GABE BIENCZYCKI FOR PATH

USAID ERADICATE TB PROJECT DECEMBER MONTHLY PROGRESS REPORT Reporting period: December 1–31, 2019

Submission date: January 20, 2019

Submitted to: Submitted by: Dr. Nancy Kasese-Chanda Dr. Joseph Nikisi Contracting Officer Representative Chief of Party USAID USAID ETB Project Email: [email protected] Email: [email protected]

USAID.GOV USAID ERADICATE TB PROJECT | 1

TABLE OF CONTENTS

ABBREVIATIONS ...... 3

PROGRAM UPDATES ...... 5

PERFORMANCE MONITORING UPDATE ...... 5

CHALLENGES ...... 24

LESSONS LEARNED ...... 25

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ABBREVIATIONS ACF active case-finding ART antiretroviral therapy CBV community-based volunteer CDC Centers for Disease Control and Prevention CEC clinical expert committee DHD district health director DISCOVER-Health District Coverage of Health Services Project DQA data quality assessment DR-TB drug-resistant tuberculosis DS-TB drug-susceptible tuberculosis DTLC district tuberculosis and leprosy coordinator ECG electrocardiogram ECHO Extension for Community Health Outcomes EID early infant diagnosis EPTB extrapulmonary tuberculosis EQA external quality assessment ETB Eradicate Tuberculosis Project HCW health care worker HIV human immunodeficiency virus HRH human resources for health ICF intensified case finding LTFU lost to follow-up MOH Ministry of Health MSL Medical Stores Limited MTB Mycobacterium tuberculosis NC not converted NE not evaluated NTLP National Tuberculosis and Leprosy Control Program NTRL National Tuberculosis Reference Laboratory OR operational research PLTFU primary loss to follow-up PTB pulmonary tuberculosis RIF rifampicin RR rifampicin resistance RR-TB rifampicin-resistant tuberculosis

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SAFE Supporting an AIDS-Free Era TB tuberculosis TDRC Tropical Diseases Research Center TPT tuberculosis preventative therapy TSS technical supportive supervision TWG technical working group USAID United States Agency for International Development ZMW Zambian Kwacha

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PROGRAM UPDATES This section summarizes activities conducted from December 1 through 31, 2019.

PERFORMANCE MONITORING UPDATE This section presents key performance indicators that the Eradicate Tuberculosis (ETB) project monitors monthly. During this reporting period (December 1 through 31, 2019), data were collected from 249 health facilities across the six ETB-supported provinces: 144 in , 34 in Central, 20 in Luapula, 14 in Muchinga, 19 Northern, and 18 in North-Western. A new TB notification site, Nkana health center, was added in district, Copperbelt in December 2019.

TB TESTING Figure 1 provides the cascade of tuberculosis (TB) testing in the laboratory from September through December 2019. In December 2019, ETB recorded 9,252 individuals presumed to have TB and 9,616 individuals tested for TB in the laboratory (representing 104% testing rate). As shown in Figure 2 below, testing rates beyond 100% are a result of referred samples, from both ETB-supported and non-supported sites, processed in GeneXpert® hubs supported by the project. ETB recorded a positivity yield of 6% in December 2019.

Figure 1. TB testing and treatment-initiation cascade, September through December 2019.

16,000 14,000 12,000 10,000 8,000 6,000 4,000

2,000 5%95% 6%101% 6%90% 6%98% 0 Sep—2019 Oct—2019 Nov—2019 Dec—2019 No. of TB presumptive individuals 10,973 11,068 9,574 9,252 No. of individuals tested for TB in 14,741 10,883 11,501 9,616 the lab No. bacteriologically confirmed 795 658 747 601 No. bacteriologically confirmed 756 665 672 587 initiated on treatment Target number of indivuals tested 4,995 4,995 4,995 4,995 in the lab

Abbreviation: TB, tuberculosis.

In February 2020, ETB will introduce the use of the OneStopTB mobile clinic to enhance screening with Computer-Aided Detection for Tuberculosis (CAD4TB) automated digital x-ray in Copperbelt and Central provinces where TB hotspots are located.

Of the 601 individuals that were diagnosed with TB in December 2019, 587 (98%) were initiated on treatment, an increased rate compared to November 2019 (90%). Through project-supported community-

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based volunteers (CBVs) and TB focal point persons, between January 3 and 30, the project will support the tracing of the 14 primary loss to follow-up (PLTFU) patients and link them to treatment.

Figure 2 gives a breakdown of laboratory testing efforts for both referred and non-referred samples. Of the total 9,252 presumptive TB patients that were documented in December 2019, only 7,714 (83%) had their sputum tested for TB. To increase the proportion of the presumptive patients’ samples that are tested for TB in the laboratory, the referral between the symptomatic screening and laboratory testing points will be strengthened starting February 2020. The positivity rate of referred samples is low, recording 3% in December as compared to 7% in diagnostic facilities; to bridge the gap, the project will provide active mentorship of clinical staff in all departments of referring facilities, on algorithms for sputum sample collection. The project will need to investigate the flow of samples between referring and diagnostic facilities in the active case finding (ACF) hotspots against the documentation practices in the presumptive registers of the referring facility to close this gap. In February, the project will also use the OneStopTB clinic as an additional diagnostic facility during community ACF activities in Copperbelt and Central provinces. The use of digital X-ray on the OneStopTB clinic will improve patient selection to be subjected for, sputum examination.

Figure 2. Individuals tested in the laboratory and confirmed to have TB: testing facilities vs referring facilities, September through December 2019.

16,000

14,000 3,751 12,000

10,000 2,533 2,472 1,902 8,000

6,000 10,973 10,990 10,892 9,574 8,968 9,252 4,000 8,411 7,714

2,000 4% 4% 6% 3% - 6% 6% 7% 7% Presume Confirme Presume Confirme Presume Confirme Presume Confirme Tested Tested Tested Tested d d d d d d d d Sep —2019 Oct —2019 Nov —2019 Dec —2019 From refering facilities 3,751 150 2,472 136 2,533 92 1,902 57 From testing facilities 10,973 10,990 645 10,892 8,411 522 9,574 8,968 655 9,252 7,714 544

Figure 3 shows the community activities’ contribution to the overall project screening efforts. Of the 1,272 patients that were notified by the project in December 2019, 449 (35%) were notified through community efforts. Of the 8,868 individuals presumed to have TB, 2,975 were unable to produce sputum and were referred to health centers for examination. The positivity rate for samples collected via routine community activities was 9%. All 449 patients diagnosed with TB were linked to treatment and care (100% linkage).

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Figure 3. CBV-led TB screening activities, December 2019.

70,000

60,000

50,000

40,000

30,000 42% 41% 20,000

33%49% 10,000 80%66% 80%81% 10% 9% 104% 100% - No. of No. of No. of individuals No. of samples No. of samples No. of patients confirmed TB individuals No. of symptomaticall referred for examined in confirmed with patients reached with presumptives y screened for examinations the lab TB. initiated on TB messages. TB treatment. Nov—2019 57,811 24,437 8,130 6,504 5,229 520 540 Dec—2019 44,449 18,233 8,868 5,893 4,754 449 449

Abbreviation: CBV, community-based volunteer; TB, tuberculosis.

Figure 4 provides a trend of GeneXpert® usage compared to microscopy in ETB-supported sites. With a low supply of GeneXpert cartridges from Medical Stores Limited (MSL) across the ETB-supported provinces, GeneXpert accounted for 60% of laboratory testing in both November and December. Continued power outages across the country have negatively impacted GeneXpert testing. Despite these challenges, the project has continued supporting facilities to promptly re-channel referred samples to GeneXpert hubs that have power supply through solar, generator, or conventional sources.

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Figure 4. Proportion of individuals tested for TB using microscopy vs GeneXpert®, September through December 2019.

100% 90% 31% 80% 40% 46% 40% 70% 60% 50% 40% 69% 30% 60% 54% 60% 20% 10% 0% Sep—2019 Oct—2019 Nov—2019 Dec—2019

% of individuals tested for TB in the lab using GeneXpert % of individuals tested for TB in the lab using Microscopy

Abbreviation: TB, tuberculosis.

TB NOTIFICATIONS Figure 5 shows the number of TB patients notified in the six ETB-supported provinces. A total of 1,272 TB patients were notified in December 2019, of whom 46% were bacteriologically confirmed and 54% were clinically diagnosed. Of the 1,272 TB patients notified in December 2019, 813 (64%) were male and 459 (36%) female.

Figure 5. TB patients notified by type of diagnosis, September through December 2019.

1,800

1,600 1,475 1,389 1,400 1,275 1,272 1,200 48% 1,000 52% 48% 54% 800 600 400 52% 52% 48% 46% 200 0 Sep—2019 Oct—2019 Nov—2019 Dec—2019 Clinically diagnosed patients 711 610 716 685 notified Bacteriologically diagnosed 764 665 673 587 patients notified Target 1,701 1,701 1,701 1,701

Figure 7 shows the breakdown of the 1,272 TB patients notified in December 2019 by type of TB and type of diagnosis. Of the total TB patients notified, 579 (45%) were bacteriologically confirmed pulmonary tuberculosis (PTB) patients, 585 (46%) were clinically diagnosed PTB patients, and 100 (8%) were bacteriologically confirmed extrapulmonary tuberculosis (EPTB) patients.

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Figure 6. TB notifications by type of TB and type of diagnosis, December 2019.

EPTB clinically diagnosed, 100, 8%

1,272 PTB PTB clinically TB patients bacteriologically diagnosed, 585, confirmed, 579, 46% notified 45%

EPTB bacteriolgically confirmed, 8, 1%

Abbreviations: EPTB, extrapulmonary tuberculosis; PTB, pulmonary tuberculosis.

Of the total individuals notified in December, 105 (8%) were children (Figure 7). Of key is the increase in number of children from 0–1 year of age (from 13 in November to 16 in December) and 5–9 years of age (from 18 in November to 21 in December). This resulted from enhanced health care worker skills and confidence in TB diagnosis among children, following training in childhood TB in November 2019.

Figure 7. TB notifications by age and sex, December 2019.

1200

1000

800

600

400

200

0 0-14 Yrs 15+ Yrs Female 50 409 Male 55 758

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Figure 8 summarizes the TB notifications by province. All the provinces recorded a reduction in TB notifications between November and December 2019. A significant reduction in TB notification was noted in Northern by 39 patients (149 to 110), representing 35% reduction; Copperbelt by 19 (780 to 761), representing 2%; Luapula by 18 (130 to 112), representing 16%; North-Western by 17 (123 to 106), representing 16%; Muchinga by 14 (63 to 49), representing 29%; and Central by 10 (144 to 134), representing 7%.

Figure 8. Notification trends by province, November through December 2019.

900

800

700

600

500

400

300

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0 Central Copperbelt Luapula Muchinga North-Western Northern Nov—2019 144 780 130 63 123 149 Dec—2019 134 761 112 49 106 110

TREATMENT OUTCOMES Figure 9 summarizes performance on smear conversion at two months for patients that were initiated on TB treatment in September 2019. ETB documented a smear conversion rate of 86% after this cohort had been on treatment for 2 months. The high proportion of patients not evaluated (9%) at two months negatively impacts smear conversion rates. The provinces with high proportions of patients not evaluated (above 5%) include Northern, North-Western, Luapula, and Central. To remediate these unfavorable outcomes, the provincial teams will work with Ministry of Health (MOH) staff and CBVs to follow up with all patients that missed their two months scheduled visit using the tracking system (patients’ sputum follow-up tracker) that is in place.

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Figure 9. Smear conversion rates and outcomes at two months of treatment for patients initiated on treatment in September 2019.

800 Not re-tested at 2 months, 86 (12%) Died, 11 (1%) LTFU, 10 (1%) 700 NE, 65 (9%) 600 NC, 15 (2%) 500

400 Retested at 2 Converted, 610 (86%) Initiated, 711 months, 625 of initiated and 98% of 300 (88%) re-tested

200

100

0 Initiated Testing at 2 months Outcomes

Initiated Re-tested at 2 months Not re-tested at 2 months Converted NC NE LTFU Died

Abbreviation: LTFU, lost to follow-up, NC, not converted, NE, not evaluated.

Figure 10 depicts trends of favorable and unfavorable TB outcomes at two months of treatment. ETB noted an increase in the conversion rate, from 81% in November to 86% in December 2019. ETB also noted a modest increase in the proportion of TB patients initiated on treatment and re-tested at two months, from 86% to 88% between November and December. Muchinga exceeded the smear conversion rate target of 90%, reporting 98% in December 2019. The incentivized ETB-supported CBVs have continued carrying out their activities diligently, giving reminders to all patients due for clinic visits and accompanying some patients to the health facility. The counseling provided by TB facility staff and CBVs to all patients commenced on treatment has also contributed to these positive outcomes. The pronounced decline in both loss to follow-up and not converted is linked to CBV efforts and high-quality services provided to patients by facility focal point persons as a result of ETB-driven technical supportive supervision (TSS) and mentorship. During TSS and mentorship activities in January 2020, ETB will focus on supporting health care workers (HCWs) to reduce the proportion of patients not evaluated.

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Figure 10. Smear conversion at two months outcomes trends, September through December 2019.

Abbreviations: LTFU, lost to follow-up; NC, not converted; NE, not evaluated.

Figure 11 depicts the monthly treatment success rates from September through December 2019. In December, ETB recorded a treatment success rate of 91%, exceeding the set target of 90%. At both facility and community levels, ETB continues to support implementation of the tracking system for patients due for end-of-treatment sputum follow-up and provides adherence support to all patients commenced on TB treatment. Provinces that had treatment success below 90% include North-Western (82%) and Central (88%). In January 2020, the project will provide focused TSS in treatment adherence and treatment monitoring to the CBVs and HCWs in facilities with low treatment success rates in North- Western and Central provinces.

Figure 11. TB treatment success rates, September through December 2019.

100% 90% 90% 92% 91% 90%

80%

70%

60%

50%

40%

30%

20%

10%

0% Sep —2019 Oct —2019 Nov —2019 Dec —2019

Cured % Completed % Target

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Unfavorable outcomes at end of treatment are depicted in Figure 12. ETB noted a downward trend in the proportion of TB patients lost to follow-up from 3% in November to 2% in December 2019. CBVs are actively supporting patients to visit health facilities to receive follow-up services. Treatment failure, not evaluated, and mortality rates remain below 5%.

Figure 12. Unfavorable outcomes at the end of TB treatment, September through December 2019.

6%

5% 5%

4% 4% 4%

3% 3% 3% 3% 3%

3% 2% 2% 2%

1% 1% 1% 1% 1% 0% 0% 0% Sep—2019 Oct—2019 Nov—2019 Dec—2019 Treatment failure 0% 1% 0% 1% Lost to follow up 3% 4% 3% 2% Not evaluated 3% 1% 1% 2% Died 4% 5% 3% 3%

TB/HIV COLLABORATION Figure 13 summarizes the performance of ETB-supported sites on TB/HIV collaborative activities from September to December 2019. ETB-supported sites exceeded the 95% targets for both TB patients tested for HIV and TB/HIV patients on antiretroviral therapy (ART): in December 2019, ETB-supported sites recorded 98% for both indicators. Of note is the increase in the proportion of TB patients infected with HIV that were either initiated on continued on ART, from 96% in November to 98% in December 2019. Contributing factors to the positive results include continuous focused site-level technical support and joint monthly data review meetings held between the TB and HIV entry points, where both ETB and HIV partner staff participate.

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Figure 13. HIV testing and treatment linkage amongst TB patients, September through December 2018.

1,600 99% 98% 1,400 99% 98% 1,200

1,000

800

42% 600 38% 96% 91% 41% 97% 40% 98%

400

200

- Sep—2019 Oct—2019 Nov—2019 Dec—2019 TB patients notified (all forms) 1,475 1,275 1,389 1,272 TB patients (all forms) with a documented 1,456 1,257 1,364 1,245 HIV status TB/HIV co-infected patients 560 510 575 504 TB/HIV co-infected patients on ART 512 497 554 496

Abbreviations: ART, antiretroviral therapy; TB, tuberculosis.

DRUG-RESISTANT TUBERCULOSIS (DR-TB) Figure 14 shows DR-TB patients diagnosed and linked to care from September through December 2019. A total of 22 DR-TB patients (10 females and 12 males) were diagnosed in December (7 from Central, 13 from Copperbelt, 1 from Northern, and 1 from North-Western). All 22 patients initiated second-line treatment in the same month (December).

Also during the reporting period ETB conducted a DR-TB data quality assessment which revealed underreporting in October and November 2019. In the submitted monthly reports, ETB reported 13 patients detected in October and 15 in November. However, the verified data revealed 21 DR-TB patients for October and 19 DR-TB patients for November 2019. The project database has since been updated with these changes and the quarterly report will reflect the revised DR-TB results.

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Figure 14. Drug-resistant TB patients diagnosed and initiated on second-line treatment in the six ETB-supported provinces, September through December 2019.

25 85%

20 77%

73% 15 122%

10

5

0 Sep—2019 Oct—2019 Nov—2019 Dec—2019 No. of individuals testing positive for RR 14 21 19 22 No. of RR positive patients initiated on 14 19 15 22 secondline TB treatment

Abbreviations: RR, rifampicin resistance; TB, tuberculosis.

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ACTIVITY UPDATE COMMENTS

TASK 1: PURSUE HIGH-QUALITY DIRECTLY OBSERVED THERAPY, SHORT-COURSE (DOTS) EXPANSION AND ENHANCEMENT.

1.1.1: Engage high-level ETB is preparing a draft concept note to be shared with Airtel and other mobile phone companies in January 2020. corporate entities.

1.1.6.2: Support the NTLP to ETB liaised with the NTLP on the format and schedule for the technical working group (TWG) meetings for 2020. The coordinate TB TWG meetings. meetings are set for the last Thursday of every month and will have a technical subject to be discussed at each meeting. No TWG meetings took place in December 2019.

1.1.7.2: Conduct awareness-raising CBVs continued to be the main conduit for TB awareness-raising in target communities. In December, 44,449 people activities via CBVs in facilities and were reached with messages, and 18,233 were screened for TB, of whom 8,868 people were presumed to have TB. A during ICF outreach. total of 5,893 presumptive produced sputum samples; of those, 4,754 samples were tested in the lab, and 449 samples were bacteriologically confirmed (9% positivity yield). TB awareness-raising activities were conducted in 141 communities linked to the facilities where the project has deployed CBVs from the 23 high-volume districts. In order to increase CBVs’ yield outputs, the project will focus on intensifying TSS and mentorship to facilities where CBVs are deployed. The TSS shall address patient outcomes issues, ACF, contact tracing for all drug-susceptible tuberculosis (DS-TB) and DR-TB patients, sputum sample collection and referrals, documentation and reporting, etc.

1.2.1: Quality-assure diagnostic ETB’s laboratory advisor attended the laboratory TWG meeting on December 12, 2019, convened by the MOH and services through GeneXpert. attended by all partners supporting laboratory services. CDC and the Clinton Health Access Initiative updated the meeting on the GeneXpert multi-disease testing for early infant diagnosis (EID): EID cartridges are available for the 18 priority districts. ETB shared the training model that is implemented for TB and was adapted to be used for the EID GeneXpert training. The ETB laboratory advisor will continue to participate in the GeneXpert multi-disease testing task force.

1.2.1.3: Support service and repair of The project continued to monitor the functionality of 136 existing GeneXpert machines in ETB-supported provinces and GeneXpert machines in six ETB- is working closely with FOBs, the local agent providing maintenance support: supported provinces. • In , ETB supported the calibration of the GeneXpert machines at five hospitals. All modules passed calibration at Mansa General and St Paul’s Mission hospitals. Two modules failed calibration each at Mwense and Chienge District Hospitals. The Kawambwa GeneXpert could not be calibrated due to a communication error between the GeneXpert and calibration softwares. ETB shared the calibration report with FOBs, who will facilitate calibration of the GeneXpert machine the week beginning January 12, 2020.

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ACTIVITY UPDATE COMMENTS

• In Northern province, ETB transported Kasama General Hospital’s repaired GeneXpert back to the province.

• In , the GeneXpert at District Hospital and Urban was non-functional for the month of December. GeneXpert had a faulty cable, which has since been replaced, and the Mpika machine has a software problem. FOBs has been notified.

• In North-Western province, two GeneXpert machines are not in use, at Chavuma Mission Hospital due to an incompatible cable, and at Sachibondo Health Center due to lack of a lightening arrester. FOBs is currently in the province and will provide a new cable. The district is in the process of procuring the lightening arrester.

• In , ETB’s laboratory specialist worked with the provincial biomedical scientist to replace and calibrate modules at Chavuma Clinic, Teaching, Kakoso Level 1, Malcom Watson, and Wusakile Mine Hospitals.

• In Central province, a GeneXpert machine in had two non-functional modules, and the GeneXpert machine in Ngungu district had one non-functional module.

1.2.2: Provide technical The project supported EQA for smear microscopy quality assessment in Northern and Copperbelt provinces: The report for assistance for quality assurance. Central province will • In Northern province, 21 laboratories participated in EQA. The province improved its performance from 77% (i.e., be ready in January 77% of participating facilities passed) in FY19 Q3 to 86% in FY19 Q4. ETB continues to provide consistent 2020. mentorship and onsite trainings to laboratories that have had poor performance, particularly in addressing low false negatives and high false positives.

• In Copperbelt province, 64 laboratories participated in EQA. The provincial performance declined from 94% in FY19 Q3 to 73% in FY19 Q4. Four laboratories recorded high false negatives, 2 recorded high false positives, 4 recorded low false positives, and 3 recorded quantification errors. The investigation of errors found high attrition of experienced laboratory staff, reduced proficiency among laboratory staff in smear examination, poorly prepared stains, and inconsistent internal quality control. ETB continues to provide mentorship and onsite training to laboratories that have had poor performance, particularly in addressing false results. Copperbelt ETB and MOH staff will conduct onsite technical support in the last week of January 2020 to provide the technical support needed in poorly performing laboratories.

1.2.4.1: Conduct quarterly technical ETB supported laboratory mentorship in 8 high-volume facilities in Muchinga province to address gaps identified during supportive supervision and September 2019 TSS, which included incomplete filling in of registers and inconsistent internal quality control. A total of mentorship visits in targeted districts 12 laboratory staff were mentored. All 8 facilities visited had worked to improve in relation to identified gaps. with high notifications.

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ACTIVITY UPDATE COMMENTS

1.2.5.1: Participate in national-level In Northern province, ETB’s laboratory specialist participated in a partners meeting, convened on December 6 by the courier system consultative meetings. MOH and attended by EQUIP and DISCOVER-Health. The objective was to incorporate and strengthen the collaboration with DISCOVER-Health on the viral load and sputum courier system integration supported by EQUIP and ETB. DISCOVER-Health has not yet provided feedback on their contribution to the courier system.

1.2.5.2: Support the intra- and inter- The project continued to support the intra-district courier system, with a total of 3,017 samples transported for There was a drop in district courier system. GeneXpert testing and 78 for culture at NTRL and TRDC. A total of 2,723 results were returned to the referring the number of facilities as summarized below: samples referred for testing by • In Northern province, 315 sputum specimens were couriered and 315 results were returned. In addition, Northern GeneXpert due to province couriered 7 follow-up MDR-TB specimens and 1 DR-TB diagnostic sputum specimen to the NTRL. stockout of • In Muchinga province, 189 samples were couriered in Mpika, , and districts for GeneXpert testing, cartridges at MSL and 189 results were returned. The project also supported the MOH to transport 8 samples from three districts to and low stocks at the NTRL for culture. facility level.

• In North-Western province, 161 samples were couriered for GeneXpert testing, and 161 results were returned in the three supported districts. Additionally, 25 DR-TB follow-up samples were referred to TDRC for culture.

• The Copperbelt intra-district system couriered 1,887 samples for GeneXpert testing, and 1,887 results were returned in Kitwe and .

• In Central province, 465 samples were couriered for GeneXpert testing in , Mumbwa, and , and 37 DR-TB follow-up specimens were referred to NTRL for culture. At the time of reporting, 294 samples for GeneXpert testing from were pending processing due to load-shedding.

• No samples were couriered in Luapula province in December due to a breakdown of the courier motorbike. ETB is supporting the repair of the motorbike, and currently the project is the process of vendor registration. This process will conclude before end of February 2020.

1.3.2.2: Strengthen capacity and Following the diary review visit to Copperbelt (Ndola, Kitwe, , and ) in November, the ETB’s HRH coordination of district TB advisor organized an online meeting on December 12 with all ETB provincial staff to discuss strategies to improve diary coordinators. use and decision-making. However, due to poor internet connectivity, only Central province was able to connect. The Central province team was oriented to the use of the diary and support they can provide to the DTLCs to ensure the diaries provide useful information. Another meeting is set for January 2020 to orient other provincial ETB staff. ETB has prioritized strengthening supportive supervision and monitoring of the DTLC diary in 2020.

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ACTIVITY UPDATE COMMENTS

1.3.3.4: Provide treatment adherence In December 2019, 3,055 patients received counseling and adherence support from ETB-supported CBVs, from a total of support to TB patients in all target 3,552 TB patients that were under the care of CBVs. districts.

1.3.4.1: Strengthen facility based ICF. ETB supported Kitwe, Ndola, and Mufulira districts to conduct facility-based intensified case finding (ICF) from December 9–14 at Kitwe Teaching, Ndola Teaching, and Ronald Ross hospitals respectively. A total of 1,375 patients were screened for TB, of whom 293 (21%) were presumed to have TB. A total of 271 sputum samples (92%) were examined in the laboratory, out of which 25 (9%) were diagnosed with bacteriologically confirmed TB, and 43 were clinically diagnosed with TB. All 68 TB patients (representing 25% of those tested) were initiated on TB treatment.

1.3.4.2: Support monthly mass TB ETB supported Kitwe, Ndola, and Chingola districts to do community-based ACF from December 9–14 at Mapalo, Buchi screenings targeting hotspot Main, and Chiwempala TB “hotspots.” A total of 1,681 patients were screened for TB, and 269 (16%) were presumed to communities in Copperbelt and have TB. A total of 247 sputum samples (92%) were examined in the laboratory, of which 19 (8%) were bacteriologically Central provinces. confirmed with TB, and 4 were clinically diagnosed with TB. All 23 TB patients (representing 9% of those tested) were initiated on TB treatment. ETB also convened preparatory meetings on December 18 and 31 for the OneStopTB mobile clinic launch. The launch will take place on January 22, 2020 in Kitwe, as Kitwe has the highest TB burden in the province and is also located in the centre of the province.

1.3.4.3: Support mass TB screening in In (Luapula province), ETB supported ACF and ICF at Chinsaka, Kasanka, Yongolo, Kantashya, and Samfya selected sites (hotspots) of 22 high- stage 2 clinics from December 9–14, 2019. At the community level, 423 individuals were reached with TB messages, and burden districts during national health all 423 were screened for TB by CBVs. Of those screened, 97 (23%) were presumed to have TB, and all 97 individuals events. (100%) submitted sputum samples for examination. Of the samples submitted, 89 samples (92%) were examined in the laboratory, and 8 samples (8%) leaked and were disposed of. A total of 3 individuals (3%) were bacteriologically confirmed, and no individuals from the community were clinically diagnosed. All 3 bacteriologically confirmed patients were initiated on treatment. At facility level, 929 individuals were reached with TB messages, 645 (69% of those reached with messages) were screened for TB, 122 (19%) were presumed to have TB, and all 122 TB presumptive patients (100%) submitted sputum samples for examination. Of the samples submitted, 113 (93%) were successfully examined in the laboratory, 6 samples (5%) were wasted due to power outages, and 3 sputum samples (2%) leaked. A total of 5 bacteriologically confirmed patients were detected (4% positivity) and 3 patients were clinically diagnosed. Of the 8 patients confirmed with TB (representing 7% of those tested), 4 bacteriologically confirmed cases and all 3 clinical cases have been initiated on treatment (88% rate of linkage to treatment). ETB engaged treatment supporters to trace and link the remaining patient to treatment and care.

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ACTIVITY UPDATE COMMENTS

A total of 11 patients were diagnosed with TB and 10 patients (91%) were linked to treatment and care during the community ACF and facility-based ICF.

Sub-task 1.4: Support the existing NTLP M&E system.

1.4.1: Conduct data quality audit ETB conducted a DR-TB mop-up exercise from December 16–19, 2019 in Central, Copperbelt, Luapula, Northern, and The NTLP will activities. North-Western provinces. ETB worked with MOH staff from provincial, district, health facility, and community levels. At continue with the each site, lists of patients testing positive for RR were generated from GeneXpert software, laboratory registers, and DQA exercise in

treatment registers from treatment centers. Additional information was obtained from patient files. Verbal reports were January 2020. also obtained from facility staff who support patient care. Information on RR was gathered from 42 GeneXpert sites. A total of 303 patients were diagnosed with DR-TB. Of the 303, 249 patients (82%) were linked to care, while 54 (18%) had incomplete data and require follow-up.

Positive findings included: 1) the list of patients from laboratory and DR-TB treatment registers were successfully entered into the DR-TB database; and 2) lists of all diagnosed DR-TB patients were given to the TB treatment supporters and facility staff to do contact investigations. Areas requiring improvement included: 1) need to consult additional source documents, like outpatient department and patient files, to obtain patient details; 2) as part of associated efforts to reduce stigma, there is need to continue providing health education to patients on the importance of treatment support during the early days of treatment, which includes an opportunity to report all drug-related adverse events; 3) need to regularly review the list of DR-TB patients to avoid double entry; 4) need to return to verify data in some GeneXpert sites where data was not collected due to prolonged power outages and equipment breakdown; 5) need to collect data from the remaining GeneXpert sites and follow up with clients who have not commenced treatment or whose treatment status is unknown; and 6) ETB noted that Northern Command Hospital had wrongly commenced a DR-TB patient on first-line anti-TB treatment. ETB supported the referral of the patient to Ndola Teaching Hospital and TSS and mentorship was provided to the TB staff at Northern Command Hospital.

1.4.1.3: Conduct four DQAs in the In order to assess key quality dimensions (accuracy, completeness, and timeliness) of data collected by ETB from target provinces (starting in Q2) to supported sites, ETB conducted DQAs in 7 selected facilities in Central province, focusing on TB notifications (all forms), assess the extent to which treatment success rate, and percentage of TB patients with documented HIV status for the period October 2018 to improvement plan recommendations September 2019. have been implemented. As indicated in the table below, ETB determined that TB patient notifications were over-reported by 2%, the treatment success rate was under-reported by 3 percentage points, and the proportion of TB patients with documented HIV status was under-reported by 2 percentage points.

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ACTIVITY UPDATE COMMENTS

The table below summarizes the DQA findings for the three indicators assessed in 7 facilities of Kabwe District.

Indicator Reported Audited Variance (audited minus reported)

Number of TB patients notified 516 506 -10 patients

Treatment success rate 71% 74% 3 percentage points

% of TB patients with documented HIV status. 98% 100% 2 percentage points

The reporting errors were mainly due to over-counting (errors during data aggregation) and errors during data entry. To reduce errors during data entry, ETB introduced electronic reporting templates with built-in validations. ETB also introduced the application program interface for importing data in the project database to avoid data entry errors. ETB emphasized to facilities the need to ensure that the registers are up-to-date at all times. To avoid counting errors leading to over- or under-reporting of TB patients, ETB will strengthen the use of the ETB-developed data aggregation tool to assist data collectors with automatic summations of patient totals.

1.4.2.1: Collect TB, DR-TB, TB–HIV, In December 2019, ETB collected data from 249 health facilities across the six ETB-supported provinces: 144 in and community data on defined Copperbelt, 34 in Central, 20 in Luapula, 14 in Muchinga, 19 Northern, and 18 in North-Western. During this data schedules to meet internal and collection exercise, ETB supervised and mentored provincial, district, and facility NTLP staff on data collection, filing, external reporting data needs. analysis, and reporting. ETB staff also discussed documentation and reporting of HIV in TB patients as well as documentation of ART patients initiated on TPT with SAFE and EQUIP. The team also discussed the need to ensure that all registers are up-to-date before the reporting period. This monthly mentorship effort has improved completeness of registers, improved timeliness of data submission, and decreased the amount of errors on reported indicators.

2.2.1.3: Collaborate with Jhpiego and Jhpiego and ETB met on December 17, 2019 to review and finalize the curriculum and schedule the 2020 TB ECHO. The TB ECHO team other HIV partners to ensure that Participants in the meeting agreed to integrate the TB sessions into the HIV ECHO for 2020 to strengthen the dissemination will be given a rapid ETB-supported provinces participate of information and reduce the number of meetings that the DTLCs will attend. orientation in January in the ECHO program to improve 2020 by Jhpiego and The major tasks completed during the meeting included review of session objectives and identification of subject experts, staff performance using an e- will receive support subject panelists, and session facilitators. The meeting resolved to have 12 TB sessions beginning February 2020. mentorship approach. to host sessions in the early part of the year.

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ACTIVITY UPDATE COMMENTS

2.2.1.5: Conduct contact tracing for The provincial team in Central province continued the contact tracing exercise that began in November 2019 and visited ETB will support DR-TB and refer contacts for 15 index patients' households in December. 122 individuals were screened for DR-TB, 16 (13%) were presumed to have contact tracing in investigation. ETB will support efforts TB and all 16 submitted sputum for GeneXpert testing. Two (13%) were diagnosed with DR-TB. January 2020 and will to conduct a contact investigation for include contacts of Northern province also conducted contact tracing for 6 DR-TB patients: 45 contacts were traced, and 19 (42%) provided each diagnosed DR-TB patient and patients that were a sputum sample. No DR-TB patients were diagnosed among the contacts. will follow up closely in all six identified as DR-TB provinces to ensure linkage to ETB supported monthly patient reviews by CEC teams in the Copperbelt province. Teams reviewed 50 patients on during the DR-TB treatment for any contacts who are treatment from Kitwe (32), Mufulira (10), and Kalulushi and Lufwanyama (8). The CEC team from Kitwe Teaching DQA, from the 42 diagnosed with TB. Hospital conducted the patient review and noted that there is good treatment adherence with reduced mortalities after GeneXpert sites in two months of treatment initiation. all the provinces. Three new patients were initiated on treatment in Northern province, from Mbala, Luwingu, and Senga districts, with ETB’s support.

2.3.2.1: Intensify contact tracing for In December 2019, from a total of 2,153 individuals screened through contact tracing, 490 (23%) were children. Of the TB-exposed children. 148 children whose samples were collected and submitted to the lab, 1 was bacteriologically confirmed with TB, representing 0.7% of the total notifications through contact tracing.

2.4.2.4: Support TB treatment Trained treatment supporters from among the inmates, with supervision from district ETB staff, provided TB treatment adherence for inmates on treatment. adherence sessions to 19 inmates with TB at Kamfinsa and at Kansenshi correctional facilities.

TASK 3: ENGAGE ALL CATEGORIES OF CARE PROVIDERS.

3.2.3: Provide transport refunds and ETB supported 300 CBVs with transport refunds of ZMW500 for actively participating in ACF activities and conducting enablers to motivate CBVs in ETB- awareness-raising activities, contact tracing, patient follow-up, and treatment adherence support. The 300 CBVs are supported facilities. deployed in 141 facilities across the 22 high-TB-burden districts in the six ETB target provinces. To improve the community contribution toward ACF and treatment adherence support, the project increased the number of CBVs being supported with transport reimbursement from 300 to 500 across the 23 high-volume districts. The additional CBVs have not yet started receiving support because formalization processes are still underway, although most of them have already started working. The project will also ensure that it supports and maintains an active stock of only CBVs who are able to deliver on key programmatic output areas. CBVs failing to meet the set minimum targets (number of people screened, number of patients confirmed with TB, and number of patients provided with counseling and adherence support) consistently, without valid reasons, will be removed from project support and replaced.

TASK 4: INTENSIFIED RESEARCH AND INNOVATION.

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ACTIVITY UPDATE COMMENTS

4.1.3: Submit OR proposals for review In December 2019, ETB submitted two OR proposals to PATH’s research determination committee for ethical review: by stakeholders. 1. GeneXpert MTB/RIF under-utilization: Knowledge, attitude, and practices of health care workers in Samfya District 2. Factors Contributing to Low Childhood TB Case Notification in , Zambia. The two proposals were cleared by PATH’s research determination committee and have been submitted to USAID Zambia for further review and approval prior to submission to the University of Zambia Biomedical Research Ethics Committee.

4.1.5: Disseminate OR findings. On December 5, 2019, ETB disseminated findings from four Cohort 1 OR studies at a national-level meeting hosted by the National Health Research Authority in . ETB staff worked with OR trainees from Kapiri-Mposhi, Ndola, Chingola, and Mpulungu districts to prepare presentations for this meeting. More than 100 people attended the meeting, including provincial health directors for Central, Copperbelt, and Northern provinces and district health directors (DHDs) for Kapiri-Mposhi, Ndola, Chingola, and Mpulungu districts. Dr. Chimzizi, who represented the NTLP manager, urged DHDs to ensure that recommendations from the four studies are implemented. He also pledged the support of the NTLP manager in areas that needed the attention of the national office.

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CHALLENGES CHALLENGE CHALLENGE DETAILS PROPOSED SOLUTION ACTIONS STATUS / RESPONSIBLE TIMELINE TAKEN TO OUTCOME DATE ECG machines and ECG paper The doctors in Northern ETB will procure additional ECG ETB procured 10 Deputy Chief of Party are not readily available in all province delayed inititation of paper for the ECG machines packets of ECG and technical advisor districts where DR-TB treatment of two patients procured by CTB and for the 10 paper for Central patients need to be reviewed diagnosed with DR-TB in ECG machines that will be and Copperblet while in the intensive phase of November 2020 in Luwingu and procured next year that will be province. the oral bedaquiline-based Mbala districts because they did distributed to some districts where regimen. not have access to ECG paper. patients can be reviewed locally by clinicains in the district. Stockout of GeneXpert There is a stock out of ETB laboratory specialists will The project is Laboratory Ongoing cartridges GeneXpert cartridges at MSL. work with the provincial monitoring the strengthening The facilities have low stocks of biomedical scientists to ensure that cartridge stock specialist and cartridges because their orders laboratory testing continues status and liaising laboratory advisor were reduced. through the use of microscopy. with NTLP on the expected delivery dates. Breakdown of the motorbike The motorbike that is used for A motorbike repair company has Vendor registration Pending Laboratory Ongoing for courier support in Luapula courier of TB and viral load been identified and vendor vendor strengthening Province. samples broke down in Mansa registration is in progress. registration assistant, laboratory district. advisor, and admin assistant Abbreviations: ACF, active case finding; ETB, Eradicate Tuberculosis; MSL, Medical Stores Limited; NTLP, National Tuberculosis and Leprosy Control Program; TB, tuberculosis; TSS, technical supportive supervision.

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LESSONS LEARNED Arising from the NTLP-led DQA, ETB learned that using the TB treatment register as a source of notification data is misleading, as ETB found that up to 40% of TB patients diagnosed with TB were not entered in the book. There is need to strengthen the communication between the laboratory and TB clinics to comprehensively document all diagnosed TB patients.

During the DQA, ETB learned that patients marked as transferred-in are normally excluded from the notification counts when they would have not been reported at original diagnosis sites. To remediate this finding, ETB will provide TSS and mentorship to TB focal point persons to ensure that the referring facilities notify all diagnosed patients. During the TSS and mentorship, ETB will support facility staff to establish low-cost communication channels for the referring and receiving facilities to share outcomes.

The project has learned that the involvement of third-level hospitals in intensified case-finding activities, and training of HCWs in these facilities, yields positive results in increasing the proportion patients notified with TB who are children. Since ETB adopted this strategy in August 2019, the project has recorded an increase in the proportion of notified patients who are children, from the stagnant 6% (between October 2018 and September 2019), to 8% from October 2019 onwards.

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