tb care annual work plan and budget

USAID TB CARE II Project

Bangladesh Funded by United States Agency for International Development, Bangladesh

Quarterly Report January – March, 2014

April 30, 2014

University Research Co., LLC Bethesda, Maryland

January-March 2014 Quarterly Report, USAID/Bangladesh TB CARE II Project; University Research Co., LLC 2

TABLE OF CONTENTS

1 EXECUTIVE SUMMARY ........................................................................................... 4

2 INTRODUCTION ....................................................................................................... 5

2.1 Implementation Approach ................................................................................................. 5

3 MAJOR ACCOMPLISHMENTS ................................................................................ 5

4 ACCOMPLISHMENTS BY RESULTS ...................................................................... 6

4.1 Improved Access to quality TB and MDR-TB Services ................................................ 6

4.2 Improved Knowledge and Practices on TB and MDR-TB ........................................... 12

4.3 Increased Adherence to TB and MDR-TB Treatment .................................................. 14

4.4 Improved Capacity for Governance and Management of TB at all levels ................... 15

4.5 Increased Private Sector Participation in TB Prevention and Control ......................... 15

4.6 Strengthened Support Systems for effective delivery of TB services .......................... 16

5 SPECIAL EVENTS .................................................................................................. 18

6 CHALLENGES ENCOUNTERED AND ADDRESSED ............................................ 19

7 PERFORMANCE MONITORING PLAN ................................................................ 19

8 PLANS FOR THE NEXT QUARTER ...................................................................... 21


LIST OF ACRONYMS ACSM Advocacy, Communications, and Social Mobilization

AFB Acid-Fast Bacilli

AIDS Acquired Immune Deficiency Syndrome

APW Agreement of Performance of Work

BIRDEM Bangladesh Institute of Research & Rehabilitation for Diabetes, Endocrine

and Metabolic Disorders

cPMDT Community based Programmatic Management of Drug Resistant TB

CDC Chest Disease Clinic

CDH Chest Disease Hospital

CHWs Community Health Workers

COPD Chronic Obstructive Pulmonary Disease

DAB Diabetic Association of Bangladesh

DOTS Directly Observed Treatment, Short-course

DST Drug Susceptibility Test

EQA External Quality Assurance

FAST Finding TB patients, Actively, Separating safely, Treating effectively

GFATM Global Fund to Fight AIDS, TB and Malaria

GLC Green Light Committee

GOB Government of Bangladesh

HIV Human Immunodeficiency Virus

IC Infection Control

IPT Isoniazid Preventive Therapy

MDR-TB Multi drug-resistant TB

MOH Ministry of Health and Family Welfare

NASP National AIDS and STD Program

NGMP Non-graduate Medical Practitioner

NIDCH National Institute of the Diseases of the Chest and Hospital

NTRL National TB Reference Laboratory

NTP National Tuberculosis Control Program

PMP Performance Monitoring Plan

PPM Public Private Mix

QA Quality Assurance

RTRL Regional TB Reference Laboratory

TB Tuberculosis

TLCA TB and Leprosy Control Assistant

UH&FPO Upazila Health and Family Planning Officer

UPHCSDP Urban Private Health Care Service Delivery Project

URC University Research Co., LLC

USAID United States Agency for International Development

USG United States Government

WHO World Health Organization

XDR Extremely Drug Resistant


1 EXECUTIVE SUMMARY

This report presents progress made in implementation of the planned activities towards achieving the

project objectives in the second quarter of FY 2014 (January-March 2014). As outlined in the work plan,

the implementation focused on developing capacity of NTP and NGOs in screening, diagnosis and

management of all forms of TB, expanding access to diagnosis and management of MDR TB,

strengthening health systems especially laboratory services and systems, improving knowledge and

awareness about TB, and strengthening private sector participation in the TB control program.

The total case notification of new and relapse cases at the national level has increased significantly over

the past 2 years. The total notification increased by 12% in 2012 over 2011 and by 13% in 2013 over the

preceding year. Increase in notification of smear negative and extra-pulmonary TB has mainly contributed

to this change. Detection of child TB remained a challenge with no noticeable change in overall

notification.

Currently, the project has been providing technical and financial support to ten local NGOs sub-grantees

for increasing detection of TB cases and improving knowledge and awareness about TB. The sub-grant

programs are implemented particularly in underperforming districts and targeted to vulnerable

populations. The DAB project contributed to detection and treatment initiation of 174 TB cases of all

forms among the DM patients. Case detection has continued to increase through other sub-grantees

supported by the project. HEED and six other sub-grantees detected an additional 1,395 TB cases among

their target populations. Apart from behavior change communication and social mobilization activities, the

networking developed with 2,897 private providers through NGO sub-grantees contributed to

identification of 13,955 presumptive TB cases during the current quarter.

Detection and enrollment of DR TB patients have been increasing steadily against all odds since 2012

when the MDR TB intervention was started. In the current quarter, 172 patients have been enrolled to

treatment. The project PMDT strategy has been remarkably successful in Chittagong district. In less than

two years after the intervention has started, the detection of MDR TB increased to 54% of estimated

yearly case load of MDR-TB in Chittagong. Enrollment has reached 100% of the diagnosed cases leaving

no patients waiting for the life-saving treatment. Expansion of community based treatment of patients is

proceeding as per work plan. During this quarter, the project has trained 345 field level health

professionals of the Outpatient DR TB teams from twelve new districts to develop their capacity for

management of patients. A total of 102 patients have been enrolled in to cPMDT for continuation phase

treatment in this quarter.

The project completed the calibration process of 12 Xpert machines by certified engineer during this

period. The Xpert MTB/RIF test has become the primary diagnostic tool for Bangladesh in detection of

MTB Rif resistant cases. The project has plans to procure and install 35 GeneXpert machines to

decentralize and increase detection of RIF resistant and smear negative pulmonary cases. The project has

already procured 12 of these machines and the remaining will be procured subject to USAID approval.

Currently, GeneXpert testing services are available through 27 sites. In this quarter, Xpert tests were

performed for a total of 8,702 samples including 1,945 DR TB presumptive cases. This helped detection

of 229 RIF resistant cases as well as 866 smear negative pulmonary TB cases.

Counseling of MDR TB patients is taking place on a routine basis. At NIDCH, the project staff provided

pre-admission counseling informing the patients about treatment duration, intensive and continuation


phase treatment, release from hospital, transfer to home for continuation phase, treatment services at

home, and infection prevention practices. Individual and group counseling were also organized for the

patients during the in-patient treatment period. At the community level, the DR TB DOT providers

regularly counseled the patients on cPMDT during home visits.

As part of health system strengthening, the project continued its effort to develop capacity of NTP and

NGOs lab technicians in the operation and management of GeneXpert, LED microscopes and culture and

DST. The project supported to jointly organize the 2nd SEAR Conference on TB and Lung Health in

Dhaka with The Union and NATAB.

Implementation of the FAST approach for active screening of presumptive TB cases especially at large

hospitals went as planned. The project has expanded this approach to all TB and non-TB wards of the

NIDCH. This initiative has contributed to identifying 1,075 presumptive TB cases this quarter and

detection of 131 TB including 7 RIF resistant cases. The project also scaled up the FAST approach in

BIRDEM.

2 INTRODUCTION

TB remains a major public health problem in Bangladesh. The country ranks sixth among 22 highest

burden TB countries in the world. It is estimated that more than 350,000 new TB cases of all forms

emerge each year (WHO 2013 report). In 2012, 161,790 new TB cases were notified to NTP. The case

detection rate for all cases has increased from 45 in 2011 to 49 in 2012 per 100,000 populations. The

proportions of smear-negative and extra-pulmonary cases are still low. The detection of childhood TB is

also low at 3% although childhood TB is estimated to be 11% of the total disease burden.

The burden of multi-drug resistant (MDR) TB is a considerable threat for Bangladesh. According to WHO

report 2012, MDR TB is estimated at 1.4% among new and 28.5% among retreatment cases.

Approximately 4,200 MDR TB cases are generated every year. Child TB remains under-diagnosed due to

lack of health system capacity. Approximately 70,000 people die from TB every year and many of these

deaths could be prevented through universal and early access to TB services.

2.1 Implementation Approach

The TB CARE II Bangladesh project works with National TB Control Program (NTP) as well as with

local NGO partners to implement the project. Technical assistance is provided to NTP to expand and

strengthen universal and early access to TB services, strengthen diagnosis and management of DR TB,

enhance capacity and quality of the lab services, and strengthen health systems.

The project also supports a grants program through the local NGO implementing partners to implement

community based activities to increase case detection through active screening of vulnerable populations

and contact tracing, public-private mix (PPM), and integrating TB with the existing MCH and FP services.

The grants program also supports a combination of ACSM activities to improve people’s knowledge and

awareness about TB, make behavioral changes in care seeking practices, improve adherence to treatment

and infection prevention.

3 MAJOR ACCOMPLISHMENTS

The project has successfully implemented a number of the activities planned for this quarter. Major

accomplishments are presented below:


National case notification of all forms of new TB cases increased by 13% from 2012 to 2013.

Notification of smear negative pulmonary TB cases increased by 73% during the same period;

Project sub-grantee DAB detected 174 TB cases among diabetes of all forms during this reporting

quarter;

Tested 1,805 DR TB presumptive cases by GeneXpert and diagnosed 172 MTB RIF cases;

Tested 6,827 smear negative presumptive cases by GeneXpert and diagnosed 866 MTB positive

including 57 MTB/RIF resistant cases;

Enrolled 172 new MDR TB patients in to treatment and transferred 102 patients to community for

continuation phase treatment;

Conducted basic and refresher training on cPMDT for 394 Outpatient DR TB team members from

Upazila Health Complexes;

Provided training on the operation and management of GeneXpert for 11 lab technicians;

Conducted training on culture and DST for 7 lab staff from RTRLs;

Organized training for 23 lab staff on AFB sputum smear microscopy using LED;

Conducted orientation including refresher on mHealth application for 244 NTP and NGO staff

including 87 DOT providers from upazilas and districts;

Provided orientation on waste management for 438 health professionals from NTP and NGOs;

Conducted training for 10 CDH staff from CDH Barisal on management of MDR TB patient to

support enrollment of MDR TB patients;

Trained 241 physicians on diagnosis and management of childhood TB and 781 health workers on

screening and referral of presumptive child TB cases;

Installed 10 solar panels in selected microscopy centers to ensure uninterrupted operation of labs for

quality and quick diagnosis;

Completed procurement of 12 Xpert machines;

Oriented 404 health professionals on TB Infection Control;

Organized networking meetings covering 1,092 graduate and 1,805 non-graduate private providers

through the NGO grants program;

Collaborated with NATAB and The Union to jointly organize the 2nd SEAR Conference on TB and

Lung Health in Dhaka;

Organized quarterly workshop to review Xpert lab data to monitor quality and performance of DR TB

diagnostics and monitoring services;

Organized EQA workshops to review the EQA procedures and developed actions for improvement;

4 ACCOMPLISHMENTS BY RESULTS

4.1 Improved Access to quality TB and MDR-TB Services

4.1.1 Increase detection and management of TB through NGOs sub-grantees

The TB control program in Bangladesh is implemented by NTP through a partnership with the local

NGOs. The NGOs are primarily responsible for the community level screening and suspect identification

which are the first two steps in the diagnosis of TB. The NGOs are also responsible for providing DOTS

to the patients, counsel patients on treatment adherence, and conduct awareness and social mobilization

activities.


Currently, the project has been supporting nine different sub-grants with local NGOs to implement

community based TB control activities particularly in underperforming districts and targeted to

populations living in urban slums and rural inaccessible areas. The results achieved through the sub-grant

programs are discussed below.

BRAC Wave 1 Grant

BRAC has been implementing the largest grants program in 12 districts of the country with a population

of 29 million. The project support to BRAC districts addresses the gaps in Global Fund supported

activities to increase detection of all

forms of TB. The major focus of the

project support is to increase detection of

smear negative TB and EPTB cases.

Financial support is given to poor

patients to reimburse diagnostic and

transportation costs incurred for detection

of smear negative and EPTB cases.

The case notification by BRAC in the

current quarter has slightly increased

compared to the previous quarter (Oct-

Dec 2013); EPTB cases have increased

by 14% as shown in the Figure 1 above.

BRAC has provided financial support to

857 smear negative and 237 EPTB

patients. The project also supports BRAC to provide TB services in 12 prisons. This effort contributed to

testing sputum samples of 326 prison inmates and detection of 9 TB cases. Treatment has been initiated to

all the patients.

BRAC Wave 3 Grant

BRAC has been awarded a new sub-grant under Wave 3 in December 2013. The objective is to increase

additional case detection in 71 sub-districts under 10 new districts covering a population of 20.5 million.

The project has just completed the first quarter of implementation. Out of 59,240 presumptive TB cases

identified, 6,177 TB cases of all forms were detected. The rate of smear negative cases detected in the

three month period is more than 50% of the yearly target set for these 10 districts under project support.

Contact tracing in the households of index cases is a focus of this project. The project screened 9,660

close contacts of TB patients, identified 1,039 of presumptive TB cases and detected 70 TB cases. The

following Table 1 shows the proportion of targets achieved in the second quarter. The baselines represent

case detection with Global fund support.

Table 1: Wave 3 BRAC Project: Case Detection Performance

Category Baseline 2014 Target Achievements Qtr 2 % Achieved of Target

Smear Positive 14,754 15,455 3,730 24%

Smear Negative 1,769 2,686 1,707 64%

EP 2,116 3,213 709 22%

Child TB 341 615 102 17%

0

2000

4000

6000

8000

10000

12000

Figure 1: Trends in case notification in 12 BRAC districts


Diabetic Association of Bangladesh (DAB)

The project has been supporting Diabetes Association of Bangladesh (DAB) to increase access to TB

services by the diabetes patients through an integrated approach with a focus on active screening of

diabetes patients for detection and

management of TB. A referral

system has been established between

diabetes service facilities and DOTS

centers for diagnosis and

management of co-morbidities.

In the January-March quarter, the

DAB project detected 174 TB cases

of all forms among the DM patients.

Treatment has been initiated for all

the diagnosed patients through the

DOT center at the BIRDEM hospital.

Figure 2 shows the case detection

trends of TB cases since beginning of the project in April 2013. DAB provides regular counseling of DM

patients to improve their knowledge about increased risks of TB among DM patients, prevention and early

care seeking for TB services. In this quarter, DAB staff counseled 6,640 DM patients.

In this quarter, the project assisted DAB in providing training to the doctors, nurses and other health staff

of the BIRDEM and affiliated facilities. A total 112 doctors and nurses from the BIRDEM General

Hospital, National Health Care Networks (NHN), Bangladesh Institute of Health Sciences (BIHS) and

other affiliated centers participated in this training on diagnoses and management of TB among diabetic

patients. The participants also received practical knowledge on DOTS strategy, its applicability and

methods of quick screening and referral.

HEED

The sub-grant with HEED Bangladesh supports implementation of DOTS and ACSM activities targeted to

650,000 people living in 157 tea gardens of Sylhet, Habiganj and Moulvibazar districts. HEED

Bangladesh has set up 25 sputum collection and smearing centers in the tea garden areas. All these centers

are linked to the labs where the sputum slides are sent for microscopy test. The case detection in the

HEED areas has steadily increased since the beginning of the project in April 2012. During this quarter,

HEED detected 198 smear positive, 128 smear negative and 66 EPTB cases. The case notification of all

forms of TB has slightly declined from the previous quarter. Poor economic conditions and low literacy

rates among the tea garden workers and limited access to health care services are major barriers to

improving and sustaining TB control activities among this target population.

Wave 3 Sub-grantee Performance

In addition to BRAC, the project also awarded 6 (six) sub-grants to local NGOs for increasing detection

and management of TB cases in low performing districts in Wave 3. The project support through these

NGOs is aimed at complementing the Global Fund activities by way of addressing the programmatic and

geographic gaps. During this quarter, 1,003 TB cases of all forms have been detected and initiated on

treatment with project support. Table 2 summarizes the performances of these NGOs for this quarter.

15

62

48

78

14

54

35

64

21

52

36 32

0

10

20

30

40

50

60

70

80

90

Apr - Jun’13 Jul – Sep’13 Oct– Dec’13 Jan-Mar'14

Figure 2: Detection of TB Among DM Patients

DM patients diagnosed as sputum positive for pulmonary TB

DM patients diagnosed as sputum negative for pulmonary TB

DM patients diagnosed as EPTB case


Table 2: Case Detection by Wave 3 NGO Sub-grantees

Name of NGO Q1 FY14 Q2 FY14

Smear positive

Smear Negative

EP TB Total Smear positive

Smear Negative

EP TB Total

BCCP 94 66 83 243 98 104 110 312

Leprosy Mission 180 15 11 206 179 34 16 229

Lepra Bangladesh 228 9 9 246 241 23 17 281

Nari Maitree 45 5 9 59 48 5 12 65

FIDA 69 33 6 108 64 47 3 114

PIME Sisters - - - - 2 0 0 2

Total 616 128 118 862 632 213 158 1003

4.1.2 Case Notification at the National Level

The total case notification of new and relapse cases at the national level has increased significantly over

the past 2 years (Figure 3). The total notification increased by 12% in 2012 over 2011 and by 13% in

2013 over the previous year. Increase in notification of smear

negative and extra-pulmonary TB has mainly contributed to this

change. Detection of child TB remained a challenge with no

noticeable change in overall notification. There has been a slight

increase in detection from 4,842 to 5045 between 2012 and

2013.

The notification of smear positive pulmonary cases has slightly

dropped in 2013 over the previous year (Fig 4). Over the past

two years, notification of smear negative pulmonary cases has

shown the highest increase (Fig 5). The total number of smear

negative cases notified increased from 24,451 in 2013 to 42,361 in 2013, an increase of 73%. Among

other factors, TB CARE II strategies geared to detection of smear negative cases using GeneXpert and

targeted community based effort through the NGO grants program have partially contributed to this

change.

Detection of extra-pulmonary TB cases has also increased over the past years (Fig 6). The notification of

EPTB increased from 27,329 in 2011 to 33,671 in 2013, an increase of 23%. The increase is 10% between

2012 and 2013. Increasing detection of EPTB is also a primary focus of the grants program supported by

the project through the NGOs.

25000

26000

27000

28000

Q1 Q2 Q3 Q4

Fig 4:Notification of SS (+)

2012 2013

5000

7000

9000

11000

13000

Q1 Q2 Q3 Q4

Fig 5: Notification of SS (-)

2012 2013

5000

6000

7000

8000

9000

10000

Q1 Q2 Q3 Q4

Fig 6: Notification of EP

2012 2013

2010 2011 2012 2013

153471 150899 164855

186481

Figure 3: National Case Notification New and Relapse


4.1.3 Detection and management of child TB cases

Strengthening and scaling up pediatric TB services will remain a major focus of TB CARE II Bangladesh

project. The project through its partnership with the Bangladesh

Pediatric Association is supporting training of pediatricians,

doctors, general physicians and health workers from the upazila

level to develop their capacity in screening, referral and diagnosis

of TB cases. In the current quarter, 241 doctors including Upazila

Health and Family Planning Officer (UHFPO), Medical Officer

(Disease Control), pediatricians and general physicians from

different upazilas of Dhaka division have been trained. As part of

this training, participants are

also required to develop local

level plans with targets for detection of child TB cases in their

respective areas. During this quarter, the project has also supported

BPA to orient 781 health workers from the upazilas on screening and

referral of presumptive child TB cases.

Detection of child TB has also been incorporated as a focus of the

grants program. The project has been supporting the NGOs to

conduct systematic contact tracing at the households of index patients

and targeted communication activities through community outreach mass media to address this challenge.

Providing IPT to eligible children living in the families of active TB patients is also part of the grants

program. As part of this program, the NGO partners evaluated 961 children and registered 72 children for

IPT in the current quarter. Also in this quarter, 13 children among the 14 registered children for IPT

during April-June 2013 quarter have completed the full course of prophylaxis.

4.1.4 Diagnosis and Management of Smear Negative and EPTB cases

Smear Negative Cases

Use of GeneXpert test for diagnosis of smear negative TB is making a significant difference in detecting

smear negative pulmonary TB as well as RIF resistant TB cases. The project has established referral

systems to enable the peripheral microscopy labs to refer smear negative cases to the GeneXpert sites for

testing. During the reporting period, a total of 6,827 smear negative presumptive TB cases have been

tested, and detected 866 MTB positive including 57 MTB/RIF resistant cases. The proportion of smear

negative cases detected is 13% of the total number smear negative presumptive cases tested by

GeneXpert. The Table 3 shows the project progress for testing and detection of smear negative TB cases.

Table 3: GeneXpert Test Results for Smear Negative TB

Period Total Tested MTB MTB Positive % MTB+RIF RIF Positive %

Oct-Dec’13 2,447 344 14 15 .61

Jan-Mar’14 6,827 866 13 57 .83

Extra-Pulmonary TB (EPTB)

The project has been supporting community level screening and awareness building activities to increase

detection of EPTB. The project also support diagnostic and transportation costs for the poor people

Local Level Planning for Child TB

Contact Tracing at a Household


suspected of EPTB. The result of this effort is showing gradual increase in the detection of EPTB cases in

the project supported areas. More than 500 EPTB cases have been detected by the NGO sub-grantees

during this quarter. The project is also continuing its work with CLA to field test and finalize the

screening and diagnostic algorithms adapted to Bangladesh context for increasing detection of EPTB

cases.

4.1.5 Expand Capacity for Detection and Management of DR TB Services

Detection of MTB and MTB/RIF by GeneXpert

In this reporting period, GeneXpert test was performed for a total of 8,702 samples including 1,805

presumptive DR TB cases.

This helped detection of 229

RIF resistant cases including

172 from among DR TB and

57 from among smear negative

presumptive cases. Of the total

samples tested, 22% were

MTB positive and 3% were

MTB RIF positive. The

detection of MTB positive and

RIF resistant TB among the presumptive DR TB cases (retreatment, Cat I and II failures, late converters)

is 9.5%. Figure 7 and 8 show the GeneXpert test results.

4.1.6 Strengthening Programmatic Management of DR TB (PMDT)

The project assisted NTP to develop a national plan for expansion of PMDT. According to this plan, the

target for NTP is to expand MDRTB treatment coverage for 70% of the estimated number of cases that

develop annually by the year 2017. In order to implement this plan, the TB CARE II project adopted a

two-pronged strategy designed to expand both facility and community based capacity for decentralized

management of MDR TB.

Improve Community Level Management of MDR TB

The community based model has been rolled out to 19 districts and three city corporation areas in the last

two years. In FY14, the project plans to expand this model to another 20 districts and consolidate the

program in the existing districts to continue increasing access to treatment. During this quarter, the project

trained 345 field level health professionals of the Outpatient DR TB teams on cPMDT from twelve new

districts to develop their capacity for management of cPMDT patients. In addition, the project organized

refresher training for 49 participants of Outpatient DR TB team. The training aims at developing

programmatic and clinical capacity of the team members to be able to provide on-going treatment and side

effects management support to the MDR TB patients.

Enrollment of patients to DR TB treatment

The project strategy seeks to ensure that all detected MDR TB patients are enrolled to treatment without

any delay. The limited number of hospital beds for treatment of MDR TB remains a challenge although

the project support has enabled NTP to double the capacity over the last two years.

60% 9%

31%

Fig 7: Xpert Test Result - DR TB Suspect

MTB+

MTBRIF

GXNeg

22% 3%

75%

Fig 8: Xpert Test Result All

MTB+

MTBRIF

GXNex


Detection and enrollment of DR TB patients have been increasing steadily against all odds since 2012

when the MDR TB intervention was started. Figure 9 shows the diagnosis and enrollment of MDR TB

patients for the last six calendar years. In the current quarter, 172 patients have been enrolled to treatment.

The project PMDT strategy has been remarkably successful

in Chittagong district. According to NTP report 2012, new

notified PTB cases were 8,646 and retreatment cases were

302. This translates to approximately 207 MDR-TB cases per

year in Chittagong district (at 1.4% of the notified new

pulmonary TB cases and 28.5% of the retreatment cases.) In

less than two years after the project has started the

interventions, the detection of MDR TB increased to 54% of

the estimated yearly

case load of MDR-

TB in Chittagong.

Most importantly, the project strategy has been effective to reach

100% enrollment of the diagnosed cases leaving no patients

waiting for the life-saving treatment.

The project has planned to expand DR TB treatment through 4

CDHs in this year. A preliminary assessment has been completed

to estimate the renovation works that will start from the next

quarter. The project has completed renovation of an XDR TB

ward with 4 beds at NIDCH. The project also conducted training

of 10 staff including doctors, nurses and other support staff from CDH Barishal to develop their skills in

clinical and programmatic management of DR TB.

The project routinely organizes performance review meetings at the district level with the DR TB DOT

providers to improve coordination of cPMDT activities and provision of DOT services for the DR TB

patients. During this quarter, the project staff facilitates review meeting in Chittagong and Gazipur

districts. These meetings are organized to identify implementation issues including coordination of

cPMDT activities, availability and supply of drugs, patient compliance with treatment, patient support,

side effects management, generation of social support for the patients, and roles and responsibilities of the

DOT providers and project staff in resolving these issues.

4.2 Improved Knowledge and Practices on TB and MDR-TB

4.2.1 Communication Activities at the National Level

The project supported 6-month long communication campaign through TV and Radio channels to improve

mass knowledge and awareness about child TB and MDR TB has ended in this quarter. A total of 1,800

TV spots and 3,000 Radio spots were aired on child TB and MDR TB through different TV and Radio

channels. A survey will be conducted in April-May to evaluate the effectiveness of this campaign in

raising knowledge and awareness about TB and its impact on care seeking for TB services.

As per the FY 2014 work plan, the project has selected a local media agency in planning and

implementing a comprehensive communication campaign on “We Want Zero TB Deaths in our Life

Time” theme. New media materials with focus on MDR TB, child TB, treatment adherence, infection

2008 2009 2010 2011 2012 2013

448 360

480

612

701

807

231 351

356 390

503

685

Fig 9: Diagnosis and Enrollment of MDR TB

Diagnosed

Enrolled

15

70

108 112

0

40

88

112

2010 2011 2012 2013

Fig 10: Diagnosis and Enrollment in Chittagong District

Diagnosed Treatment Enrollment


prevention, and referral by private providers will be developed and aired through TV and Radio channels

and displayed through bill boards. Talk shows and health programs will also be aired to inform and

educate the public about TB, and initiate discussions for a wider understanding of the disease burden and

its consequence. The campaign is expected to start beginning the third quarter.

In this quarter, the project supported DAB to organize a television program on TB-DM that was aired on

private local television channel (RTV). The live program was aired for 15 minutes and the discussion

covered different critical issues on TB-DM co-morbidities. Besides the TV program the project has also

conducted two radio programs through “Abc Radio.” Discussion aimed to sensitizing people about the

increased risk of TB for diabetes patients, benefits of early detection, and management of co-morbidities.

The viewers also joined the discussion through phone and asked questions for expert opinions.

4.2.2 Community-based Awareness Activities

The project sub-grantees conducted different behavior change communication and social mobilization

activities to increase people’s knowledge and awareness about TB and promote early care seeking for TB

services. The project partner HEED conducted orientation for 959 tea factory workers and 826 tea garden

women workers to reach TB messages. The sub grantee also arranged advocacy meetings with tea garden

management staff, local health managers and community leaders; enter-educational events such as pot

show, drama and gombhira in the tea gardens to communicate TB messages. The project also oriented 183

cured TB patients as peer educators to support existing TB patients in treatment adherence as well as to

identify and refer presumptive TB cases from the community.

The grants program through Bangladesh Center for Communication Programs (BCCP) oriented 25

graduate private practitioners on identification and referral of presumptive TB cases, organized 105 video

shows in the slums and 10 street dramas at different locations, conducted 207 community group meeting

and 34 advocacy meetings with local community leaders. BCCP also organized orientation on the use of

BCC materials for 50 NGO service providers. This generic guideline for the use of BCC materials on TB

screening will be used as a job aid by the field workers of all the NGOs working on TB.

TLMI Bangladesh oriented 10 graduate private practitioners on identification and referral of presumptive

TB cases. Project staff visited household of TB patients for contact investigation. During these visits,

7,426 family members investigated for TB screening, 431 suspects identified and 21 TB cases were

detected. The sub grantee conducted 9 advocacy meetings for 119 union council members and government

senior health staff, 5 community group meetings, 7,595 courtyard meetings, and 4 events of folk songs

and drama to raise community awareness about TB.

The project sub-grantee Lepra oriented 515 non-graduate private practitioners, 197 government. health

staff and 220 MCH health workers on screening and referral of presumptive TB cases. This NGO also

conducted orientation for 1,300 school students on signs and symptom of TB using different IEC

materials. The NGO staff conducted household visits for contact tracing, 820 community group meetings

and 11 film shows in the evening reaching more than 8,000 people with messages on TB.

Nari Maitree conducted orientation on FAST approach for 80 staff of different Primary Health Care

Centers (PHCC). The project volunteers conducted 6,111 household visits in the specified slum areas to

identify people with TB symptoms, 3 community awareness meetings and 5 advocacy meetings with local

community leaders and teachers from religious institutes and orphanages to generate their support to and

participation in the project activities.


The project staff of FIDA made 4,622 household visits and conducted 359 courtyard meetings with the

community people to sensitize them about TB disease and promote early case detection. FIDA installed 45

sign boards with TB messages at Union Parishad premises and distributed 100 festoons in different

institutions. The sub-grantee conducted 90 STOP TB forum meetings with community leaders to raise

awareness on TB.

PIME Sisters has started the project in December 2013. The sub-grantee completed recruitment of project

staff in the reporting period. During the quarter, the project staff conducted 2,023 household visits and

contacted 8,092 family members for TB screening. A two-day long orientation for 10 field workers and 2

supervisors was conducted by the project staff on program implementation, recording and reporting.

4.2.3 Promotion of TB Messages through Print Media

The project printed and distributed different communication materials, e.g., posters, stickers, and leaflets

with TB messages to raise public awareness about TB. The materials are displayed at the government and

NGO health facilities, DOTS centers, and sub-grantee working areas. During this quarter, the project

printed 2,000 posters on infection control, MDR TB brochure, 2,000 child TB poster and 40,000 stickers.

The project also developed and printed 10,000 Bangla child TB booklets for field health workers to assist

them in community screening for identification of child TB presumptive cases.

4.3 Increased Adherence to TB and MDR-TB Treatment

4.3.1 Counseling of DR TB Patients

The DR TB patients are counseled at the time of admission, during inpatient treatment at the hospital and

continuation phase of treatment at the community. The project has been supporting a Counselor at the

NIDCH where the largest number of DR TB patients is enrolled for treatment. During the current quarter,

all the patients received pre-admission counseling informing the patients about treatment duration,

intensive and continuation phase treatment, when patients are released from hospital and shifted to home

for continuation phase, how the patient will receive treatment services at home, and infection prevention

practices.

The counselor also organizes individual and group counseling for the patients. The counseling is tailored

to ensure treatment adherence by the patients and to provide psychological and emotional support to help

patients manage the side effects and overcome depression and stress due to prolonged and complicated

treatment. During this quarter, the Counselor conducted 79 individual counseling sessions at the NIDCH.

The counseling during the continuation phase of the treatment is provided by the DR TB DOT providers

who visit the patients at their homes for administration of drugs. During home visit, the DOT providers

also provides counsel tailored to individual patient needs with emphasis on helping the patients to adhere

to the treatment regimen, manage the side effects and complete the treatment successfully. Almost all the

patients on continuation phase of treatment received counseling by the DT providers.

4.3.2 Vocational training for MDR-TB patients

The project continued to support a Vocational Trainer at the NIDCH for providing training on cutting and

sewing dresses. The training is intended to help the patients manage depression and stress and complete

the treatment, and develop vocational skills that they would be able to use for income generation. A total

of 31 DR TB patients, mostly female, participated in this training. The trainer also helped patients make

protective masks which are used by the patients themselves.


4.3.3 Education and counseling for the DM patients

The education and counseling of the diabetic patients are routinely conducted at the BIRDEM hospital.

DAB with project support has integrated TB counseling with diabetes and uses audio-visual materials for

interactive and effective counseling. Following each sessions, counselors and health assistants operate

active screening to identify presumptive TB cases among DM patients and refer them to the DOTS center

located at the hospital for microscopy test. During this quarter, DAB organized 72 counseling sessions and

counseled 6,640 diabetes patients at the BIRDEM hospital.

4.4 Improved Capacity for Governance and Management of TB at all levels

4.4.1 Exposure to best practices and innovations

The project supported NATAB and The Union to jointly organize the 2nd SEAR Conference on TB and

Lung Health in Dhaka from 9-12 March, 2014. The project supported NTP and sub-grantee staff to

participate in the conference to expose them to the best practices and innovative models and share their

experience on TB and MDR TB management.

The project staff made oral presentations on scaling up of community based management of MDR TB and

rolling out Xpert MTB RIF in Bangladesh. Several poster presentations were made covering project

experience in improving drug adherence using smartphone application, increasing case detection among

vulnerable populations, and potentials for diagnosis of smear negative and extra-pulmonary TB using

GeneXpert. The project sub-grantees Bangladesh Pediatric Association and Diabetic Association of

Bangladesh made oral presentations to share their experiences in management of childhood TB and

management of TB-Diabetes Co-morbidities which are being implemented by these two partners with

technical support of the TB CARE II project.

4.5 Increased Private Sector Participation in TB Prevention and Control

4.5.1 Expanded Public Private Mix (PPM) network through NGO Sub-grantees

The project has been supporting PPM activities through the grants program to engage formal and informal

private sector service providers in TB control program. In order for enhancing functional linkage and to

increase suspect referral, the NGOs conducted orientation of graduate and non-graduate private providers

on screening and referral of presumptive TB cases. The project also supported BRAC to conduct

networking meetings with these providers to strengthen linkage and referral of cases to the DOTS centers

for diagnosis and management.

During this quarter, the project supported NGOs oriented 35 graduate doctors and 515 non-graduate

doctors. Networking meetings were conducted with 1,057 graduate and 1,290 non-graduate private

providers. The PPM effort contributed to identification and referral of 13,955 presumptive TB cases to the

DOTS centers for diagnosis and management during this quarter. The progress in PPM activities by NGOs

comparing the current quarter with the previous period is presented in the Table 4 below.


Table 4: Orientation and Referrals through PPM

Oct-Dec 2013 Jan-Mar 2014 Sub-Grantee Orientation/

Networking with

Graduate PPs

Orientation/ Networking with Non-

graduate PPs

Presumptive TB case referrals

by PPs

Orientation/ Networking

with Graduate PPs

Orientation/ Networking with Non-

graduate PPs

Presumptive TB case

referrals by PPs

BRAC 1,055 1,207 11,989 1,057 1,290 12,353

FIDA 20 0 15 0 0 118

BCCP 4 16 298 25 0 227

Lepra 0 417 319 0 515 347

Leprosy Mission 0 60 133

10 0 842

Nari Maitree 0 0 38 0 0 68

PIME Sisters 0 0 0 0 0 0

Total 1,079 1,700 12,792 1,092 1,805 13,955

4.6 Strengthened Support Systems for effective delivery of TB services

4.6.1 Strengthen laboratory capacity and performance

Support to NTRL, RTRL and NIDCH

The project has continued its assistance to NTRL Dhaka and RTRL Chittagong with equipment e.g., AVR

for auto generator and autoclave, reagents and consumables, minor renovations and technical support that

were necessary for smooth functioning of the lab as well as for expanding and ensuring quality of

diagnostic services. The project continued to support 4 Microbiologists based at the NTRL and RTRL to

enhance its capacity to provide lab services including DST and culture services. Table 5 shows the

performance of lab services provided through the NTRL for the reporting quarter.

Table 5: NTRL Laboratory Performance

Type of service Laboratory Performance (January-March 2014)

October November December Total

Routine Microscopy 4,921 5,592 5,341 15,854

Routine TB culture 29 47 46 122

Number of 1st line DST 10 10 9 29

Number of 2nd

line DST 5 3 5 13

Improve staff capacity on GeneXpert, Culture and DST

During this quarter, the project assisted NTP to organize GeneXpert training for 11 lab staff. The training

was intended to develop participants’ skills in the new diagnostic tool and use of the national guidelines

for routine screening of MDR TB suspects and smear negative cases. The project also supported the NTP

to organize training on culture & DST for 7 lab staff including microbiologists from RTRLs. Orientations


on GeneXpert and national guidelines for routine screening of MDR TB presumptive cases were

conducted at CDC Shaymoli, Dhaka and in Cox’s Bazar district. A total of 178 participants including

district and upazila level health managers, Chest Disease Consultants, Medical Officers, Lab

Technologists, nurses and NGO staff attended these orientations.

The project organized a workshop to review Xpert lab data to monitor quality and performance of DR TB

diagnostics and monitoring services. An SOP was developed for culture and DST for diagnosis of

TB/MDR TB and organized workshop to finalize SOP. The project supported NTP to organize EQA

workshops to review the EQA procedures, findings and recommended actions for improvement.

Coverage of GeneXpert Services

Expansion of the GeneXpert technology is a project priority for this year as well. The project completed

the calibration process of 12 Xpert machines by certified engineer during this period. The project procured

12 GeneXpert machines to improve nationwide coverage of the service. The installation will be completed

by early of next quarter after necessary renovation works have been completed. During this period, 28,000

cartridges have been procured and distributed to Xpert sites.

Installation and Operation of LED Microscopes

During this quarter, the project conducted a two-week training course for 23 lab technologists on sputum

microscopy using LED fluorescence microscope. Work is in progress for procurement and installation of

100 LED microscopes planned for FY 2014. These microscopes in additional 200 installed in FY 2013

will be an important resource for NTP to make a system wide improvement in quality and capacity for

smear microscopy for increased and more reliable diagnosis of TB. The 100 LED microscopy sites have

been finalized in discussion with NTP.

Facilitate completion of Khulna RTRL

Commissioning of the Khulna RTRL is one of the priorities of the project. During this quarter, the project

completed renovation works and also completed the procurement of reagents, consumables and glassware

required for Khulna RTRL. Equipments procured with project support have been transported to the lab

site and the operation of the center is expected to start next quarter.

4.6.2 Improve capacity for TB Infection Control

Implementation of FAST

Implementation of the FAST approach for active screening of presumptive TB cases especially at large

hospitals is part of project’s strategy for active case finding. With technical support from PIH, the project

has expanded this approach to all the TB and non-TB wards of NIDCH. This initiative has contributed to

testing 1,075 current TB, other lung diseases patients and lung disease with previous TB patients and

detection of 131 TB cases and 7 RIF resistant cases at NIDCH. The project also scaled up this approach at

BIRDEM.

Capacity development on IC

Training on TB Infection Control is now integrated with other regular training programs on TB. With the

project support, a booklet in Bengali on TBIC has been finalized. During this quarter, the project

organized TB IC orientation for 404 health professionals including doctors, nurses, health assistants, lab

technicians and other staff associated with TB services. The orientation was also designed to update the

participants on waste management procedures for lab and health facilities.


Waste Management

Managing bio hazardous waste is another area which has never received due attention as it needed. The

project conducted orientation for 438 hospital staff to update them on the essential waste management

procedures and requirements. In addition, the project has plans to extend technical and logistics support to

improve waste management systems at 4 hospitals providing DR TB services. During this quarter, the

project has already functionalized waste management system at RTRL and CDH, Chittagong.

4.6.3 Improved Monitoring and Evaluation of TB control activities

Monitoring cPMDT activities

The project has set up an intensive monitoring and supervision system for effective implementation of

cPMDT activities. The Outpatient DR TB Team members regularly monitor and supervise the DR TB

DOT providers. In addition, project field staffs made monthly visit

to patient’s home to monitor treatment compliance, assess patient

management needs and take follow up actions in discussion with the

Outpatient MDR TB Team.

During this quarter, all the 378 patients under cPMDT treatment

have been visited. Joint monitoring team consisting of

representatives from NTP, WHO and the project also visited the field to

monitor the performance of the Outpatient Team, DR TB DOT providers and patients’ compliance with

treatment.

mHealth for monitoring DOT providers

Currently, mHealth is operational in 16 districts and will be scaled up to cover the remaining other

cPMDT districts in FY14. During this quarter, the project conducted orientation including refresher on

mHealth in Dhaka, Chittagong, Pabna and Sylhet districts. The orientation was attended by 244

participants including 87 DR TB DOT providers and other relevant government and NGO staff. At

present, 229 DOT providers including 71 in this quarter are using mHealth.

As of now, a total of 376 DR TB patients including 108 patients in this quarter have been registered in to

mHealth. Out of them, 19 patients got cured, 4 died in this period and remaining patients are being

supported and monitored through the mHealth. The project is in process of updating the mHealth

applications, expand it to all the cPMDT districts, and use it as a tool for routine monitoring of the DOTS

for patients, administration of drugs, and treatment adherence by patients. The system changes will enable

the project to analyze and generate reports and graphs on patient data by geographic units, treatment

status, gender, etc.

5 SPECIAL EVENTS

Observation of World TB DAY 2014

The theme of the World TB Day 2014 was “Reach the 3 million. Find, Treat and Cure TB”. The project

supported NTP to observe the World TB Day in various ways including organized rallies at national and

divisional levels to raise mass awareness about TB. At regional level mikings and street songs were

organized at different public places to disseminate TB message.

DR TB patient monitoring


The project also printed and distributed T-Shirts with TB message, distributed leaflet on TB and sticker on

Child to improve awareness about child TB, the project distributed printed entry ticket in two amusement

parks with child TB messages. Using mobile, voice messages were distributed to 600,000 mobile phone

subscribers using the mobile phone network.

USAID Mission Director Visit Project Sites

USAID Bangladesh Mission Director, Ms. Janina Jaruzelski,

visited Kajuri Chora Tea garden in Srimangal to observe the TB

control activities implemented by HEED Bangladesh with TB

CARE II project support. The Mission Director observed two

different ways of TB awareness raising program; group

orientation on TB for local women, and TB awareness raising

outreach activity through "pot song," a popular type of local folk

songs.

6 CHALLENGES ENCOUNTERED AND ADDRESSED

Utilization of GeneXpert is satisfactory in large metropolitcan cities, RTRLs and some Chest Disease

Hospital. Challenges remain to increasing utilization particularly at the district level facilities. Many

physicians at these facilities do not fully comply with the policy guidelines that require referral of

presumptive MDR TB and smear negative cases for GeneXpert test. Referral from the peripheral

microscopy centers on which the uilization of GeneXpert depends to a large extent is also a challenge

either because the doctors are not fully aware of the availability of the test or the patients are unwilling to

come to the Xpert facilities as they are unable to bear the transportation costs. The project has planned

advocacy meetings at the district levels involving physicians from the districts and upazilas to update them

on the national policy and expand sputum collection and transportation system to address these issues.

The limited number of MDR TB beds continues to be an issue with regard to increasing enrollment of

diagnosed patients across the country and reducing treatment initiation delay. The project is supporting

NTP to increase inpatient management capacity through district level chest disease hospitals. Besides, the

project staff is enaged in continuous dialog with NTP to initiate ‘zero day’ treatment for all diagnosed

patients unless the clinical assessment indicate the need for hospitalization.

The proportion of child TB cases detected is very low. Acute shortage of skilled staff both at the facilities

and field level and limited or no availability of diagnostics at the local level are major barriers to change

the situation. The project strategies to address this challenge include training of doctors and fields

workers on screening and diagnosis of child TB cases, systematic contact tracing, developing referral

linkages with diagnostic facilities, and supporting communication activities at the community level and

through mass media.

7 PERFORMANCE MONITORING PLAN

The TB CARE II project is designed to strengthen and improve performance of National TB control

program. Except for some project specific indicators, the project has adopted the NTP service delivery

indicators for reporting its performance. Therefore, the project exclusively relies on NTP Management

Information System (MIS) for collection and reporting of TB case detection, treatment outcomes, and

laboratory performance data. At this time, the NTP MIS has completed compilation of data for the

USAID mission director visits HEED project


October-December quarter of 2013. The project used this data for analysis and reporting the performance

as presented in Table 6.

Table 6: Indicators reported using NTP Management Information System

Outcome Indicators Baseline

2010

Target

CY 2013

Result

CY 2013

CY 2013

Qtr 1

CY 2013

Qtr 2

CY 2013

Qtr 3

CY 2013

Qtr 4

Notification Rate of all forms of TB cases 100 104 119.73 Annually Annually Annually Annually

Number of all forms of new TB cases

notified

155,138 163,802 181,436 43,951 48,250 45,677 43,558

Notification Rate of new smear-positive

(SS+) TB cases

70.5 65 68.47 67.7 71 69 65.9

Number of smear Positive (SS+) patients

notified

105,772 106,471 105,404 26,064 27,448 26,534 25,358

Number of smear negative (SS-) patients

notified

21,625 24,196 42,361 9,856 11,600 10,622 10,283

Number of extra pulmonary patients

notified

23,506 26,213 33,671 8,031 9,202 8,521 7,917

Number of child TB patients notified 4,235 6,045 5,045 1,137 1,409 1,341 1,158

Number of children under 5 registered for

IPT

0 0 0 0 0 0 0

Number of new multi-drug resistant-TB

(MDRTB) patients diagnosed and initiated

to treatment

183 600 685 162 170 181 172

Cure Rate of notified SS+ TB cases

90.80% >90% 91.82% 91% 92% 92% 92.1%

Treatment Success Rate of notified SS+ TB

cases (disaggregated by sex)

92.30% >90% 92.9% 92% 93% 93% 93.2%

Treatment Success Rate for MDR-TB cases

65% >65% 69% 77% 56% 69% 68.8%

Percent of labs participating in EQA for

smears

100% 100% 100% 100% 100% 100% 100%

Percentage of concordant slides under EQA

system (high false positive, high false

negative, scanty false positive, scanty false

negative)

99% >95% 98% 98.5% 99% 98% 98.2%

Percent of labs performing TB microscopy

with over 95% correct microscopy results

100% >95% 94.7% 94% 94.8% 94% 94.5%

Smear Conversion Rate of new smear

positive TB cases.

87.1% >75% 85% 86% 85.5% 81% 85.8%

The TB CARE II project also maintains Project Management Information System (PMIS) for monitoring

and reporting on project specific data that is not generated by NTP. The PMIS specifically tracks outputs

of US government investments in capacity building and NGO contributions to TB suspect identification

and referrals as shown in Table 7 below:

Table 7: Indicator reported using TB CARE II Project Management Information System

Indicators Target FY

2014

FY 2014

Qtr 1

FY 2014

Qtr 2

FY 2014

Qtr 3

FY 2014

Qtr 4

1 Number of people trained in DOTS with USG funding 9,235 3,831 3,891

2 Number of service providers trained on management of 16,765 87 1,072


child TB with USG funding

3 Number of people trained in MDR-TB (clinical care,

MDRTB DOTS, ambulatory care) with USG funding

1,800 197 404

4 Number of private providers participating in TB

program through referrals, diagnosis, treatment, and

follow up

30,000 3,634 3,497

5 Number of TB suspects referred by health care provider

(e.g., health assistant, shasthya shebika, private

practitioners, others) with USG funding

65,000 13,204 14,790

6 Number of lab technologists trained on AFB, LED and

other new diagnostic technology with USG funding

300 33 41

7 Number of service providers trained on Infection

Control with USG support

2,500 67 404

8 Number of people trained in other strategic information

management with USG funding

500 137 258

9 Number of children under 5 registered for IPT with USG

funding

3,000 85 72

10 Number of DR TB suspects tested by GeneXpert 0 1,425 1,805

11 Number of smear negatives sputum samples tested

GeneXpert

0 2,447 6,827

12 Number of HIV patients tested for TB by GeneXpert 0 69 70

13 Number of MTB positive identified by GeneXpert 0 1,311 1,945

14 Number of MTB RIF identified by GeneXpert 0 196 229

8 PLANS FOR THE NEXT QUARTER

Starting next quarter, the project will expand its grants program to support community level activities for

increasing case detection especially in low performing districts. The grants program will have major focus

in conducting systematic contact tracing at households of active TB patients to increase detection of child

TB cases. Communication activities to improve knowledge and awareness about TB and MDR TB and

care seeking for services will be supported at the community level as well as through mass media.

Training of physicians and field workers on screening and diagnosis of child TB will be expanded to other

divisions.

Procurement and installation of GeneXperts at the district facilities will be a major initiative in the

following quarter. Besides, the project has planned to conduct a number of advocacy meetings at the

district levels to update physicians on national guidelines and algorithms for Xpert test. Expansion of

sputum collection and transportation system will be a priority in the next quarter. The system will link the

peripheral microscopy centers with the GeneXpert sites for referral of presumptive DR TB and smear

negative TB cases.

In this quarter, project will support an international expert to develop a bio-safety manual and to

support repair, maintenance, calibration and certification of equipments to improve diagnostic

quality at reference labs. The consultant will provide training of RTRL and NTRL staff on bio-

safety and maintenance of laboratory equipment. Trainees who will serve as bio-safety officers at

their respective laboratories will also receive 2-day training on the development and

implementation of a bio-safety manual. These manuals will be developed by them over the next 5

months. The consultant will also certify 14 bi-safety cabinets during this quarter.


Procurement and installation of additional 100 LED microscopes, training of lab technologists on sputum

microscopy and strengthening supervision and monitoring of labs are major tasks planned for

implementation in the next quarter. Actions will be planned to review the quality of reagents prepared at

the EQA centers for LED microscopy and take corrective measures.

The project has selected 4 (four) district TB hospitals for expansion of NTP capacity for inpatient

management of MDR TB patients. These facilities need minor renovation works which will be completed

in the next quarter. Developing capacity of staff from these facilities in programmatic management of

MDR TB patients is also planned to start soon.

tb care annual work plan and budget

Documents