ENGAGE-TB Operational Guidance Paris, 1 November 2013 1
Outline Background Purpose Target audience Integrating TB activities The ENGAGE-TB approach 2
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Background TB second largest killer after HIV; but is curable A third of those with TB are either not diagnosed or not reported MDR-TB growing; requires longer treatment and adherence A wider range of stakeholders needs to be involved 33% Persons with TB 67% NGOs and other CSOs are able to reach remote and marginalized populations Community-based TB activities can help to reach many more Reached/reported Unreached/not reported 4
Who carries the burden of TB? People living in crowded & poorly ventilated settings 10 million TB orphans in 2010 Migrants, prisoners, minorities, refugees face risks, discrimination & barriers to care TB linked to HIV infection, malnutrition, alcohol, drug and tobacco use, diabetes 5
Risks from TB in pregnancy for mothers and neonates Risk Normal TB Neonatal effects (per 1000 pregnancies) Low birth weight (<2.5Kg) 165 342 Prematurity (<37wk) 111 228 Small for dates 79 202 Perinatal death 16 101 Fetal death (16-28wk) 2.3 20.1 Maternal effects Pre-eclampsia 47 74 Vaginal bleeding 22 44 Bjerkedal 1975;Jana 1994;Bothamley 2001;Khan 2001; Figueroa-Damian R,1998 6
Purpose Provide guidance on the implementation of community-based TB prevention, diagnosis, treatment and care activities Provide guidance on collaboration between NTPs and NGOs and other CSOs working on community-based TB activities ENGAGE-TB approach 7
Target audience NGOs and other CSOs NTPs and their equivalents Patients and communities affected by TB Funding agencies Researchers 8
Integrating TB Assisting early detection Assisting treatment support Preventing TB transmission Addressing the social determinants 9
Integrating TB into projects HIV screen for TB; help them receive IPT MCH pregnant women test for HIV; screen for TB. Watch children under 5 Education TB messages in curricula; children recognize TB symptoms Agriculture/income generation/water and sanitation Raise awareness Encourage those with symptoms to get their sputum examined Provide support eg nutritional, psychosocial, treatment adherence, transport 10
Principles Mutual understanding and respect Consideration for local contexts and values A single national system for monitoring with standardized indicators 11
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Situation analysis Collect basic data Review the main actors and factors Gather qualitative information Analyse SWOTs 13
Enabling Environment Supportive policies; simple procedures 14
Enabling Environment NGO coordinating body and regular meetings with NTP 15
Guidelines and tools National operational guidance Standardized tools - forms for referrals, diagnosis, treatment; registers Training curriculum Locally tailored how-to manual 16
Task identification NTPs should include engagement of NGOs in their plans NGOs should consult with NTPs and link with facilities Full range of options for community-based TB services and advocacy e.g. prevention, screening, referral, treatment support, advocacy 17
Capacity building Human resources Financial resources Physical assets Management and leadership Systems and processes 18
Monitoring and evaluation Two indicators monitored: Referrals and new notifications: how many referred by CHWs and CHVs Treatment success rates among those receiving support from CHWs and CHVs Periodic evaluation qualitative information as well Presence of an NCB, trends in membership, etc Quality of NTP interaction with NCB 19
Community contributions to TB case notifications and treatment adherence support, 2012 Notified patients Patients who received Country from referrals treatment support (2011 cohort) %age Source of data %age Source of data Burkina Faso 9% All districts 33% All districts Côte d'ivoire 16% 59/82 districts N/A Democratic Republic of Congo 20 10% 45/515 districts 3% 8/515 districts Ethiopia 33% 98/821 districts 40%* 98/821 districts India 3% 374/662 districts 50% All districts Kenya 5% All districts 88% All districts Malawi 20% 2/28 districts 91% 2/28 districts Myanmar 2% 92/330 districts 2% 92/330 districts Nigeria N/A 5% 36 districts Rwanda 28% All districts 46% All districts Senegal 6% All districts N/A Tanzania 14% 63/162 districts 86% All districts
Indicator 1: Referrals and new notifications Definition Number of new TB patients (all forms) diagnosed and notified with TB who were referred by community health workers and community volunteers expressed as a percentage of all new TB patients notified in the basic management unit (BMU) during a specified period Numerator Denominator Purpose Method Number of new TB patients (all forms) referred by community health workers or community volunteers to a health facility for diagnosis and notified in the BMU(s) in a specified period Number of new TB patients (all forms) notified in the BMU(s) in the same period To measure the level of engagement of community health workers and community volunteers in increasing new notifications of TB. It can also indicate the effectiveness of the referral system in ensuring the flow of persons with presumptive TB from community-based structures to the BMU. Entries on tuberculosis treatment cards, the presumptive TB register (also known as TB suspects register) kept at facilities, the BMU TB register and the laboratory register should be modified to include Referral by community health workers and community volunteers, to allow standardized recording of the community contribution to referral. The quarterly report on TB registration in the BMU should also be adjusted to record this contribution. 21
Indicator 2: Treatment success Definition Numerator Denominator Purpose Method New TB patients (all forms) successfully treated (cured plus completed treatment) who received support for treatment adherence from community health workers or community volunteers among all new TB patients (all forms) provided with treatment adherence support by community health workers or community volunteers (number and percentage) Number of new TB patients (all forms) successfully treated and provided with treatment adherence support by community health workers or community volunteers in the BMU(s) in a specified period Total number of new TB patients (all forms) given treatment adherence support by community health workers or community volunteers in the same period To measure the scope and quality of implementation of community-based TB activities particularly relating to treatment outcome of patients. It can also indicate the acceptability of community health workers or community volunteers to patients with TB as treatment adherence support providers. Treatment adherence includes all efforts and services provided by community health workers and volunteers to TB patients receiving treatment to help them complete their treatment successfully. These can include treatment observation, adherence counselling, pill counting and other activities to monitor both the quantity and timing of the medication taken by a patient. 22
Annex 2. Periodic evaluation Purpose Periodic evaluation provides a qualitative view of the progress of community-based TB activities. In particular, it helps to assess the contributions of NGOs and other CSOs to new case notifications and to treatment outcomes. It also indicates whether NGO contributions are increasing or decreasing and reflects the quality of the relations between NTPs and NGOs on the basis of variables such as the frequency of meetings, the quality of such meetings, the cooperation of people involved, the factors in success and the overall interest and drive of the NTP in involving NGOs and other CSOs in TB activities. Indicators Existence of an NCB *trends in membership *frequency of meeting *spread to subnational levels *coordination between levels *mechanisms for transferring knowledge, skills and resources Quality of interaction with the NTP at various levels *frequency of meetings *quality of follow-up on agreed actions *availability of TB diagnostic services and drugs The relative contributions of NGOs and other CSOs and of the government to new case notifications and treatment success, with trends in these variables over time Challenges and hurdles faced by different actors in government and civil society as well as successes and new opportunities 23
Thank you 24