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World TB Day 2013: URC Supports Innovative, Integrated Approaches to Address TB
Tuberculosis (TB) has reemerged as one of the leading health challenges of our time, causing more deaths than any other curable infectious disease. Nearly nine million people contracted TB worldwide in 2010, and 1.4 million died from the disease. TB disproportionately affects poor and vulnerable populations, including those with immune systems weakened by HIV.
URC supports anti-TB activities and national TB programs through integrated and innovative approaches that address systemic barriers to effective prevention and treatment in many of the 22 countries that account for more than 80% of TB cases worldwide. On this World TB Day, URC joins the voices of those recognizing both progress made and challenges that remain in the fight against TB.
URC's programs in Bangladesh, Georgia, Guatemala, Honduras, Malawi, Panama, South Africa, Swaziland, and Uganda provide snapshots of our ongoing efforts to support TB control efforts with our partners.
Increasing Awareness of, Access to, and Demand for TB Services in South Africa
URC works closely with national, local, and community leaders to raise awareness of TB and improve access to and demand for quality TB services. We design our community-based activities to support the reduction of TB-related stigma and help increase awareness and understanding of TB risk.
The US Agency for International Development (USAID) TB South Africa Project works with South Africa's National TB Control Program to implement its Advocacy, Communication, and Social Mobilization (ACSM) strategy. The strategy incorporates mass media and community mobilization to help people recognize the symptoms of TB, test early, receive and adhere to treatment when positive, and take simple infection prevention and control precautions. The project supports the development of TV public service announcements (PSAs); TB messages through popular TV shows and radio dramas; and pamphlets, fact sheets, and posters placed at a variety of venues such as health facilities, non-governmental organizations (NGOs), faith-based organizations, sports clubs, schools, taxi stands, bus stops, and libraries. To date, the TV commercials have reached 72% of South Africans aged 16 to 64 and 62% of children aged five to 14. See the PSA below to raise awareness of TB prevention and treatment for children.
Improving TB Treatment in Georgia
In Georgia, through the USAID-funded Georgia Tuberculosis Prevention Project, URC is supporting efforts to improve the early detection of TB-suspected cases in general health facilities, strengthen the quality of full implementation of Directly Observed Treatment, Short Course (DOTS), an internationally recommended TB treatment strategy, and DOTS plus. We are also working to improve infection control within primary health centers, along with technical assistance to newly opened private treatment sites.
Promoting an Integrated Response to TB and HIV in Swaziland, Guatemala, Honduras, and Panama
In some high-burden countries, up to 80% of TB patients also have HIV. A leading cause of death among people living with HIV/AIDS, TB is easily spread among people whose immune systems are suppressed by HIV. URC is leveraging our global expertise in HIV/AIDS to assist partners to provide comprehensive, decentralized, and high-quality TB/HIV services at community and facility levels.
In Swaziland, through the USAID Health Care Improvement Project, we are assisting the Ministry of Health and Social Welfare, the National TB Control Program, and the Swaziland National AIDS Program to reduce the number of deaths caused by TB and HIV. In supporting hospitals, health centers, and primary care clinics to provide high-quality TB screening, diagnostic, and treatment services and to expand access to anti-retroviral therapy (ART) for TB patients, the project has seen measurable improvements in patient care and outcomes. From 2007 to 2010, TB case detection increased from 32% to 70%, treatment success rose from 43% to 73%, and uptake of the preventive antibiotic cotrimoxazole among TB-HIV co-infected patients increased from 32% to over 95%.
In the Central American region, with funding from the Centers for Disease Control and Prevention (CDC), URC has facilitated the coordination of TB/HIV co-infection committees in Guatemala, Honduras, and Panama and developed methodologies, materials, and curricula for training workshops according to local needs. URC has worked to introduce provider-initiated counseling and testing, develop/review national norms and guidelines for case management, and arrange regional fellowships to allow countries to learn from well-functioning integrated TB and HIV programs in the region. These and other URC-led activities have helped increase the number of TB patients who are tested for HIV and receive their results. For example, in Guatemala's Escuintla Health Region, the percent of TB patients tested for HIV increased from an average of 28% in 2010 to 94% in 2012 (see figure).
Improving Responses to Drug Resistance in Bangladesh
Multi-drug resistant TB (MDR TB), when TB becomes resistant to at least two of the main anti-TB drugs, is more life-threatening to the patient and more difficult and costly to treat.
In Bangladesh, through the USAID TB CARE II project, URC has initiated efforts to quantify the level of MDR TB in the country, strengthen MDR TB diagnostic capacity, and prepare for the increasing need to treat MDR TB patients. Collaborating with the National TB Program, we conducted a situational analysis of laboratory services at the national level and in targeted districts to identify gaps and weaknesses in the labs' quality assurance system. URC has provided assistance to set up an MDR TB surveillance system in targeted districts through specialized chest disease clinics. All such clinics now routinely send the samples of MDR TB suspects to a national TB reference lab for culture and drug susceptibility testing, an indicator of resistance.
Strengthening Health Systems to Effectively Manage TB in Malawi and Uganda
In Malawi, TB CARE II is working at the national level to strengthen the laboratory network, strengthen the National TB Program centrally, and pilot novel diagnostics. At the district level, the project is applying a comprehensive set of interventions, including integration of ART into the TB program, training community health workers in TB/HIV intervention, expanding the smear microscopy network, and upgrading infrastructure in selected facilities to accommodate increased HIV testing and counseling and ART for TB patients.
In Uganda, we are working with health workers in 16 hospitals through the USAID-funded Strengthening Uganda's Systems for Treating AIDS Nationally (SUSTAIN) project to identify and initiate a series of activities to increase TB treatment completion rates, or the proportion of TB patients who completed TB treatment (eight months for adults; six months for children). Nationally, these rates hovered around 25% in early to mid-2011—below the target rate of 85%.
At Gulu Regional Referral Hospital (RRH) in Uganda's Northern Region, we supported health workers to convene a focal TB care team comprised of clinicians from the facility's TB clinic and the infectious disease clinic that provides chronic care services to HIV-positive clients. We supported teams to improve data management and review; establish proactive patient follow-up and transfer procedures; strengthen service provider skills, such as training in TB-HIV co-management; and improve collaboration for HIV and TB services.
As a result, TB treatment completion rates increased from about 20% in the first quarter (January to March) of 2011 to 54% in the last quarter. Health workers at Gulu RRH maintained this completion rate during the January to March 2012 period despite national stock-outs of TB medicines; they improved rates to 64% by June 2012. Similarly, average TB treatment completion rates in all 16 project-supported facilities, including Gulu RRH, increased to nearly 70% just one year after we helped introduce changes.