 A total of 588 inmates were released from the correctional facilities in all six ETB-supported provinces, and 331 released inmates were screened for TB, representing a 56% screening rate at exit. Only three presumptive TB individuals were identified and had their sputum examined in the laboratory; however, all three samples were negative.
Though screening at exit remains a challenge, rates have improved since ZCS facility staff agreed to share the list of inmates with HCWs one month in advance of discharge so that inmates may be screened for TB and linked to health facilities for continuation of treatment in the event they are found to have TB upon exit.
ETB has observed low positivity rates in correctional facility screening activities (only 1% during mass screening and 2% at entry). In order to improve the yield of bacteriologically confirmed cases, ETB will continue to mentor HCWs on the correct use of the TB symptomatic screening tool, selection of presumptive TB patients, and submission of high-quality sputum samples.
2.4.3. COORDINATE PARTNERS WORKING WITH ZCS. From March 13 to 15, 2019, ETB hosted a three-day TB/HIV technical review meeting with ZCS facilities and partners including In But-Free (a nongovernmental organization supported by the Norwegian Lung Health Association), CIDRZ, and DISCOVER-Health. CIDRZ supports ZCS to conduct TB mass screening at entry and exit points at Mukobeko Medium, Kamfinsa, Ndola Remand, and Chingola; DISCOVER-Health focuses on HIV activities at Kansenshi; and In But-Free supports ZCS at Kamfinsa, Mukobeko Medium, Mukobeko Maximum, and Kansenshi correctional facilities.
Areas for collaboration identified during this forum included: 1. Conducting joint planning for mass TB screening through establishment of a coordinated, periodic mass-screening schedule using a standardized screening tool, which ETB has since printed and distributed. 2. Creating synergies on provision of laboratory supplies during mass screening activities. 3. Jointly implementing TB/HIV activities in correctional facilities.
During this meeting, correctional facilities shared several performance challenges, including loss to follow-up of TB patients once released from correctional facilities; miscommunication between facility health personnel and the personnel handling the entry and discharge of inmates; uncertain dates for discharge of inmates, which makes it difficult for health workers to conduct TB screening on discharge; lack of standard isolation rooms for TB patients; inadequate stationery to use during entry and exit screening; and a weak sample-referral system to diagnostic facilities. To mitigate the challenges highlighted above, the participants resolved to implement the following immediate and long-term measures on a continuous basis:
• Track all inmates released from the prison suffering from TB and connect them to the nearest facility for continuation of treatment (other partners to learn from In But Free’s best practices, such as nutrition support and creation of linkages to treatment for inmates discharged from correctional facilities). • Provide orientation to correctional facility staff handling inmates at entry and discharge on TB symptomatic screening and improve communication between reception and health facility staff by developing a list of inmates one month before discharge so that they are screened for TB and linked to health facilities for continuation of treatment in the event they are found to have TB upon discharge (see section 2.4.2. above).
33 | USAID ERADICATE TB PROJECT USAID.GOV • Orient correctional facility HCWs on collection, storage, and transportation of sputum samples and link them to the existing district TB sputum sample courier system. (The ETB-supported correctional facilities are already linked to the existing courier system.) • Orient correctional facility staff on infection control in the facilities and possibly provide isolation cells for inmates on TB treatment. (Although there is inadequate accommodation in all correctional facilities, Kamfinsa correctional facility has attempted to provide an isolation cell for the TB patients in their custody.)
TASK 3. ENGAGE ALL CATEGORIES OF CARE PROVIDERS.
SUB-TASK 3.1. ENGAGE TRADITIONAL PROVIDERS. ETB has requested guidance from the MOH on the best approach to incentivize ETB-supported traditional health providers. The MOH is widely consulting its partners to standardize and concretize the incentive packages. ETB also met with the NTLP and the World Bank on 30th January, 2019 to discuss the possibility of using the results-based funding model that they are currently implementing.
SUB-TASK 3.2. IMPROVE CBV ENGAGEMENT IN TB CASE FINDING AND TREATMENT SUPPORT. During the quarter, ETB engaged the NTLP through the Southern Africa Tuberculosis Health Systems Support project to discuss and explore standardization of the incentive package for CBVs in the TB program. Based on these consultations, ETB developed a draft standardized incentive package that will be rolled out to motivate CBVs to raise awareness about TB in the community, find and refer presumptive TB patients to the facilities, and provide standardized treatment, care, and support within the project’s target provinces. ETB also consulted the MOH on the best approach to provide transportation support to CBVs. After confirming with each district the active CBVs to be supported, ETB will begin paying incentives in FY19 Q3.
The project also procured 450 T-shirts, 450 caps, 450 umbrellas, 450 bibs, and 450 backpacks as enablers for CBVs supporting community activities. The project will finalize the procurement of 450 identification cards toward the end of April 2019. These enablers will motivate CBVs to continue working and improve visibility of the project and TB awareness in target provinces.
Also during the reporting period, ETB developed a supervision guide for CBVs. ETB will field-test the supervision guide in FY19 Q3 in Kabwe district and subsequently orient TB focal persons supervising CBVs on the use of the guide.
TASK 4. INTENSIFIED RESEARCH AND INNOVATION.
SUB-TASK 4.1. BUILD CAPACITY IN OR AND ESTABLISH NATIONAL TB OR PRIORITIES. ETB received 104 applications for TB operational research (OR) training for cohort 2. A team of stakeholders—including the NTLP, the National Health Research Authority (NHRA), CIDRZ, ZAMBART, and the University Of Zambia School Of Public Health (UNZA-SPH) met at PATH’s office on January 24, 2019 to select candidates for the first phase of the training. Participants were scored as follows: clarity of the problem statement (25%), feasibility of the study (25%), relevance of the study (25%), novelty of the study (15%), research-related experience (6%), and academic qualifications (4%). A total of 19 candidates from 15 ETB-supported districts across five provinces
USAID.GOV USAID ERADICATE TB PROJECT | 34 (Copperbelt, Central, North-Western, Luapula, and Northern provinces) were selected. The maximum possible score for selection was 5: from the 19 candidates who were selected (2 females and 17 males), the highest score was 4.66, and the lowest score was 3.54. The successful candidates included district TB focal persons, district information officers, and district laboratory officers.
4.1.5. DISSEMINATE OR FINDINGS. During the period under review, all four districts’ OR teams (Ndola, Mpulungu, Kapiri-Mposhi, and Chingola) from cohort 1 successfully conducted four separate district level meetings to share preliminary findings. The objectives of these meetings were to 1) share preliminary findings from the OR projects with health center staff; 2) obtain grassroots and district-wide input to contextualize key findings; 3) develop immediate remedial actions at grassroots level; and 4) identify key policy recommendations for the DHOs and NTLP for the final study report. ETB and the four DHOs shared the cost of hosting these meetings. District medical officers and TB focal point persons from all of the health facilities attended these meetings. In total, 147 individuals attended these meetings (30 in Ndola, 45 in Chingola, 29 in Kapiri-Mposhi and 43 in Mpulungu). ETB was represented at these meetings by central- and provincial-level staff and consultants.
During these meetings, district OR teams received valuable feedback from the audience, which will be incorporated in the final study reports. A key outcome of this activity was the commitment demonstrated by the DHO management teams to ownership of OR activities and the commitment of the district and health center staff to implement simple and low-cost interventions to address the gaps in the TB diagnosis and care cascade identified through the research.
4.2. DEVELOP STRATEGIC PARTNERSHIPS FOR OR. As a key partner to the NHRA, ETB actively participated in an NHRA-organized workshop in Lusaka from January 21 to 25, 2019 to develop online modules that will be used to assess researchers in Zambia prior to accreditation and standardize the way research is conducted in the country. Other partners in attendance included the MOH, UNZA-SPH, the National Curriculum Development Centre, the Tropical Diseases Research Centre, and CIDRZ. Each partner drafted one module; ETB was assigned module 1, titled “Introduction to Research and Health Research.” The NHRA will circulate a consolidated draft document to all partners for comments and input in FY19 Q3.
On March 17, 2019, ETB’s OR staff, ZAMBART’s chief executive officer, and the dean for UNZA- SPH met to discuss collaboration on OR capacity-building activities. It was agreed that ETB could provide financial resources to support Master of Public Health (MPH) students to implement TB- related OR projects as part of their masters-level thesis work. Since the discussions are still in early stages of development, ETB has not made any financial commitments at this time. UNZA-SPH faculty would supervise MPH students implementing TB OR projects. During this meeting, ETB learned that UNZA-SPH already teaches implementation research, a subject closely related to OR, in partnership with the World Health Organization, to MPH students as part of standard curriculum. This existing research mechanism will make it easier for the school to promote TB-related OR projects to students that demonstrate interest in this field of research. ETB will submit a detailed concept note on the proposed partnership between UNZA-SPH and ETB in FY19 Q3.
35 | USAID ERADICATE TB PROJECT USAID.GOV FINANCE AND ADMINISTRATION TABLE 7 provides an overview of ETB’s financial status as of the end of March 2019.
TABLE 7. FINANCIAL UPDATE (CUMULATIVE: MAY 2017 THROUGH MARCH 2019). Planned life of project $ 21,467,448 Obligations $ 10,249,959 Accrued expenditures $ 7,778,682 Average monthly expenditures Actual: $ 338,204 Ideal: $ 357,791 Pipeline $ 2,471,277 % life of project burn rate, May 2017 to March 2019 Actual: 36% Ideal: 38%
CHALLENGES TABLE 8 summarizes challenges faced during FY19 Q2 and corresponding solutions.
TABLE 8. CHALLENGES AND MITIGATION MEASURES.
ACTIVITY DESCRIPTION PROPOSED SOLUTIONS AND SUPPORT REQUIRED
Conduct monthly data The Excel-based electronic data For March reporting, the M&E team pre-created collection exercise. collection tool that was introduced templates for each facility to facilitate easy data- in February 2019 has greatly capture. As a result of this adjustment, data is being improved the quality of data at the captured on the Excel tool without compromising the facility level. However, some field built-in quality control checks. teams altered the data collection template validations in the process of creating copies.
Abbreviations: ETB, Eradicate Tuberculosis; M&E, monitoring and evaluation; OR, operational research; PY, Project Year; USAID, United States Agency for International Development.
LESSONS LEARNED From hosting and sponsoring district-level OR dissemination meetings in Chingola, Mpulungu, Kapiri- Mposhi, and Ndola DHOs, ETB learned that engaging DHOs can result in program ownership and allocation of resources for research activities.
In addition, preliminary results-sharing meetings at the local level play a pivotal role in public health research. During the district-level meetings, facility- and district-level staff were able to identify and commit to immediately implement low-cost measures to cover identified OR gaps. This bottom-up approach is cost-efficient and facilitates prompt response to gaps, thereby improving TB program performance.
USAID.GOV USAID ERADICATE TB PROJECT | 36 ACTIVITIES CARRIED-OVER FROM FY19 Q2 TO Q3
The table below shows activities planned for the period January to March 2019 but were moved to the next quarter of implementation.
Planned Activity Progress and status Lead Rescheduled time Partner A M J Outputs To allow for NTLP’s participation Conducted national DQA dissemination this activity was moved to April meeting that will be attended by NTLP 01 and 02. It has been Action plan for addressing gaps identified during PATH X and all its partners. accomplished and will be reported the DQAs conducted. in the next quarterly report.
Supported data review meetings at district, provincial, and national levels to allow a thorough peer interrogation of This activity has been moved to PATH X Data review meeting held TB, DR-TB, and TB/HIV data, and May and June by NTLP facilitate learning and use of data for decision-making. Participate in national-level courier This activity was moved to April, PATH X Participated in national-level courier system
system consultative meetings. to be reported in Q3 report. ASLM consultative meetings
37 | USAID ERADICATE TB PROJECT USAID.GOV
PLANNED ACTIVITIES FOR FY19 Q3 Lead Activities A M J Outputs partner TASK 1. PURSUE HIGH-QUALITY DIRECTLY OBSERVED THERAPY, SHORT-COURSE (DOTS) EXPANSION AND ENHANCEMENT. SUB-TASK 1.1. PROVIDE AN ENABLING ENVIRONMENT FOR TB CONTROL EFFORTS. 1.1.1. Engage high-level corporate entities. Convene two high-level corporate breakfast meetings with identified national and Two high-level corporate breakfast meetings held with identified multinational private-sector corporate entities to create awareness of and pursue PATH X X national and multinational private-sector corporate entities. funding opportunities for TB in Lusaka and Copperbelt provinces. Develop a “telecommunication for TB” initiative and convene a meeting with A “telecommunication for TB” initiative developed and meeting with PATH X X telecommunications companies (Airtel, MTN, and Zamtel) to create awareness. telecommunications companies held. PATH Develop a memorandum of understanding with at least one of the companies. X At least one memorandum of understanding developed. CITAM+ Convene provincial meetings for potential private-/corporate-sector partnerships PATH X X Six provincial meetings held. and funding opportunities at the local level. 1.1.2. Hold meetings to advocate for OR funding. Hold two one-day OR advocacy meetings, organized through the provincial ZAMBART chambers of mines, with mining companies in Copperbelt and North-Western PATH X X Two OR advocacy meetings held with mining companies. provinces. NTLP Hold two breakfast meetings with “Zambian Businesses Against TB” in Lusaka and ZAMBART Two breakfast meetings with “Zambian Businesses Against TB” (one in Copperbelt provinces. At each of these meetings, ETB will present concept notes PATH X X Lusaka and one in Copperbelt) convened. on high-priority research areas, which the private sector can choose to fund. NTLP 1.1.4. Participate in midterm expenditure framework (MTEF) planning and review. Engage in MTEF process to ensure that planned USG support is incorporated in the MOH/NTLP action plans for calendar year 2020. ETB will engage with the X PATH USG support incorporated in the MOH/NTLP action plans. NTLP at all levels and participate in provincial/district planning meetings to discuss support that will be provided in 2020. 1.1.5. Engage private medical practitioners and pharmacies. Collaborate with SATBHSS to train 40 PMPs or HCWs from private health facilities on TB case detection and management in Copperbelt, Central, North- PATH X X Training on TB case detection and management for 40 PMPs conducted. Western, and Muchinga provinces. Collaborate with SATBHSS to train 30 (10 per province) private-sector 30 private-sector pharmacists trained in TB patient identification and pharmacists in TB patient identification and referral in Muchinga, Northern, and PATH X X referral. Luapula provinces.
USAID.GOV USAID ERADICATE TB PROJECT | 38 Lead Activities A M J Outputs partner Conduct quarterly TSS and mentorship visits to private health facilities and Quarterly TSS and mentorship visits to private health facilities PATH X pharmacies. conducted. Support private-sector pharmacists and general practitioners to attend MOH Private-sector pharmacists and PMPs participate in four MOH district PATH X district quarterly technical review meetings. technical review meetings. Link general practitioners to the sputum courier system to access GeneXpert PATH X 30 general practitioners linked to the sputum courier system. hubs for diagnosis and follow-up. 1.1.6. Strengthen TB leadership and management to improve coordination of TB services and interventions. Support the NTLP manager to conduct an annual online address to harmonize PATH X Annual online address conducted. understanding of the NTLP’s priorities and goals among all TB officers. Support the NTLP to coordinate TB TWG meetings. PATH X X 12 monthly TWG meetings supported. 1.1.7. Build capacity for increased TB awareness and community-based case finding and treatment support in communities. Conduct biannual supervision and mentorship among TB associations and CBVs. CITAM+ X Biannual supervision and mentorship conducted. SUB-TASK 1.2. INCREASE TB CASE DETECTION THROUGH IMPROVED DIAGNOSTICS. 1.2.1. Quality-assure diagnostic services through GeneXpert. Procure 10,000 GeneXpert cartridges. ASLM X Procurement of 10,000 GeneXpert cartridges completed. Link GeneXpert machines to DataToCare software and support internet ASLM X X Day-to-day operational costs of DataToCare provided. connectivity. Support service and repair of GeneXpert machines in six ETB-supported ASLM X X 105 GeneXpert machines calibrated and serviced. provinces. Train 15 provincial medical equipment officers and laboratory staff in GeneXpert 15 provincial medical equipment officers and laboratory staff trained in ASLM repair and maintenance. GeneXpert service and repairs. Hold one four-day meeting for ten laboratory personnel to revise the SOPs for Meeting held to revise the SOPs and develop job aids for ASLM X GeneXpert/microscopy and develop job aids for GeneXpert/microscopy. GeneXpert/microscopy. ASLM X 500 laboratory SOPs printed. Support the printing of 500 GeneXpert and mmicroscopy SOPs, 150 national ASLM X 150 national courier guidelines printed. courier guidelines, and 800 sputum collection job aids. ASLM X 800 sputum collection job aids printed. 1.2.3. Provide technical assistance for quality assurance. Support the MOH at the district and health center levels to conduct quarterly EQA performance reports produced and shared with the target smear microscopy EQA visits for quality improvement in the six ETB-supported ASLM X provinces. provinces. Conduct TSS and follow-up with provincial laboratory supervisors for facilities Quarterly supportive supervision and follow-up conducted. ASLM X performing poorly in EQA. On-site investigations conducted and reported errors resolved. 1.2.4. Implement laboratory mentoring program. Conduct quarterly technical supportive supervision and mentorship visits in targeted districts with high notifications in Copperbelt (6 districts), Central (3 ASLM X Supportive supervision and mentorship visits conducted in 20 districts. districts), Muchinga (3 districts), Northern (2 districts), Luapula (3 districts) and North-Western (3 districts) provinces.
39 | USAID ERADICATE TB PROJECT USAID.GOV Lead Activities A M J Outputs partner 1.2.5. Strengthen the laboratory specimen courier system. Participate in national-level courier system consultative meetings. ASLM X X X Courier consultative meetings attended and documented. Finalize maps showing the routes for the intra-district TB courier and ASLM X integration with the VL system ASLM X X X Targeted districts supported with fuel and repair costs for motorbikes. PATH ASLM 63 targeted districts supported with air-time for communication and X X X PATH coordination. Support the intra- and inter-district courier system. ASLM X Procurement of packaging materials completed. PATH ASLM X X X Targeted staff supported with lunch allowance and air-time. PATH ASLM Targets set on the number of samples referred for testing and number X X X PATH of cases notified per month. 95 laboratory staff, CBVs, and motorbike riders trained in sputum ASLM Conduct training in sputum collection, packaging, and transportation. X collection, packaging, and transportation; biosafety; documentation Afya Mzuri process; and feedback of results. 1.2.6. Provide technical assistance to the NTRL to strengthen its capacity to process specimens (especially to diagnose DR-TB). Conduct monthly visits to the NTRL to review quality management system Monthly technical assistance to the NTRL to review quality implementation and provide technical assistance to improve its capacity to process ASLM X X X management system implementation conducted. specimens. 1.2.7. Procure laboratory supplies and equipment. Procurement of 1,000 N95 respirators for infection control Procure laboratory supplies. ASLM X ccompleted. SUB-TASK 1.3. STANDARDIZE TB TREATMENT, SUPPORT, AND CARE. 1.3.1. Procure laboratory supplies and equipment. Conduct meetings to update TB guidelines and job aids for childhood TB based on PATH X X One meeting to revise the NTLP treatment guidelines convened. NSP and current global recommendations. 5,000 copies of the revised guidelines (to include the LTBI treatment Print and distribute 5,000 copies of the revised guidelines (to include the LTBI PATH X X guidelines and revised DR-TB treatment guidelines) printed and treatment guidelines and revised DR-TB treatment guidelines). distributed. Develop job aids for childhood TB. PATH X X Job aids for childhood TB developed. Disseminate the printed copies of the childhood TB job aids to the six target PATH X Dissemination of the printed copies conducted. provinces while the other partners distribute to the remaining provinces. 1.3.2. Strengthen TB supportive supervision and coordination systems. Orient six provincial and 65 district TB officers in the new TB supportive Supervision training completed for six provincial TB officers and 65 Initiatives X X X supervision tools and process. district officers. Support NTLP to develop and implement activity diaries for DTLCs. Initiatives X X X DTLCs’ diaries developed and distributed at the local level.
USAID.GOV USAID ERADICATE TB PROJECT | 40 Lead Activities A M J Outputs partner 1.3.3. Train CBVs to support patients receiving treatment. Conduct refresher training for CBVs in high-burden districts. Afya Mzuri X 100 CBVs refreshed on TB treatment support. Strengthen information dissemination in TB clinics/corners through integration of CITAM+ X X TB association members integrated into health facility system. TB associations into health facility TB activities Strengthen information dissemination in TB clinics/corners by identifying facilities PATH Facilities in 10 TB hotspot communities supported with TB information in 10 TB hotspot communities (4 in Kitwe, 4 in Ndola and 2 in Kabwe districts) X CITAM+ dissemination. for information dissemination support. Provide treatment adherence support to TB patients in all target districts. Afya Mzuri X X X TB patients provided treatment adherence support. 1.3.4. Increase TB case detection through active TB case finding. Strengthen facility-based ICF. PATH X X X Increased case notification at facility. Support monthly mass TB screenings targeting hotspot communities in Afya Mzuri X X X Mass TB screenings held in identified hotspot communities. Copperbelt and Central provinces. PATH 4 mass screening sessions conducted during the National Health Week Support mass TB screening in selected sites (hotspots) of 22 high-burden districts Afya Mzuri X X in May, Child Health Weeks in June and November, and World AIDS during national health events. PATH Day in December. SUB-TASK 1.4. SUPPORT THE EXISTING NTLP M&E SYSTEM. 1.4.1. Conduct data quality audit activities. The key product of this meeting will be draft data management tools, Conduct national DQA dissemination meeting that will be attended by NTLP and such as data flow maps and indicator definition sheets, that address the PATH X all its partners. gaps documented in previous assessments conducted. Precise improvement plans will also be developed. Conduct a DQA dissemination meeting with each province to discuss the gaps and 6 DQA dissemination meetings conducted and a plan for addressing PATH X roll out the action plan for addressing the gaps. gaps in place. Conduct four DQAs in the target provinces (starting in Q2) to assess the extent Quarterly DQAs conducted in the targeted 219 facilities in the 6 PATH X X to which improvement plan recommendations have been implemented. provinces. Support data review meetings at district, provincial, and national levels to allow a 126 peer data quality assessments conducted in the 63 supported thorough peer interrogation of TB, DR-TB, and TB/HIV data, and facilitate learning PATH X X districts (2 per district). and use of data for decision-making. 1.4.2. Collect and report TB, DR-TB, TB/HIV, and community data. Collect TB, DR-TB, TB–HIV, and community data on defined schedules to meet PATH X X X Data on TB, DR-TB, TB/HIV, and community activities collected. internal and external reporting data needs. Support the design and monitoring of the public-private facility referral tool to PATH X X X Functional referral system including referral tools in place. strengthen the referral system between public and private facilities. 1.4.3. Strengthen the health management information system. Support rollout of SmartCare system, including training of provincial TB PATH X Provincial TB district coordinators trained in SmartCare system use. coordinators.
41 | USAID ERADICATE TB PROJECT USAID.GOV Lead Activities A M J Outputs partner Support NTLP efforts to incorporate a module in the SmartCare system that TB patient management module developed and incorporated in PATH X supports TB patient management and continuity of care. SmartCare system. Support printing and distribution of TB, DR-TB, TB/HIV, and community data collection forms, manuals, and reporting tools, including SmartCare manuals, to Data collection forms, manuals, and reporting tools, including PATH X X ensure availability of data collection and reporting tools in the facilities in all six SmartCare manuals, printed and distributed. target provinces. Conduct DHIS2 on-site mentorship on a quarterly basis to provincial ETB and DHIS2 on-site mentorship conducted on a quarterly basis to provincial NTLP staff, who will also mentor district staff (DTLCs and information officers) on PATH X ETB and NTLP staff. DHIS2 reporting. Provide support to the NTLP to launch and roll out the DR-TB database. ETB will support database installation at provincial levels and mentor provincial DR-TB PATH X X DR-TB database launched and rolled out. focal point persons on data capture and report generation. Orient the NTLP and partners to enter data and use the training database for PATH X X 20 NTLP and partner staff oriented in data entry, use, and analysis. analysis. Strengthen ETB’s project database to enhance data collection and accessibility and Functional ETB database able to track indicators and generate reports PATH X X X allow the project to track programmatic indicators. strengthened. 1.4.4. Strengthen the NTLP’s data analysis and visualization systems. Conduct training and provide mentorship on Tableau and DHIS2 data visualization for 2 NTLP central level M&E staff, 2 NTLP provincial TB and leprosy 7 NTLP staff from central, provincial, and district offices and 6 ETB staff PATH X X X coordinators, 3 NTLP DTLCs, 3 ETB provincial staff, and 3 ETB central unit M&E trained in Tableau and DHIS2 data visualization. staff to facilitate effective data analysis and visualization. 1.4.5. Participate in activities that share project experiences and facilitate learning. Participate in international, regional, and national strategic conferences to International, regional, and national strategic conferences attended by PATH X showcase project work and share lessons learned, best practices, and successes. ETB. Support staff to prepare presentations, abstracts, and other materials that allow Project staff coached on preparation of acceptable materials for PATH X X X participation in learning platforms. presentation during conferences. 1.4.6. Participate and support review meetings at national, provincial, and district levels. Provide technical and financial support to convene the provincial data review PATH X One provincial review meeting conducted. meeting. Provide technical and financial support to convene district data review meetings. PATH X 126 district review meetings convened (2 per each of the 63 districts). Provide technical and financial support to national monthly data review meetings. PATH X X X 7 national monthly data review meetings held. TASK 2. INCREASE ACCESS TO TB/HIV AND DR-TB SERVICES FOR POOR AND VULNERABLE POPULATIONS IN TARGET PROVINCES. SUB-TASK 2.1. REDUCE THE BURDEN OF TB/HIV CO-MORBIDITY. 2.1.1. Support provision of TPT. Print and distribute 5000 copies of LTBI guidelines. PATH X X 5,000 copies of LTBI guidelines printed and distributed.
USAID.GOV USAID ERADICATE TB PROJECT | 42 Lead Activities A M J Outputs partner Disseminate guidelines by conducting one-day orientation for district staff, who PATH X One-day dissemination meeting held. will subsequently conduct onsite orientation for facility staff. 2.1.2. Support ICF in PLHIV and HIV screening in TB patients. Orient health care staff in both TB and ART clinics on TB/HIV collaborative PATH X Health care staff oriented in TB and HIV collaboration. activities. Work with other USAID-supported implementing partners and groups conducting HIV provider on-site orientation on treatment initiation with emphasis on TB case PATH X X X TB case finding onsite orientations conducted with other partners. finding among PLHIV. Support joint monthly TB/HIV clinic meetings to ensure coordinated support and PATH X X X Monthly TB/HIV clinic meetings conducted. care of co-infected patients. 2.1.3. Implement context-specific infection control packages. Conduct infection control training for 105 HCWs (15 per facility) in selected general hospitals (Kabwe, Ndola Teaching, Kitwe Teaching, Solwezi, Kasama, PATH X 105 HCWs trained in infection control. Mansa, and Chinsali). 2.1.4. Provide technical and administrative support. Support quarterly provincial and district TB/HIV coordination meetings. PATH X Quarterly TB/HIV coordination meetings supported. Conduct quarterly TSS and mentorship visits to selected districts and facilities in Quarterly TSS and mentorship visits to selected districts and facilities each of the six target provinces. Provincial and district teams will also conduct TSS PATH X conducted. visits to health facilities. PATH’s Regional Advisor for TB/HIV will travel to Zambia to provide technical ETB's TB/HIV strategies and activities refined. assistance to address TB/HIV co-infection, bi-directional screening, TPT, data PATH X Improved quality of TB/HIV activities. collection and review, and coordination with PEPFAR-supported programs. 2.1.5. Support TB training for HCWs through e-learning. Provide learning opportunities needed to deliver high-quality care without PATH X X X HCWs access learning opportunities. disrupting health care services through e-learning platform. SUB-TASK 2.2. STRENGTHEN SYSTEMS TO HALT DR-TB EXPANSION. 2.2.1. Build HCW capacity in diagnosis and clinical management of DR-TB. Conduct DR-TB training workshops for 45 HCWs (15 per province, drawn from PATH X 15 HCWs trained in Muchinga, Central, and Luapula provinces. clinical, nursing, and laboratory staff) in Muchinga, Central, and Luapula provinces. Support DR-TB clinicians to conduct monthly DR-TB clinical outreach services to review patients on DR treatment in the surrounding districts and at the same time PATH X X X Monthly DR-TB clinical outreach services conducted. provide mentorship to local clinicians. Collaborate with Jhpiego and other HIV partners to ensure that ETB-supported PATH provinces participate in the ECHO program to improve staff performance using an X X X HCWs in ETB-supported provinces participate in the ECHO program. Initiatives e-mentorship approach.
43 | USAID ERADICATE TB PROJECT USAID.GOV Lead Activities A M J Outputs partner Biannual DR-TB technical support and mentorship visits to the Conduct biannual DR-TB technical support and mentorship visits to the provinces. X PATH provinces conducted. Conduct contact tracing for DR-TB and refer contacts for investigation. ETB will PATH support efforts to conduct a contact investigation for each diagnosed DR-TB Contact tracing for DR-TB and referring contacts for investigations Afya Mzuri X X X patient and will follow up closely in all six provinces to ensure linkage to supported. CITAM+ treatment for any contacts who are diagnosed with TB. SUB-TASK 2.3. INCREASE TB DETECTION AND TREATMENT AMONG CHILDREN AND PREGNANT WOMEN. 2.3.1. Strengthen childhood TB management. Conduct HCW training on childhood TB in collaboration with ZPA in Muchinga, PATH X 60 HCWs trained in childhood TB. Central, and Copperbelt provinces. Support on-site zonal trainings and facility mentorship. PATH X 8 zonal trainings conducted. Develop and print childhood TB job aids in collaboration with the ZPA. PATH X Childhood TB training materials, job aids, and monitoring tools printed. Design scorecard for pediatric TB diagnosis jointly with ZPA. PATH X Scorecard for pediatric TB diagnosis completed. Nutrition program staff in 22 high TB burden districts oriented to Orient health workers in nutrition program in childhood TB detection. PATH X childhood TB detection. Conduct TB training focused on MCH staff in 22 high TB burden districts in Copperbelt and Central provinces. The trained MCH coordinators will in turn Six provincial nursing officers and 63 district MCH coordinators trained PATH X orient staff working in various MCH departments of health facilities to detect in TB case detection and management. presumptive TB patients among those seeking MCH services. Support development of gender-specific module for inclusion in HCW capacity- PATH X Gender-specific module developed and printed. building. 2.3.2. Conduct childhood TB screening. Intensify contact tracing for all TB-exposed children. Afya Mzuri X X Contact tracing conducted for all TB-exposed children. Support provision of TPT in children. PATH X X X Increased number of children initiated on TPT. Conduct TB outreach activities in the 6 targeted provinces during Child Health PATH Outreach activities conducted during Child Health Weeks in June and X Weeks. Afya Mzuri November. Support monthly TB screening services during MCH outreach activities. PATH X X X Monthly TB screening conducted during MCH outreach activities. Conduct TB awareness and screening activities in schools and colleges. Afya Mzuri X X Increased case detection among students in schools and colleges. SUB-TASK 2.4. PROVIDE SUPPORT TO INCREASE TB DETECTION AND TREATMENT AMONG PRISONERS. 2.4.1. Support capacity-building. Conduct quarterly TSS to ZCS facilities by provincial teams. PATH X ZCS TB technical review meetings supported. Conduct biannual TSS to selected ZCS facilities by central team. PATH X Technical support and mentorship provided to ZCS facilities. 2.4.2. Support TB screening among inmates. Conduct entry, exit, and biannual mass TB screenings in correctional facilities. PATH X Mass TB screenings in correctional facilities supported. Conduct onsite orientation for correctional facility staff on the use of the X X On site orientation on use of registers conducted registers. Support TB treatment adherence and referral at exit for inmates on treatment X X X Treatment adherence and referral at exit supported
USAID.GOV USAID ERADICATE TB PROJECT | 44 Lead Activities A M J Outputs partner 2.4.3. Coordinate partners working with ZCS. Conduct quarterly technical review meeting to review performance and technical aspects of implementation by all partners working in ZCS facilities in TB/HIV Afya Mzuri X Quarterly technical review meeting for ZCS facilities conducted. programs. ETB will support 1 meeting and other partners are expected to support the other 3 meetings. TASK 3. ENGAGE ALL CATEGORIES OF CARE PROVIDERS. SUB-TASK 3.1. ENGAGE TRADITIONAL PROVIDERS. 75 THPAZ members trained as referral agents from 35 districts Conduct quarterly supportive supervision and monitoring meetings with Afya Mzuri X supported and monitored to encourage their commitment to traditional healers trained as TB referral agents. contribute. Conduct biannual progress review meetings with THPAZ provincial and national Two meetings engaging ETB, MOH, and THPAZ from both the national Afya Mzuri X leadership. and provincial leadership levels convened. Explore the provision of incentives to traditional health practitioners involved in Incentives provided based on targets for every positive case and Afya Mzuri X X X notifying TB patients. presumptive referral provided. SUB-TASK 3.2. IMPROVE CBV ENGAGEMENT IN TB CASE FINDING AND TREATMENT SUPPORT. Initiatives Implement a nonfinancial recognition system for CBVs. X X Nonfinancial recognition system for CBVs developed and implemented. Afya Mzuri Provide transport refunds and enablers to motivate CBVs in ETB-supported 450 CBVs given transport refund and enablers to conduct TB case Afya Mzuri X X X facilities. finding activities. Develop a supervision guide and orient TB focal persons to supervise community Initiatives Group supervision guide developed and 14 facility TB focal point volunteers, conduct record reviews, lead data assessments, and conduct joint X X Afya Mzuri persons oriented to the CBV supervision tool. planning to set targets and monitor achievements against targets. SUB-TASK 3.3. ENGAGE TRADITIONAL LEADERS. Afya Mzuri Awareness-raising during three major traditional ceremonies Conduct ICF and awareness raising during three major traditional ceremonies. X X PATH conducted. TASK 4. INTENSIFIED RESEARCH AND INNOVATION. 4.1. BUILD CAPACITY IN OR AND ESTABLISH NATIONAL TB OR PRIORITIES. 4.1.1. Conduct TB OR introductory workshops and research priority-setting meetings (phase 1). Conduct one 3-day TB OR introductory workshop and research priority–setting ZAMBART X OR prioritization meeting held for 15 applicants. meetings for 15 district-level staff. 4.1.2. Conduct a TB OR proposal development workshop (phase 2). Conduct a six-day TB OR proposal development workshop for 20 district-level One OR proposal development workshop held for the ten selected ZAMBART X staff. applicants and their co-investigators.
45 | USAID ERADICATE TB PROJECT USAID.GOV Lead Activities A M J Outputs partner 4.1.3. Submit OR proposals for review by stakeholders. Ten full-length OR proposals and application forms submitted X simultaneously to PATH’s institutional review board, USAID Zambia, and the MOH for review. Ten full-length OR proposals, proposal summaries, and completed X application forms submitted to UNZABREC for expedited ethical
Support submission of OR proposals for review by stakeholders. review. ZAMBART Revised, full-length OR proposals, detailed revision summaries, and X cover letters resubmitted to UNZABREC for ethical review (number determined by outcome of first UNZABREC review). X Ten request letters sent to NHRA for approval of proposals. X Ten letters sent to MOH for approval to collect data. 4.1.4. Conduct mentorship visits to districts implementing OR projects. Conduct three mentorship visits to districts implementing OR projects. ZAMBART X X Three OR mentorship visits conducted. 4.1.5. Disseminate OR findings. ZAMBART PATH X One national-level research dissemination meeting held. NTLP Hold stakeholder meetings to disseminate OR findings. ZAMBART OR findings disseminated at three provincial data review meetings PATH X (Copperbelt, Northern, and Central). NTLP 4.1.6. Support quarterly meetings for the OR subcommittee of the TB TWG. ZAMBART Support quarterly meetings for the OR subcommittee of the TB TWG. PATH X Four OR subcommittee meetings held. NTLP 4.1.7. Support implementation of the DESTRoy TB study. ZAMBART Support implementation of the DESTRoy TB study. PATH X X One study on DR-TB treatment implemented. NTLP 4.2 Develop strategic partnerships for OR. Engage training institutions like UNZA School of Public Health, the Zambia Medical Association, Chainama College of Health Sciences, and the General ZAMBART X X Training institutions engaged in including OR for TB in curriculum Nursing Council to discuss potential cooperation in OR as well as inclusion of OR X for TB in their training curricula.
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