STRENGTHENING TUBERCULOSIS CONTROL IN UKRAINE ANNUAL REPORT APRIL 2, 2012 SEPTEMBER 30, 2013 20 October 2013 This publication was produced for review by the United States Agency for International Development. It was prepared by Chemonics International in partnership with Project HOPE. STRENGTHENING TUBERCULOSIS CONTROL IN UKRAINE ANNUAL REPORT APRIL 2, 2012 SEPTEMBER 30, 2013 Contract No. AID-GHN-I-00-09-00004 Task Order No. AID-121-TO-12-00001 s of the United States Agency for International Development or the United States Government. CONTENTS Acronyms .................................................................................................................... vii Executive Summary .......................................................................................................1 I. Accomplishments by Objective ...............................................................................3 Objective 1: Improve the quality and expand availability of DOTS-based TB services .... 3 Objective 2: Create a safer medical environment ............................................................. 19 Objective 3: Build capacity to implement PMDT programs for MDR/XDR-TB ............. 24 Objective 4: Improve access to TB/HIV co-infection services ......................................... 29 II. Schedules ..............................................................................................................36 III. Challenges ..............................................................................................................37 Annexes Annex A. Performance Monitoring and Evaluation Report.............................................. 39 Annex B. Qualitative Baseline Assessment of Local TB Control Measures .................... 52 Annex C. List of Sub-Awards ........................................................................................... 77 STRENGTHENING TUBERCULOSIS CONTROL IN UKRAINE: ANNUAL REPORT v ACRONYMS ACSM Advocacy, communications, and social mobilization AR Autonomous republic ART Anti-retroviral therapy CoE Center of excellence DOT Directly observed treatment DOTS Directly observed treatment, short-course DRS Drug resistance survey DST Drug susceptibility testing EQA External quality assurance FDU Foundation for the Development of Ukraine GF Global Fund to Fight AIDS, Tuberculosis, and Malaria GoU Government of Ukraine GTBI New Jersey Medical School Global Tuberculosis Institute HIV/AIDS Human immunodeficiency virus/acquired immune deficiency syndrome HCW Health care worker IC Infection control IEC Information, education, and communication IQA Internal quality assurance KAP Knowledge, attitude, and practice M&E Monitoring and evaluation MDR-TB Multidrug-resistant tuberculosis o Ministry of Health NGO Nongovernmental organization NRL National Reference Laboratory NTP National Tuberculosis Program OR Operational research PAL Practical approach to lung health PHC Primary health care PLWH People living with HIV PMDT Programmatic management of drug-resistant TB PPE Personal protective equipment URCS Ukrainian Red Cross Society UV Ultraviolet R&R Recording and reporting SES State Sanitary and Epidemiological Service SIAPS Systems for Improved Access to Pharmaceuticals and Services SOPs Standard operating procedures STbCU Strengthening Tuberculosis Control in Ukraine TB Tuberculosis TIRC TB Training and Information Resource Center TST Tuberculin skin test UCDC Ukrainian Center for Socially Dangerous Diseases Control USAID United States Agency for International Development WHO World Health Organization XDR-TB Extensively drug-resistant tuberculosis STRENGTHENING TUBERCULOSIS CONTROL IN UKRAINE: ANNUAL REPORT vii EXECUTIVE SUMMARY Project Overview The five-year USAID Strengthening Tuberculosis (TB) Control in Ukraine (STbCU) project, implemented by Chemonics International in partnership with Project HOPE and the New Jersey Medical School Global Tuberculosis Institute (GBTI), seeks to improve the health status of Ukrainians by reducing the burden of TB through specific quality assurance and system strengthening measures for routine TB services, multidrug-resistant TB (MDR-TB), and TB/human immunodeficiency virus (HIV) co-infection. This report summarizes key accomplishments and progress by objective for Year 1 (April 2, 2012-September 30, 2013). Accomplishments Summary Objective 1: Improve the quality and expand availability of the World Health Organization (WHO)-recommended directly observed treatment, short-course (DOTS)-based TB services. In Year 1, new curricula on TB and MDR-TB case management, laboratory diagnostics, and infection control (IC) based on WHO-recommended best practices were introduced by the project and approved for use at Ukrainian medical universities. In addition, 790 health care providers successfully completed project-organized training and started applying best practices in TB detection, treatment, and prevention at their workplaces. National-level external quality assurance (EQA) guidelines were drafted to address deficiencies in the quality of laboratory practices. These guidelines now are undergoing legislative review. The health administrations in all USAID-supported regions issued local orders requiring that TB microscopy quality assurance be performed annually. Of these laboratories, 78.6 percent underwent EQA with over 95 percent correct microscopy results. Objective 2: Create a safer medical environment at the national level and in USAID- supported areas. Two regulatory documents on TB infection control (IC) were developed: one for TB treatment facilities and one for laboratories that perform TB diagnostics. In addition, two specific legal sections were proposed during the revision of the Ukrainian Law on Ensuring Sanitary and Epidemic Safety of the Population that specify IC and medical waste management procedures. Due to these and other reforms promoted by USAID, the State Sanitary and Epidemiological Service (SES) now implements evidence-based TB IC measures rather than focusing on punitive actions, as it previously did. The SES also established a new national group of TB IC experts to provide regional health facilities with recommendations and mentorship. IC plans in 18 health care facilities in USAID-assisted regions became operational. These plans included such measures as assessing transmission risk within facilities, distinguishing high-risk zones, separating patients in accordance with resistance profiles and contagiousness, establishing outdoor sputum collection points, and using personal protective equipment (PPE) and ultraviolet (UV) radiators. Objective 3: Build capacity to implement programmatic management of drug-resistant TB (PMDT) for (MDR) and extensively drug-resistant (XDR) TB at the national level and in USAID-supported areas. STRENGTHENING TUBERCULOSIS CONTROL IN UKRAINE: ANNUAL REPORT 1 New MDR-TB recording and reporting (R&R) forms were adopted by of Health to improve decision-making, aimed at the application of complete examinations, improving diagnostics and timeliness of treatment, selecting better treatment regimens, and improving drug management. The project implemented -resistance survey (DRS) in Kharkiv and Kherson in partnership with the WHO. A reliable DRS is essential to determine and justify the variety and volume of second-line drugs (pharmaceuticals used for the treatment of TB in cases of drug resistance) needed to control MDR-TB. These decisions should be made according to the drug resistance profile of Ukrainian MDR-TB patients. The DRS procedure now includes EQA of culture tests and drug susceptibility testing (DST) both within and beyond the 10 USAID-supported regions. With project support, the TB Center of Excellence (CoE) in Dnipropetrovsk is becoming a key implementer of the cascade training approach. To date, the CoE has facilitated 19 training events. Additionally, during nine supervisory/mentoring visits, mentoring teams have provided more than 100 TB specialists from the Dnipropetrovsk oblast with on-the- job training and consultation on issues related to TB case detection in primary health care (PHC) facilities, laboratory diagnostics, DOTS, TB/HIV management, and TB IC. The CoE clinical arm also worked to improve patient case management according to WHO recommendations on PMDT. National TB IC experts have recognized the CoE as a model to be followed by other TB facilities. Objective 4: Improve access to TB/HIV co-infection services at the national level and in USAID-supported areas. The project introduced a TB screening questionnaire in AIDS Centers. All people living with HIV (PLWH) now undergo TB screening procedures to identify TB symptoms in a timely manner. With project support, the MoH added a new TB section to its R&R forms on provider- initiated HIV testing and counseling (PITC) to capture information on TB prevalence among individuals who undergo HIV testing. This has improved the timeliness of dual infection detection and treatment, helping to increase patient survival. 2 STRENGTHENING TUBERCULOSIS CONTROL IN UKRAINE: ANNUAL REPORT I. ACCOMPLISHMENTS BY OBJECTIVE Objective 1: Improve the quality and expand availability of the WHO-recommended DOTS-based TB services. Activity 1.1: Build institutional capacity to improve the quality of DOTS-based programs. Per Task 1.1.1, to strengthen the formal medical education system to include internationally recognized, modern approaches to TB control, the project incorporated international standards of TB care into the pre- and postgraduate medical education curricula