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 Zambia 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 2 | USAID ERADICATE TB PROJECT USAID.GOV 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 3 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 4 | USAID ERADICATE TB PROJECT USAID.GOV 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 Copperbelt, 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 Lufwanyama 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- 5 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). 6 | USAID ERADICATE TB PROJECT USAID.GOV 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. 7 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