A young multidrug-resistant tuberculosis (MDR-TB) patient in a well ventilated ward waiting to receive care in Bangladesh. Photo credit: URC

TB CARE II

The Challenge

In 2008, the world saw approximately 9.8 million TB case and 1.8 million deaths. TB causes more deaths than any other curable infectious disease, disproportionately affecting poor and working-age people. The HIV epidemic has amplified the impact of TB: TB is the leading cause of death among people living with HIV (PLHIV), in part because TB spreads easily through immune systems compromised by HIV. In some countries, up to 80% of TB patients also have HIV.

Overview and Objectives

TB CARE II complemented existing and planned projects in the USAID Bureau for Global Health to provide leadership and support to national TB programs (NTPs) and other in-country partners. The project assisted these stakeholders to accelerate the implementation of TB directly observed treatment, short course (DOTS), TB/HIV, and the programmatic management of drug-resistant (DR) TB. The project helped countries scale up evidence-based interventions and improve outcomes in TB prevention and control in USAID TB priority countries. TB CARE II brought extensive expertise in strengthening TB services, including establishing community-based multi-drug resistant (MDR) TB prevention and treatment strategies. At the global level, TB CARE II supported the prevention of MDR-TB, infection control, TB/HIV, and health systems strengthening.

TB CARE II Project Overview

The objectives of this project were:

  • TB care and treatment, including DOTS expansion and strengthening
    Partner with national programs to provide universal and early case detection to surpass the 70% detection target and successfully treat more than 85% of those cases.
  • Programmatic management for MDR-TB
    Assist national TB programs to provide universal access to drug-susceptibility testing for suspected cases and treatment to everyone with MDR-TB.
  • TB/HIV treatment
    Help countries to increase early case detection, expand intensified case finding, enhance airborne infection control efforts, and expand access to and integrate treatment of TB and HIV in co-infected people.
  • Health systems strengthening
    Fully contribute to health systems strengthening in relation to TB, especially for improving political commitment, strengthening human resources, enhancing health information and surveillance systems, infection control, and engaging all care providers.

Achievements

Supporting countries’ efforts on TB and MDR-TB: Between 2010 and 2020, TB CARE II implemented more than 36 multi-year activities to control and prevent the spread of TB and MDR-TB. These activities improved treatment outcomes and the quality and breadth of services provided through national TB control programs in more than 15 countries. Activities include efforts to encourage innovation and standardization around implementation approaches to control TB, such as developing tools, guidelines, operating procedures, training manuals, and frameworks.

Developing the FAST model for infection prevention and control and supporting country implementation: In June 2011, TB CARE II sponsored a meeting of global stakeholders with expertise in TB and infection prevention and control (IPC) to design a simple package of IPC interventions for high TB burden countries. Components of the programmatic strategy are captured by the acronym, FAST: Find cases Actively, Separate safely, and Treat effectively. FAST’s strategy is that prompt diagnosis and effective treatment is by far the most important tactic for preventing the spread of TB. FAST integrates active case finding, rapid diagnosis, and effective treatment, and identifies critical roles for other services, such as cough monitors, couriers, laboratories, and the effective management of MDR-TB.

TB CARE II piloted FAST at certain hospitals in Bangladesh, Malawi, and Vietnam. In Vietnam, TB CARE II also developed a simple MS Access database to record, track, and report visiting patients and FAST indicators. Records were merged regularly with other data management systems maintained by hospital departments. The functionality of the FAST database resulted in expanded TB CARE II technical support to develop a single, integrated hospital data management system which allowed all departments to access patient records using unique patient identifiers. This improved patient management and enabled the hospital to detect missed opportunities for earlier diagnosis and effective treatment. For this and other efforts in Vietnam, TB CARE II received two awards from the NTP for its outstanding contribution to TB control in Vietnam. And in 2017, the NTP adopted FAST for national scale-up and approved the National Guideline for the Implementation of FAST, drafted with TB CARE II support.

Understanding barriers to diagnosis and treatment: TB CARE II conducted a study in Bangladesh to identify the causes of delays in TB diagnosis and treatment initiation. The study found that most of the delay was due to patient-level factors – such as misunderstanding symptoms, distance to facilities, transport costs, fear of diagnosis, and social stigma – which could be better addressed at the community level. As a result, in addition to interventions to improve facility-level TB services, TB CARE II focused on community-level strategies for case TB CARE II in finding and management of TB and MDR-TB. As a result, the median number of days between diagnosis and treatment initiation was decreased from 69 days in 2011 to 6 days in 2014. Read more about TB CARE II’s achievements in Bangladesh.

Increasing demand for TB treatment: In 2016, TB CARE II was tasked by the South Africa National Department of Health to develop a campaign for advocacy, communication, and social mobilization for the National Tuberculosis Program’s 3-year “Massive TB Screening Campaign.” Leveraging funding from Johnson & Johnson, the campaign included community outreach, public service announcements, and interviews in mass media. Celebrity ambassadors, many of who had experienced TB, encouraged their followers to be screened for TB, HIV, and diabetes. Between October-December 2015 alone, more than 45 million people were reached with TB messaging, with almost 30,000 screened for TB. Key partners in the effort were 28 non-governmental organizations (NGOs) which received TB CARE II subgrants. NGOs played an essential role in extending TB screening and sputum collection or referral, reaching specific populations such as PLHIV, children, and prisoners, and supporting DOTS and community-based programmatic management of MDR-TB patients. Read more about TB CARE II’s achievements in South Africa.

Promoting integrated TB/HIV services: In Malawi, TB CARE II worked intensively with both the national TB and HIV programs to increase integrated delivery of TB and HIV services, with an emphasis on improving the availability of TB screening and diagnostic services at HIV care and treatment sites. The project established one-stop shops in the Mangochi District Hospital and Ntcheu and Neno Health Centres, at which TB/HIV patients could access a full package of services at one location, managed by one healthcare worker or health care team. Significant achievement was observed in the uptake of co-trimoxazole preventive therapy (CPT) which decreases risk of TB and antiretroviral therapy (ART): CPT uptake increased from 78% to 95%, and the ART uptake increased from 81% to 93% during the project. Read more about TB CARE II’s achievements in Malawi.

Duration
2010–2020

Countries
Bangladesh, China, Eswatini, Haiti, India, Indonesia, Kazakhstan, Kenya, Lesotho, Liberia, Malawi, Mozambique, Myanmar, Namibia, Nigeria, Pakistan, Peru, Philippines, Russia, Sierra Leone, South Africa, Tajikistan, Ukraine, Vietnam, Zambia, and Zimbabwe

Regions
Africa, Asia, Eurasia, and Latin America and the Caribbean

Expertise
Digital Health, Health Service Delivery, HIV/AIDS, Quality Health Systems, Social and Behavior Change, and Tuberculosis

Funders
USAID

Partners
BEA Enterprises, Brigham and Women's Hospital, Canadian Lung Association, Clinical and Laboratory Standards Institute (CLSI), Dartmouth Geisel School of Medicine, Euro Health Group (EHG), Jhpiego, McGill International Tuberculosis Centre, Medical Service Corporation International (MSCI), National Jewish Health, Partners In Health (PIH), Project HOPE, Rutgers Global Tuberculosis Institute, The Foundation for Innovative New Diagnostics (FIND), and World Health Organization (WHO)