Control and Prevention of Tuberculosis (CAP-TB)

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Leading up to World TB Day 2014, the CAP-TB “Cover your Cough” campaign used creative social and mass media to reach
Summary Report

Control and Prevention of Tuberculosis (CAP-TB) October 2012 to September 2015

Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

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Overview

Background

The U.S. Agency for International Development Control and PreventionTuberculosis (USAID CAP-TB) project has been funded in Myanmar from October 2011 through December 2015. The overall goal of the CAP-TB project is to develop a model for multi-drug resistant tuberculosis (MDR-TB) control and prevention in the Greater Mekong Sub-region (GMS) of Myanmar, China, and Thailand, with impact on incidence and mortality from MDR-TB in these countries. The CAP-TB model is a patient-centered, community-driven approach to strengthen health systems with the overall goal to impact MDRTB control and prevention.

TB/ MDR-TB Risk Groups

MMP: migrant and mobile population ups PREVENTION AND EDUCATION PLHIV: people living with HIV DM: diabetes mellitus population DOTS success ENTION AND EDUCATION Elderly: > 65 years old HIV Community mobilization ccess Infection control TB/ MDR-TB Risk Groups nity mobilization Training of trainers and physician mentoring control MMP: migrant and mobile population PLHIV: people living with HIV of trainers and physician mentoring

CAP-TB Model

DM: diabetes mellitus

TB/ MDR-TB Risk Groups Elderly: > 65 years old

TREATMENT SUCCESS migrant and mobile population

PREVENTION AND EDUCATION

DOTS success Community mobilization Infection control Training of trainers and physician mentoring

PREVENTION AND EDUCATION

DOTS success Community mobilization Infection control PREVENTION AND EDUCATION Training of trainers and physician mentoring

MMP: DOTS success DIAGNOSIS Directly therapy (DOT) PLHIV: people living withobserved HIV Community mobilization RISK GROUPS Chest X-rays Community-based DOT DM: diabetes mellitus Infection control MMP, PLHIV, DIAGNOSIS bserved therapy (DOT) Elderly: > 65 years Early case detection Patient old education Training of trainers and physician mentoring DM, Elderly RISK GROUPS ity-based DOT Build TB lab capacity Living Support Package Chest X-rays DIAGNOSIS MMP, PLHIV, Early case detection ducation GeneXpert DM, Elderly Build TB lab capacitySUCCESS pport Package Chest X-rays Microbiology studies TREATMENT Early case detection GeneXpert Directly observed therapy (DOT) Build TB lab capacity Microbiology studies RISK GROUPS Community-based DOT GeneXpert MMP, PLHIV, Patient education Microbiology studies TREATMENT SUCCESS DM, Elderly DIAGNOSIS Directly observed therapy Living (DOT) Support Package RISK GROUPS Chest X-rays Community-based DOT TREATMENT INITIATION MMP, PLHIV, Second-line drug availability Early case detection Patient education DM, Elderly TREATMENT INITIATION Build TB lab capacity Living Support Package MDR-TB treatment guideline Second-line drug availability Package of services GeneXpert MDR-TB treatment guideline Microbiology studies Package of services

MENT SUCCESS

Strengthened Services TREATMENT

Existing Services Strengthened Services Added Services

Second-line drug availability MDR-TB treatment guideline Package of services

Existing Services

Effective MDR-TB control is a challenge for TB platforms and health systems, as evidenced by the large diagnosis and treatment gaps reported from global data. Despite progress since 2009, fewer than 41% of estimated MDR-TB cases worldwide were diagnosed in 2014, and the global success rate remains at 50%. Starting in 2012, the CAP-TB project developed a model for MDR-TB control using a “patient-centered” perspective to identify gaps in the health system. The CAP-TB model starts with finding presumptive TB and MDR-TB patients in the community; linking presumptive patients with the national TB system for early diagnosis and initiation of treatment; and supporting those diagnosed throughout their 20-24 month regimen. Community

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Chest X-rays Early case detection Build TB lab capacity GeneXpert Microbiology studies

INITIATIONAdded Services

Second-line drug availability Added Services MDR-TB treatment guideline TREATMENT INITIATION Package of services

The cornerstone of the project is the development of Strengthened Services Services a Existing comprehensive prevention to care model for MDRTB, based on the foundational building blocks for tuberculosis (TB) control.

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DIAGNOSIS

Strengthened Services

Added Services

mobilization to support patients was done using Servicesmethods: by engaging both standard and Added innovative community volunteers and outreach workers to provide support and accountability through a bundle of patient-support interventions; as well as through technology and innovation, introducing Myanmar’s first mobile health application for TB control. CAPTB’s implementation has been led by FHI 360, working in close partnership with local implementing agencies as well as with the Myanmar National Tuberculosis Program (NTP). The Myanmar Medical Association (MMA), the Myanmar Health Assistant Association (MHAA), Pyi Gyi Khin, and the Myanmar Business Coalition on AID (MBCA) successfully implemented the CAP-TB model in Yangon, Mandalay, and Monywa over the course of the project’s lifetime. This report summarizes highlights from the USAID CAP-TB project over the three primary years of implementation.

Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

Partners Myanmar Medical Association (MMA)

As the largest academic body of general practitioners (GP) in Myanmar, the MMA CAP-TB team focused on improving screening and case finding of MDR-TB patients through strengthening referral linkages between private and public sectors. MMA developed a training curriculum for programmatic management of drug-resistant tuberculosis (PMDT) to GPs (private medical doctors) in accordance with national guidelines working with the NTP. The trainings were then conducted in high priority MDR-TB townships in close collaboration with the NTP. The MMA CAP-TB team also piloted the country’s first community volunteers to provide directly observed therapy (DOT) for MDR-TB patients. These community volunteers were also trained to provide health education and basic counselling services not only to the patients but also to the family members in pilot townships. This community DOT model is currently being scaled up by The Three Millennium Development Goals Multi-Donor Trust Fund (of which USAID is also one of seven donors). Technology integration was also piloted through “DOTsync”, an m-Health application with case management features, the first m-Health application for TB in Myanmar.

Pyi Gyi Khin (PGK) and Myanmar Health Assistant Association (MHAA)

PGK is a local community-based organization which was originally founded to work with the HIV population using selfhelp groups and networks. This background among people living with HIV was an asset for the CAP-TB project in reaching its target populations as the PGK CAP-TB team worked among PLHIV networks, conducting health education sessions and referring presumptive TB cases to Yangon township health centers. MHAA contributed its strengths in coordination with government counterparts and proven strong experiences in field implementation. MHAA’s strengths in community outreach also contributed to the CAP-TB strategy for providing comprehensive home-based care (infection control, side effect monitoring and household contract tracing). This comprehensive package was designed to ensure continuity of care for MDR-TB patients, with the overall goal to maximize treatment success.

Myanmar Business Coalition on AID (MBCA)

Under the CAP-TB project, MBCA utilized its existing strengths in engagement with the business sector to advocate for workplace policies on TB. In the Monywa industrial zone and businesses, MBCA conducted health education sessions and recruited volunteers with the goal to improve case finding. These volunteers were trained as ‘TB Champions’ to serve as focal points within their workplace for referring presumptive TB patients and other TB related services.

Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

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Timeline FY12

FY13

FY14

FY15

Community based activities January 2013

Launched 3 phases of Organizational Capacity Development: Technical and Organizational Capacity Assessment Tool (TOCAT)

March 2013

Launched package of support and community based activities

May 2013

Launched TB Champions for workplace

June 2013

Launched PMDT trainings to PPM/private sector doctors/General Practitioners

August 2013

Launched Community based MDR-TB DOT by community volunteers Installed solar panel to power GeneXpert machine

March 2014

Launched Cover Your Cough Campaign

October 2014

Launched m-Health (DOTSync mobile app for community supporters)

November 2014

Launched Multi-disciplinary analysis for MDR-TB risk factors in Yangon

April 2015

Initiated CAP-TB model scale up

Geographic coverage

Yangon Region

Mandalay Region

Sagaing Region

11 townships in Yangon region 7 townships in Mandalay region 2 townships in Sagaing region

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Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

Project Implementation

Community engagement

Increasing early case detection through community engagement, especially close contacts of MDR-TB patients and other high risk groups as defined by the CAP-TB strategy.

Individuals Referred

Sputum Positivity Rate

Sputum testing done

Sputum smear positive

Positive

Starting from March 2013, CAP-TB implementing agencies conducted community outreach in project townships by providing health education and disseminating information on TB symptoms, diagnosis, treatment and available health services. A broad range of activities and strategies were implemented including one-on-one counseling, with an emphasis on promoting communication from the community. Health education events were also popular, where field staff disseminated information on TB diagnosis and treatment services available at township health centers. Referral Cascade Presumptive cases referred Access to diagnosis centers Sputum microscopy done Diagnosed as TB (All Form)

Female

Male

CAP-TB’s trained outreach workers strengthened linkages between families, communities and the TB teams at the township level by coordination among township health centers. This strengthened referral linkages between communities and health service providers. Population Categories for Presumptive Patients Referred for Diagnosis

The patient-centered approach for MDR-TB care and prevention improved the efficiency of referral services and sputum positivity rates, focusing on those at risk for TB and MDR-TB.

Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

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Living Support Packages

Nutrition and Transportation Package

Infection control: Accommodation pilot during intensive phase MDR-TB treatment

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Outreach workers and trained community members delivered CAP-TB’s “living support package”, comprising a monthly supply of nutrition, transportation support to ensure clinic follow-up and monthly home visits. Home visits were done to counsel patients on treatment, check on infection control and provide accountability and support to ensure treatment completion and cure. CAP-TB living support package: Gender ratios for three funding years. FY13

223 43%

FY14 296 57%

241 39%

FY15 373 61%

106 39%

169 61%

In early FY 14, the CAP-TB FHI 360 team gathered the project’s implementers to brainstorm on infection control interventions during the intensive phase of MDR-TB treatment. The team decided on eligible criteria for patients to receive accommodation as well as monitoring, with the goal to provide temporary shelter for infectious MDR-TB patients during the intensive phase of their treatment. With recommendation from respective NTP personnel and township medical officers, 49 MDR-TB patients (from 13 project townships) were provided with rented accommodation or housing renovation in order to meet the needs of infection control standards.

Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

CAP-TB Myanmar: A Patient-Centered, Community-Driven Model for MDR-TB

LOWER MYANMAR MEDICAL CENTER & AUNG SAN TB HOSPITAL Regional centers for outpatient and inpatient TB and MDR-TB care. Oversee diagnosis and treatment for largest number of patients in the country

Community driven solution: Directly observed Treatment (DOT) by community health workers In FY13, the Myanmar Medical Association (MMA), collaborated closely with the National TB Program and basic health staff to pilot community-DOT for MDR-TB patients. This model later expanded to 12 townships through CAP-TB’s 3 Implementing agencies, MMA, MHAA, and PGK. Community volunteers were recruited from existing community networks in the focus townships. They worked alongside basic health staff to conduct daily home visits to MDR-TB patients for evening DOT, providing psychosocial support and health education to patients and family members.

TOWNSHIP HEALTH CENTER

Township Medical Officers and Basic Health Staff oversee treatment once patients are at home. Strengthening capacity at the township level is a top priority for decentralization so that patients can get care close to home

These were the country’s first community volunteers to provide DOT for MDR-TB patients, and the community-driven DOT model was recognized by the international sector for its potential for scale-up. The NTP also valued the potential of this model to support rapid scaleup of PMDT through expansion to other project townships. With support from the Three Millennium Development Goal (3MDG) Fund, the CAP-TB model has now been scaled up to 43 townships in Yangon.

Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

COMMUNITY & HOME Comprehensive package of support: home visits, infection control, psychosocial support, DOTsync mobile app

PATIENT HOME

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Innovation and Technology Solar-powered Gene Xpert machine

The NTP recognized the underutilization of Gene Xpert machines installed at MDR-TB treatment centers where access to the electrical grid and voltage stability were major concerns. To provide a solution to this problem, CAP-TB procured the country’s first solar powered system for the Gene Xpert machines at Yangon’s Lower Myanmar TB Center. The solar panel provides stable, continuous power enabling uninterrupted analysis of sputum for MDR-TB. This helped to pave the way for the NTP to scale up solar-powered Gene Xpert machines in district level and more remote facilities, improving access to diagnosis in unreached areas of the country.

DOTsync: Integration of Mobile Technology in MDR-TB response

The community volunteers trained by MMA to provide DOT for MDR-TB patients were equipped with smartphones that run a powerful data collection and patient tracking application. “DOTsync” was built using Dimagi’s CommCare, an opensource platform, bringing the fight against dangerous TB strains into the mobile technology era. Compared to pre-DOTsync, the identification of presumptive TB/ MDR-TB cases was more efficient, with a higher sputum positivity rate.

• • •

After launching DOTsync in select townships, the number of people reached for health education increased by 40% (from 324 to 452). At the start of DOTsync, 29 presumptive TB/MDR-TB cases had sputum tested of which 28% were smear positive. After DOTsync, 39 of 65 (60%) presumptive cases had sputum tested with a smear positivity rate of 33%.

DOT provision was monitored through daily data uploads, enabling timely follow-up for missed doses and quality control for community volunteers. Data on treatment outcomes for 30 MDR-TB patients supported with DOTsync are promising, with a treatment success rate of 93%.

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Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

Public transportation

Tools: nearly 12,000 stickers and over 1,800 T-shirts Stickers

posted inside the public buses and taxis in Yangon

Posters

Bus stop

T-shirts

posted in the waiting areas at highway bus terminals

Used to promote public awareness for following good cough etiquette when using public transportation.

distributed to transportation workers

Community engagement ? ?

Public quiz shows at selected hot spots

96 events

A big community event

49 at markets 34 at bus stops 5 at highway bus terminals 2 at railway stations 4 at other public places

Celebration of the campaign achievements including awards to winners of social media contests and contributors.

Tools: over 7,000 IEC materials distributed

a simple

Mass media THE

NEWS

NO:1234

message with

/11:12:2014

7 Days Daily NO:1234 /11:12:2014

THE

NEWS

7 Days Daily

life-saving impact

Radio

Television

Printed media

Health talk in collaboration with national TB program through City FM & Mandalay FM radio stations with live feedback during popular spots on the air.

Skynet health TV channel: broadcasted campaign launching ceremony and field activities

Campaign activities posted in 5 popular journals and newspapers (7 Days Daily, Daily Eleven newspaper, Health Digest Journal, The street view journal, Myanmar Post Global News journal) in Myanmar

paper, or mask. CONTEST

Like & share photo contest

Total likes: 5,539 for FB page

Social and mass media for effective communication: Cough campaign

and nose using

a cloth, tissue

Social media Cover your cough Facebook

when you cough, cover your mouth

Leading up to World TB Day 2014, the CAP-TB “Cover your Cough” campaign used creative social and mass media to reach patients, families, and communities on simple methods to reduce TB and MDR-TB transmission. Through effective partnership with Myanmar’s top hip hop celebrity, publicizing over the airwaves on FM radio stations, and working with event organizers and different stakeholders, CAP-TB conducted public quiz shows at selected hot spots on TB and infection control-related health messages. Radio listeners’ live feedback through the FM radio station was also solicited during popular spots on the air. Thousands of stickers with photos of the campaign’s celebrity spokesperson demonstrating good cough etiquette were posted on hundreds of buses and taxis on the crowded roads of Yangon. Many of these methods were innovative and to our knowledge, some had never been done in the country before— demonstrating the impact of social and mass media communication to teach a simple, life-saving message.

Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

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Building technical capacity for Programmatic Management of Drug-resistant Tuberculosis (PMDT)

The NTP’s plan for PMDT covered 22 townships in 2011, 38 townships in 2012, 53 townships in 2013, 68 townships in 2014 and 108 townships in 2015. To strengthen the human resource capacity for PMDT, CAP-TB supported “Training of Trainers” for clinicians from the public sector in 2012. The training curriculum was in line with the NTP PMDT training guidelines and approved by the NTP. Trainers and facilitators were drawn from NTP, WHO, FHI 360 and MSF-Holland (the only organization which supports MDR-TB management outside the NTP). Along with the expansion of MDR-TB treatment townships, 2 PMDT trainings were conducted in Yangon and Mandalay during 2014, with participation from clinicians in expanded townships. In addition to MDR-TB treatment training, CAP-TB addressed the gap of case finding from the private sector through MMA’s trainings for 280 general practitioners (179 men and 101 women) from 18 PMDT townships (Figure, left, showing townships and approximate number of participants). This was done in collaboration with the MMA PublicPrivate Mix project with the objective of strengthening referral linkages between private and public sectors. Given the high priority focus on children as a risk group for TB, CAPTB supported the National Workshop on Childhood TB Management organized by the NTP in August 2013. Professor Stephen Graham from the University of Melbourne carried out field visits and reviewed the NTP guidelines on childhood TB management. A total of 75 participants from the country (3 chest physicians, 41 pediatricians, 19 staff from the NTP, 4 from WHO and 8 from NGOs) drafted an action plan with recommendations resulting from the group discussion.

In October 2012, TB REACH training laid the groundwork for the CAP-TB- supported training strategy. This training covered the standard diagnosis of TB and the chest X-ray recording and reporting system (CRRS). Clinicians from the government and private sectors were targeted to build capacity in clinical reporting of chest radiographs to identify TB. These trainings were conducted in Mandalay and Yangon by the NTP and the Union, with support from CAP-TB. Attendees included a total of 57 clinicians (26 In Mandalay and 31 in Yangon) including public sector township medical officers and NTP TB Team leaders from 22 project townships as well as private sector general practitioners (32 Public and 25 Private).

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Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

Evidence based planning and implementation Community survey on health seeking/ purchasing behavior for TB diagnosis and treatment

In March 2013, during the initial phase of designing CAP-TB’s patient-centered, community-driven model, the project launched the “TB Trends” survey within target communities to clarify health seeking/purchasing behavior for diagnosis and treatment of TB. Communities were also asked where they purchased their medication, to better understand access to quality assured TB drugs. The CAP-TB team trained field staff to conduct this module in the community. Data were collected over one month from March 25 to April 26, 2014 and a total of 1,022 beneficiaries (410 MBCA, 410 MHAA and 202 PGK) in Yangon, Mandalay, and Monywa completed the survey. Results from this survey helped the CAPTB team to design strategies for patient support.

Money is a barrier for seeking care

Time traveled to nearest health facility

Treatment outcomes and cost-effectiveness analysis for the CAP-TB model Avg Cost per Patient by Group

Description (Group #)

Treatment Success Rate (%) †

Total # of Patients

Total # of Patients with Treatment Outcome

$ 223.11

Minimal support (Home visit only (1))

38.5%

329

26

$ 846.52

Home visit +Pkg of Support (2)

85.3%

510

485

$ 1,902.30

Home visit +DOT (3)

85.7%

34

14

$ 2,508.78

Home visit +Pkg of Support + DOT (4)

92.6%

110

94

†Success rate is defined as treatment completion or cure, following the WHO definition for treatment success.

The CAP-TB project developed a patient-centered, community-driven model for MDR-TB support that was designed to be a scalable, sustainable, and cost-effective approach for patient support. From April 2013 through September 2015, the CAP-TB team supported 983 patients for the full duration or a portion of their 20-24 month long MDR-TB treatment. The main CAP-TB intervention was the monthly “package of support” comprising home visits (counseling, infection control, contact referrals); food, and transportation allowance: 510 patients received this monthly package of support, of whom 485 have completed treatment to date, with 85.3% treatment success. The highest level of intervention (Group 4) comprised the monthly package of support with the addition of daily, evening DOT by community volunteers: 110 patients received this level of support, of whom 94 have completed treatment, with 92.6% treatment success. The “minimal support” group (usual care with intermittent home visits) had a total of 329 patients of whom 26 have completed treatment, with 38.5% treatment success. These results are still preliminary as most patients in this group are currently on treatment and their outcomes will be available in mid-2016. Thus, the results cannot be fully interpreted at this time for the minimal support group. The CAP-TB team thanks the Myanmar NTP for the strong support throughout the project’s implementation, as well as the USAID Burma Mission for funding this work.

Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015

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Control and Prevention of Tuberculosis (CAP-TB) | October 2012 - September 2015