B ANGLADESH USAID TB CARE II Bangladesh: Grants Spotlight 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.
Table of Contents 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
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 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 corporations. 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 Bangladesh 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 strengthening and expanding PMDT is a major technical focus of the TB CARE II project. The project provides exclusive technical 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 improve the capacity of culture and DST services throughout the country. n Strengthening diagnostic capacity for drug susceptible and drug resistant TB; USAID TB CARE II Bangladesh: Grants Spotlight 1
Introduction to the Small Grants Program As a component of the project, TB CARE II Bangladesh supports nongovernmental, community based organizations (NGOs) in urban and rural areas with TB case notification rates below the national average to increase detection and management of TB and MDR TB services 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; 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 services to formerly unreached or underserved populations. Grant Waves No. 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; Wave 3 9 16 districts: Bagerhat, Narail, Jhenaidah, Noakhali, Magura, Shatkhira, Comilla. Laxmipur, Nilphamari, Bandarban; Dhaka and Khulna city corporations; 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 April 2012 to June 2014; activities in tea gardens from April 2012 to March 2014 April 2013 to March 2015 September 2013 to July 2014 April 2013 to March 2015 2 USAID TB CARE II Bangladesh: Grants Spotlight
TB CARE II Bangladesh Small Grants Geographic Coverage Area City Corporations Districts USAID TB CARE II Bangladesh: Grants Spotlight 3
The TB CARE II Bangladesh Small Grants Capacity Building Model While the primary goal of the small grants program is to provide TB services to people, the program has also acted as a capacitybuilding 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. Grantee Focus Areas Intensified TB Case Finding 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 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. 4 USAID TB CARE II Bangladesh: Grants Spotlight
45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 Figure 1. Number of Cases Detected in Brac TB CARE II - Supported Districts, 2011-2014 30,315 22,015 3,994 4,306 Baseline (APR 11 - MAR 12) 36,153 23,265 7,316 5,572 Year 1 (APR 12 - MAR 13) 40,122 23,094 10,463 6,565 Year 2 (APR 13 - MAR 14) Smear Positive Smear Negative EP Total 160 140 120 100 80 60 40 20 0 Figure 2. Case Detection Rates per 100,000 Population in Brac TB Care II Project - Supported Districts, 2011-2014 106 76 29 Baseline (APR 11 - MAR 12) 126 80 44 Year 1 (APR 12 - MAR 13) Year 2 (APR 13 - MAR 14) Smear Positive Smear Negative and Extra-pulmonary Total 139 77 51 USAID TB CARE II Bangladesh: Grants Spotlight 5
1,600 1,400 1,200 1,000 800 600 400 200 0 Figure 3. Number of Cases Detected in Heed TB Care II Project - Supported Districts, 2011-2014 377 271 68 38 Baseline (APR 11 - MAR 12) 498 70 51 Year 1 (APR 12 - MAR 13) 1,449 Year 2 (APR 13 - MAR 14) Smear Positive Smear Negative EP Total 377 873 393 183 Under Wave 3, the project started funding 6 NGOs for additional case detection in under-performing and hardto-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 6 USAID TB CARE II Bangladesh: Grants Spotlight
Addressing TB among Vulnerable and High-Risk Populations 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 Bangladesh (DAB) is working to address this dual burden by expanding 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 detected 675 cases of TB among diabetes patients (Figure 5). 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. Figure 5. Detection of TB Among DM Patients 675 Intervention Period 15 14 21 50 62 54 52 48 35 36 Baseline (APR - JUNE 13) 168 119 78 64 32 JUL - SEP 13 OCT - DEC 13 JAN - MAR 14 APR - JUN 14 Year Total 174 97 86 31 SS+ SS- EP Total 214 285 239 151 USAID TB CARE II Bangladesh: Grants Spotlight 7
TB in Prisons Prisoners are at a heightened risk for TB because of overcrowded, 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 Bangladesh, 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 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 Linking with Private Providers 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 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 nongraduate private providers. ¹ Banu, S.et al. PLoS One. 2010 May 21;5(5):e10759. http://www.ncbi.nlm.nih.gov/pubmed/20505826 8 USAID TB CARE II Bangladesh: Grants Spotlight
TB CARE II small grantee LEPRA oriented 61 private medical doctors on TB screening and referral from Sirajgong, Pabna, and Natore districts. These providers in turn referred 704 TB suspects for diagnosis and follow up. Sample BCC materials designed by grantee BCCP. 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. Advocacy, Communication, and Social Mobilization Activities TB CARE II grantees engage in a variety of advocacy, communication, and social mobilization (ACSM) activities 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 community 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. Outreach to Community Leaders One of TB CARE II grantee Nari Maitree s main project objectives was to mobilize communities to increase awareness about TB and encourage timely utilization of TB services 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 Programs (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 designed 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 community-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. USAID TB CARE II Bangladesh: Grants Spotlight 9
Drama and Folk Songs Several grantees, including BCCP and Leprosy Mission International Bangladesh reached out to their communities 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. 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. Human Resource Department 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 childhood 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. A child TB training supported by TB CARE II. 10 USAID TB CARE II Bangladesh: Grants Spotlight
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 544 Government 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 8,345 Health 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 referral of presumptive child TB cases. USAID TB CARE II Bangladesh: Grants Spotlight 11
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