usaid tb care ii bangladesh

This document has been developed by the TB CARE II project and is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents of this document are the sole responsibility of University Research Co., LLC and do not necessarily reflect the views of USAID or the United States Government.

Grants SpotlightUSAID TB CARE II Bangladesh:

B ANG L AD E S H B ANG L AD E S H

Background ....................................................................................................1

Introduction to TB CARE II Bangladesh .......................................................1

Introduction to the Small Grants Program ...................................................2

The TB CARE II Bangladesh Small Grants Capacity Building Model .........4

Grantee Focus Areas .....................................................................................4

Intensified TB Case Finding .........................................................................4

Addressing TB among Vulnerable and High-Risk Populations .....................7

Linking with Private Providers ......................................................................8

Advocacy, Communication, and Social Mobilization Activities .....................9

Human Resource Department .................................................................. 10

Table of Contents

USAID TB CARE II Bangladesh: Grants Spotlight 1

Background

Tuberculosis (TB) remains a major public health

problem in Bangladesh. Bangladesh currently

has the sixth highest TB burden in the word, with

approximately 350,000 new cases of TB in 2012. Of these,

the total number of all new TB cases detected was 164,855

– signifying that 53% of TB cases remain undetected every

year (WHO Global TB Report 2013). While Bangladesh

has made significant progress in the past several years

in increasing detection of smear positive TB, increasing

the rates of treatment success, and achieving nationwide

coverage of the directly-observed therapy short course

(DOTS) program, more remains to be done to detect a

larger proportion of cases and contain the spread of the

disease. Treatment adherence is also a major problem,

which is in part responsible for the increasing rates of

multidrug resistant TB (MDR TB) in the country. Currently,

MDR TB represents 1.4% of new and 29% of retreatment

cases. The total number of MDR TB cases among notified

pulmonary TB cases is estimated at 4,200. Because of

limited capacity for diagnosis, only a small proportion of

estimated MDR TB cases are identified. The situation is

same with the treatment of MDR-TB patients. The capacity

for in-patient treatment of MDR TB is far less than the

patients who need this service. As a result, a large number

of patients remain on waiting lists for treatment for MDR-TB.

Introduction to TB CARE II Bangladesh

TB CARE II Bangladesh, funded through the global

USAID TB CARE II Project, is designed to enhance the

capacity of the National TB Control Program (NTP) to

achieve its national objectives for preventing and controlling

TB. The project, implemented by University Research Co.,

LLC (URC) along with its global partners, leverages Global

Fund and Government of Bangladesh resources to facilitate

implementation of strategies to strengthen and expand

DOTS, Programmatic Management of Drug Resistant TB

(PMDT), and the overall health systems.

The specific objectives of the project include:

n Improving universal access to TB diagnosis and treatment;

n Working with Government of Bangladesh to reach

and sustain the global targets of > 70% case detection

and > 85% cure rates under DOTS;

n Providing high quality DOTS through all levels including

those of private providers;

n Improving programmatic management of MDR TB and

increasing access to MDR TB prevention and treatment

through community-based approaches;

n Strengthening diagnostic capacity for drug susceptible

and drug resistant TB;

n Strengthening health systems with an Upazila-based

approach for decentralized management of TB control

and prevention activities.

TB CARE II Bangladesh is currently working to strengthen

community-based interventions for TB DOTS activities in

18 districts and parts of Dhaka and Khulna city corpora-

tions. The focus of the project’s community-based work is

to address programmatic gaps that are currently not being

addressed by the Global Fund or Government of Bangla-

desh activities. The project also complements the Global

Fund and GOB activities with main focus on strengthening

capacity and quality of the sputum microscopy services all

over the country. Developing national capacity for strength-

ening and expanding PMDT is a major technical focus of

the TB CARE II project. The project provides exclusive tech-

nical and logistics support to increase access to GeneXpert

services throughout the country and community-based

management of DR TB cases in 39 districts and three city

corporations. The project also supports activities to im-

prove the capacity of culture and DST services throughout

the country.

USAID TB CARE II Bangladesh: Grants Spotlight2

Introduction to the Small Grants Program

As a component of the project, TB CARE II Bangla-

desh supports nongovernmental, community based

organizations (NGOs) in urban and rural areas with

TB case notification rates below the national average to in-

crease detection and management of TB and MDR TB ser-

vices and to improve community knowledge and awareness

of TB and MDR TB. The geographic coverage varied under

different waves of grants as indicated in the table below.

Since April 2012, TB CARE II has supported 11 grantees

for periods of one-to-two years each. These grantees have

carried out a range of community-based activities, including:

n Tracing contacts to identify and refer presumptive

(suspected) TB and MDR TB cases among children

and adult members of active and cured TB and

MDR-TB patients;

n Sputum collection and transportation systems for

people living in remote areas with no easy access to

microscopy centers;

n Identifying and referring presumptive MDR TB cases to

GeneXpert sites for testing;

n Diagnosis and management of smear negative and

extra-pulmonary TB (EPTB) cases;

n Providing isoniazid preventive therapy (IPT) for children;

n Engaging and developing capacity of graduate and

non-graduate (village doctors) private doctors,

homeopaths, herbal practitioners and traditional

healers in TB screening and referral;

Grant WavesNo. of

Awards Made Areas Covered Award Period

Wave 1 3 15 districts: Manikganj, Gazipur, Narayanganj, Feni, Chittagong, Rangamati, Dinajpur, Joypurhat, Sunamganj, Jessore, Khulna, Barisal, Rangpur city corporation, and 157 tea gardens in Sylhet, Moulvibazar and Habiganj districts;

April 2012 to June 2014; activities in tea gardens from April 2012 to March 2014

Wave 3 9 16 districts: Bagerhat, Narail, Jhenaidah, Noakhali, Magura, Shatkhira, Comilla. Laxmipur, Nilphamari, Bandarban; Dhaka and Khulna city corporations;

April 2013 to March 2015

Sole source 2 BPA: 17 districts of Dhaka division for child TB training;

DAB: BIRDEM hospital and district level outpatient facilities for detection of TB among diabetic patients

September 2013 to July 2014

April 2013 to March 2015

n Developing capacity of maternal and child health (MCH) and family planning (FP) workers in screening and referral of presumptive TB cases;

n Coordinating with the NTP/NGOs to initiate early initiation of TB treatment and DOTS services;

n Counselling TB patients and family members on treatment adherence, side effects management, infection prevention, follow up services, etc.

n Financial support to poor patients for diagnosis of smear negative and EPTB;

n Developing capacity of NGO staff/volunteers in TB screening, referral, DOTS, counselling, contact tracing, and data collection and recording;

n Organizing community meetings to educate people about TB, importance of early diagnosis and treatment adherence, social barriers and stigma related to TB;

n Organizing drama, folk songs, and rallies to promote awareness and counter stigma about TB;

n Developing and engaging peers (cured TB patients);

n Organizing advocacy meeting with local community leaders to engage them in supporting communication activities

Grants are given to local NGOs with a proven track record or interest in the area of TB and MDR TB management. Through the grants program, these organizations have been able to provide TB education, screening and treatment ser-vices to formerly unreached or underserved populations.


TB CARE II Bangladesh Small Grants Geographic Coverage Area

City Corporations

Districts


The TB CARE II Bangladesh Small Grants Capacity Building Model

Grantee Focus Areas

While the primary goal of the small grants

program is to provide TB services to people,

the program has also acted as a capacity-

building mechanism for local NGOs, helping them build

their technical, financial and management systems. It

also helps them establish and cultivate collaborative

partnerships with the NTP and other NGOs to sustain and

expand the provision of services after the grant ends.

With about half of TB cases remaining undetected

each year in Bangladesh, improving TB case

detection through intensified case finding efforts

is a critical activity that nearly all TB CARE II grantees

actively engage in. Grantees engage in door-to-door

campaigns, household visits to contacts of known TB

patients and defaulters (contact tracing) and community

mobilization events to screen individuals for TB, identify TB

suspects, and refer them for diagnosis and treatment. As a

result, grantees are helping to improve the case notification

and case detection rates in the districts where they work.

Through TB CARE II project support, grantee BRAC was

able to identify an additional 56,302 in 27 months over its

2011 baseline (Figure 1) - increasing case detection rates for

all cases from a baseline of 106 per 100,000 population to

139 per 100,000 population in 2014 (Figure 2).

Case detection of TB among the tea garden population has

always been lower than other parts of the country. With the

financial and technical support of the TB CARE II project,

HEED Bangladesh was able to streamline its strategies for

Intensified TB Case Finding

Intensified case finding (ICF)

Health workers, NGO staff, and/or

community volunteers screen individuals for

TB by asking a series of symptom screening

questions. When the symptom screen is

positive, sputum samples of suspected TB

cases are collected for diagnostic testing.

If the laboratory test confirms a diagnosis

of TB, the patient is put on appropriate

treatment and their contacts are in turn

screened and tested for TB.

TB case detection and raising community awareness and

implement them in a systematic manner among this target

population. As a result, since beginning of the project in

April 2012, case detection and notification of all forms of TB

has increased significantly compared to the baseline.


Figure 1. Number of Cases Detected in Brac TB CARE II - Supported Districts, 2011 - 2014

0

10,0005,000

Baseline(APR ‘11 - MAR ’12)

Year 1(APR ‘12 - MAR ’13)


20,00015,000

25,00030,000

40,00035,000

45,000

30,315

22,015

3,994

4,306

7,316

5,572

23,265

36,153

10,463

6,565

40,122

23,094

Smear Positive Smear Negative EP Total

Figure 2. Case Detection Rates per 100,000 Population in Brac TB Care II Project - Supported Districts, 2011 - 2014

0

4020




8060

100120

160140

106

76

29

126

80

44

139

77

51

Smear Positive Smear Negative and Extra-pulmonary Total


Under Wave 3, the project started funding 6 NGOs for

additional case detection in under-performing and hard-

to-reach urban and rural areas. These NGOs contributed

to detection of 2,612 additional TB cases of all forms from

April 2013 to June 2014 with project support. Active case

finding at the community level such as contact tracing and

screening of other vulnerable populations, networking

with private providers, awareness activities, and financial

support to cover investigation costs for poor patients are

the factors that contributed to increasing case detection

through these NGOs. The table below shows the additional

TB cases detected by these NGOs.

Type of TB BCCP Nari Moitree Lepra TLMI FIDA PIME Total

Smear Positive 50 170 879 655 273 20 2,047

Smear Negative 19 44 53 93 150 3 362

EPTB 22 51 64 43 18 5 203

Total 91 265 996 791 441 28 2,612

Figure 3. Number of Cases Detected in Heed TB Care II Project - Supported Districts, 2011 - 2014

0

200




600

400

800

1,000

1,400

1,200

1,600

377

68271

498

1,449

873

393

183377

5170

38

Smear Positive Smear Negative EP Total


Baseline(APR - JUNE ‘13)

JUL - SEP ‘13 OCT - DEC ‘13 JAN - MAR ‘14 APR - JUN ‘14 Year Total

Figure 5. Detection of TB Among DM Patients

15 14 2150 62 54 52 48 35 36

11978 64

32

174

97 8631

214

285239

151

675

168

SS+ SS- EP Total

TB CARE II Bangladesh grantees are uniquely situated

to provide TB services to targeted hard-to-reach

populations, many of whom are also at a higher risk

of contracting TB.

TB/Diabetes

Globally, people with diabetes have a 2-3 times higher

risk of TB compared to those without diabetes, and about

10% of all TB cases are linked to diabetes. TB patients with

diabetes have a higher risk of death during TB treatment,

and cases of diabetes can be complicated by co-infection

with TB.

TB CARE II grantee the Diabetic Association of Bangla-

desh (DAB) is working to address this dual burden by ex-

panding access to TB services for diabetes patients as well

as ensuring TB patients are screened for diabetes in Dhaka

City Corporation and 63 districts. To date, DAB has detect-

ed 675 cases of TB among diabetes patients (Figure 5).

Addressing TB among Vulnerable and High-Risk Populations

A lab technician at BIRDEM hospital uses a GeneXpert machine to

test a sputum sample for TB. BIRDEM is the largest hospital providing

diabetes and diabetes related services in Dhaka.

Intervention Period


¹ Banu, S.et al. PLoS One. 2010 May 21;5(5):e10759. http://www.ncbi.nlm.nih.gov/pubmed/20505826

TB in Prisons

Prisoners are at a heightened risk for TB because of over-crowded, cramped living conditions and inadequate diets often found in prison settings. Prison health care systems are often ill equipped to deal with TB patients and patients often lack access to TB diagnostics and treatments. A 2010 study of Dhaka Central Jail, the largest prison in Bangla-desh, found a prevalence rate of sputum-positive pulmonary TB of 2,227/100,000¹.

TB CARE II partner BRAC used funding from a Wave 1 grant to conduct enhanced screening in twelve prisons within the project target districts. As a result, 2554 prison inmates were tested for TB and 96 cases of TB were diagnosed. Of these, 94 prisoners were registered for TB treatment.

TB in Children

TB remains a serious threat to children’s health in many parts of the world. The WHO estimates that children account

for around 500,000 new cases of TB annually, and that

In Bangladesh, more than half of TB patients seek care

in the private sector, both formal and informal. Therefore,

private medical practitioners and traditional healers must

be well-equipped to screen patients for TB and referral

them for diagnosis and treatment. TB CARE II Bangladesh

grantees are currently playing an important role in linking

private and public sector providers to ensure effective

referral and proper diagnosis and treatment follow up for

Linking with Private Providers

up to 74,000 children die from TB each year. Of the

total number of TB cases detected in Bangladesh, only

3% are childhood TB cases – compared with 9-11%

globally – signifying that many cases of childhood TB in

Bangladesh are left undetected and untreated.

Through intensified case finding and contact tracing,

eight TB CARE II grantees have detected 692 cases

of TB in children. Two grantees, BRAC and LEPRA

have also been actively engaged in the provision of INH

prophylaxis to prevent TB from developing in children

who have been in close contact with a TB patient. BRAC

had a total of 541 children registered in April – June 2013

complete the full course of INH prophylaxis during the

Wave 3 grant period.

TB CARE II grantees are actively engaged in contact

tracing and referral of childhood TB cases, as well as in

provision of isoniazid preventive therapy (IPT) for eligible

children under five.

FY 12 (Apr - Sep ‘12) FY 13 FY 14 (Oct ‘13 - Jul ‘14) Total

Child contacts <5 year evaluated for IPT 1,642 2,965 2,996 7,603

Children <5 year registered for IPT 587 545 321 1,453

Children <5 years completed INH - 1,049 78 1,127

TB CARE II small grantee Family Income Development Association

(FIDA) conducts an orientation session for non-graduate private

providers on TB screening and referral. Through a Wave 3 TB CARE II

Bangladesh grant, FIDA was able to reach 20 graduate and 150 non-

graduate private providers.


TB patients in line with the NTP DOTS strategy. Grantees

also conduct advocacy meetings and networking events

with private health care providers to increase their support

for TB control and prevention efforts. Since 2012, TB CARE

II Bangladesh have reached 7599 graduate and 12,801

non-graduate providers with orientation and training on

proper TB screening and referral practices. These private

health practitioners are now poised to effectively aid TB

control efforts. For example, from April 2013 – March 2014,

the 61 private medical doctors trained by grantee LEPRA

referred 704 TB suspects for diagnosis and follow up.

TB CARE II small grantee LEPRA oriented 61 private medical doctors

on TB screening and referral from Sirajgong, Pabna, and Natore dis-

tricts. These providers in turn referred 704 TB suspects for diagnosis

and follow up.

TB CARE II grantees engage in a variety of advocacy, communication, and social mobilization (ACSM) activi-ties designed to 1) increase knowledge and awareness

of local leaders about the burden of TB disease and its impact on communities and families with TB patients, and promote their active participation in TB control, care and prevention activities; 2) improve community knowledge of TB prevention strategies as well as TB symptoms to motivate communi-ty members to seek care from health workers when TB is suspected; and 3) mobilize communities to reduce stigma

associated with TB and provide support for TB patients.

Advocacy, Communication, and Social Mobilization Activities

Sample BCC materials designed by grantee BCCP.

Outreach to Community Leaders

One of TB CARE II grantee Nari Maitree’s main project objectives was to mobilize communities to increase aware-ness about TB and encourage timely utilization of TB ser-vices in 14 wards of Dhaka City Corporation. Nari Maitree organized a series of advocacy meetings and orientation sessions with a variety of influential community leaders, including ward commissions, slum leaders, teachers at local madrasahs and orphanages, as well as with family members of current TB patients. Over the course of the one year grant, Nari Maitree was able to reach 90 teachers, 420 ward commissioners and slum leaders, 360 community leaders, and 210 family members of TB patients.

Behavior Change Communications

Grantee the Bangladesh Center for Communication Pro-grams (BCCP) received a TB CARE II grant to implement advocacy and social awareness interventions in 5 wards of Dhaka City Corporation. As part of its grant, BCCP de-signed and developed behaviour change communication (BCC) materials including posters, brochures, booklets, and stickers on TB topics including childhood TB, MDR TB, and infection control which they distributed during communi-ty-based events.

BCCP also hosted 146 video screening, where huge crowds gathered in the slum area of Mirur, Dhaka to learn about TB symptoms and be encouraged to visit the nearby clinic for a cough test.


Grantee Nari Maitree holds a TB orientation session for teachers from

Dhaka City madrasahs and orphanages. An informational meeting for

families of TB patients.BCCP hosts a street drama to inform community members about the

symptoms of TB.

Pre-Service Training in TB for Intern Doctors

URC awarded a sub-grant to Research, Training and

Management (RTM) International to conduct pre-service

training on programmatic management of TB for intern

doctors. Through this project, 1,308 intern doctors from 10

public and private medical college hospitals participated in

this training. The participants also received various training

materials including national guidelines on TB and child TB,

and handbook on TB control.

Child TB Training

To improve capacity of service providers to address child-

hood TB, TB CARE II awarded a sole source sub-grant to

the Bangladesh Pediatric Association (BPA) to train doctors

and health care workers from Dhaka division to improve

their skills in screening, diagnosis, and management of

child TB.

Human Resource Department

A child TB training supported by TB CARE II.

Drama and Folk Songs

Several grantees, including BCCP and Leprosy Mission

International – Bangladesh reached out to their communi-ties through street performances, dramas, and folk songs. Leprosy Mission hosted 20 events in 2013 – 2014, which drew 17,992 participants to learn about early signs and symptoms of TB. As a result, 79 TB suspects came forward to access TB services.


Type of Training Number Trained Participants

Training of Facilitators (Trainers) 70 Pediatricians from Medical College and District Hospitals

4-day training on Diagnosis and management of child TB

544Government doctors - UHFPO, Peditric Consultant, Medial Officer

1-day Orientation of on Child TB 15 District Civil Surgeons

1-day Orientation on National Child TB Guidelines 622 Private graduate doctors from upazilas and districts

1-day Orientation on screening and referral of children with TB symptoms

8,345Health Assistant, SACMO, Health Inspector, Program Organizer

The training content and duration were tailored to meet

varying needs of the participants. A total of 544 doctors,

including paediatricians from sub-district hospitals and

medical college hospitals, attended the four-day training

with focus on diagnosis and management of child TB. The

one-day orientation on national guidelines for management

of child TB was conducted for 622 private medical doctors.

Additionally, 8,345 health workers, most of whom work at

the community level, were oriented on screening and refer-

ral of presumptive child TB cases.

For more information, please visit:

http://tbcare2.org or http://www.urc-chs.com/

usaid tb care ii bangladesh

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