Bay of Bengal Mayanmar

ANNUAL REPORT 2015

MDR Project expanded to Rajshahi Division (Old) in 2008 Damien Foundation working area Bay of Bengal Mayanmar

2015 Projects:FTLCP, MTLCP, NTLCP, RTLCP, TTLCP, DFCOtogether Report prepared and written by : Mr. Bart Rombaut, Country Director Dr. Aung Kya Jai Maug, Medical Specialist Khondoker Habebul Arif, HR & Admin. Director Md. Mutakabber Hossain, Finance Director Dr. Dipak Kumar Biswas, Medical Coordinator Date of Publication : June 2016 3

Address of the DF Project offices "BISWAS BARI",House # 63,Kabi Jashim Uddin Road, South Alipur, Faridpur 4

ANNUAL REPORT 2 Content s Page Number 1. Damien Foundation: Background Information 07 2. Tuberculosis 08 2.1 Progress towards case detection and treatment outcome targets 08 2.2 TB control activities in workplace (Dhaka Export Processing Zone) 12 2.3 Tuberculosis in children 13 2.4 TB in prisoners and other vulnerable groups 14 2.5 TB HIV co-infection 14 2.6 MDR - TB 15 2.7 Tuberculosis Infection control 15 3. Leprosy 16 3.1 Care of Leprosy patients (POD) 17 4. Leprosy Integration Project (LIP) 18 5. BASIC Project 20 6. Hospital Activity 23 7. Advocacy, Communication & Social Mobilization (ACSM) 24 7.1 Engaging all care providers and community 25 7.1.1 Public-public and public-private mix approaches 25 7.1.2 Partnership with the Village Doctors 28 7.1.3 Working with the Government Health & Family Planning staff and General Physician s 30 7.2 Empowering patients and communities 31 7.2.1 Working with the Former patients and Elites (TB Club Meeting) 31 7.2.2 Working with other NGOs 33 7.2.3 Health Education Activities in Community and Govt. Health Facilities 33 7.2.4 Community participation in DOT expansion 34 8. Operational Researches in Damien Foundation Bangladesh 35 8.1 Diagnosis and Management of MDR-TB 35 8. 2 Drug resistance monitoring 36 8. 3 FDA staining and slide DST 37 8. 4 Six months MDT Regimen trial For MB Leprosy Patients 37 8.5 Optimization of TB treatment regimen (OneRIF study) 37 9. Human Resource Management & Development 37 9.1 Overview 37 9.2 Training organized by DF throughout the year 2015 38 9.3 Participation in different training courses within the country 2015 38 9.4 Participation in International training courses/meetings/conferences 2015 38 10 Visiting Group Communication Department 39 11. Programme Management and Coordination 40 12. Monitoring, Supervision & Evaluation 41 12.1 Internal monitoring, supervision & Evaluation 41 12.2 Supervision from NTP & NLEP: 41 12.3 Supervision by DF Brussels and other visitors: 42 13. Annex (Different Tables) 43-52 5

List of abbreviations BangladeshRural Advancement Committee Coordinating Physio-Technician RIT Research Institute of Tuberculosis URC University Research Co. VT Vocational Training Research, Injecting ILEP International LeprosyFoundation LIP LTCC 6 Leprosy Integration Porject Leprosy & TBCoordinating Committee

1. Damien Foundation: Background Information Damien Foundation (DF), a Belgian non-denominational and pluralistic NGO founded in 1964, is dedicated to the fight against Leprosy and Tuberculosis until these are no longer a threat to public health. The foundation is active in 15 countries of Asia, Africa and Latin America. The Foundation takes its name from Father Damien, a Belgian missionary who worked in the Hawaiian archipelago in the second half of the nineteenth century. He sacrificed his life caring for the lepers abandoned on the island of Molokai. The Foundation is a member of the International Federation of Anti-Leprosy Associations (ILEP) which coordinates the activities of organizations active in the field of leprosy control and care worldwide. Damien Foundation also contributes to operational and epidemiological research projects, the publication of scientific literature on leprosy and TB. The Damien Foundation started its journey to serve leprosy patients in 6 districts of Bangladesh in 1972 and thus it has been more than three decades since the start of its journey in reaching the people affected by Leprosy in Bangladesh. In the beginning, DF fully concentrated on the elimination of Leprosy, and later on, since 1991 Tuberculosis (TB) Control has been included as the other major component considering the size of TB burden in Bangladesh. The organization is now involved in the control of Tuberculosis and further management of Leprosy in close collaboration with the National Leprosy and Tuberculosis programme of the Ministry of Health and Family Welfare, Government of Bangladesh (GoB). This collaboration is based on the Memorandum of Understanding (MoU) signed between the GoB and 11 NGOs in 1994 and renewed afterwards with 9 NGOs. As per MoU, each NGO partner is allocated to implement the programme in a defined geographical area and GoB agreed to ensure supply of essential drugs, equipments (e.g. microscopes), laboratory reagents, other consumables, recording and reporting forms, registers etc. Besides 6 existing districts, 3 new districts from Rajshahi division were included in this collaborative agreement and daily centres from sub-district level were started gradually since 1995. Full geographical coverage from each upazila was achieved by mid-1998 in these 9 districts. Expansion to a new area consisting of 5 districts (27 sub-districts) in greater Faridpur region was started in October 2001 upon request of the government and full geographical coverage in this new area was achieved by mid 2003. Thus the organization now covers 14 districts (111 sub-districts) and serves about 33 million people (20% of total country population). The organization operates through 4 projects, namely Tangail, Mymensingh-Netrakona, Rajshahi & Faridpur projects. The Damien Foundation Bangladesh works as a non political organization duly registered with NGO Affairs Bureau, Govt. of Bangladesh, under the Foreign Donations (Voluntary Activities) Regulations Ordinance 1978. A total of 150 daily combined (TB & Leprosy) clinics including in 5 medical college hospitals and one workplace- Dhaka Export Processing Zone and 10 daily leprosy (only) clinics are functional in 111 sub-districts. Additional second microscopy centers were established in 2005-2006 in order to ensure better geographical coverage and to improve access. Moreover, sputum collection centers (261) were established at the remote areas of the Upazilas as a further step to increase the accessibility and effective coverage. The project has also established a network of patient friendly directly observed treatment (DOT) services at the community level through voluntary involvement of village doctors, cured patients, religious leaders, school teachers etc. At present around 6,500 Fixed DOT Providers (FDPs) are involved in providing DOT in the area covered by DF. The Damien Foundation program is providing specialized hospital care for complicated TB & Leprosy patients including MDR and XDR-TB patients by its own three referral hospitals with a total of 255 beds situated in Tangail Jalchatra hospital-95 beds, Mymensingh hospital- 100 beds & Netrakona hospital-60 beds. In addition to the treatment of MDR TB cases in the DF working area since 1997, DF also expanded its MDR-TB project to the 13 new districts of the Rajshahi division through establishing a culture & drug-susceptibility testing (DST) laboratory in Rajshahi Chest Disease Hospital (CDH). As per MoU, Government provided all necessary equipments and DF provided technical expertise, culture laboratory products and drugs for the diagnosis and management of MDR-TB cases in the new expanded area. Government has also allocated 40 beds in CDH Rajshahi for MDR-TB patient management. MDR TB patients from Rajshahi division are being managed through admission to the Rajshahi chest disease hospital since May 2008. A total of 376 MDR TB patients from non-df area of Rajshahi division have been enrolled for treatment since the start of the service through Rajshahi CDH including 45 cases during 2015. 07

Funding sources Damien Foundation Bangladesh is mainly co-financed by DGD (Directorate-General for Development Belgium Government) for two field projects, namely Mymensingh-Netrakona and Tangail projects plus coordinating office in Dhaka. The other two projects, Rajshahi and Faridpur are funded by the Global Fund (GFATM). In 2015, a total amount of Taka 111,564,910.84 (1,310,503.57 Euro) was received as grant from Damien Foundation Belgium to cover the expenses of DGD supported projects. And a total fund received from GFATM in local currency was 35,245,845.00 Taka, (equivalent to 414,017.46 Euro). In addition, a considerable contribution was also received from the Government of Bangladesh equivalent to Taka 70,316,491.00 which was realized in kind as for drugs, lab materials, logistic supplies, and so on. Besides, an estimated clinic-rent for 160 clinics was Taka 2,898,000.00. So, in total the government contribution was Taka 73,214,491.00 (equivalent to 860,018.48 Euro) in 2015. Besides DGD, GFATM and Govt. of Bangladesh, Damien Foundation also received some other funds from different stakeholders to carry out some studies and other activities. Details are as follows: In collaboration with LEPRA Bangladesh, Damien Foundation started an intensive awareness activity under the Leprosy Integration Project (LIP) for two years (2014 & 2015), which started in June 2014. To implement these project activities, a total 324,930.00 Taka or 38,168.15 Euro was received from LEPRA in 2015. Moreover, DF has signed an agreement with Management Science for Health (MSH) for the Challenge TB (CTB) project for one year period from July 2015 to June 2016. According to the nature of the agreement (cost reimbursement) DF is carrying out the planned activities. 2. Tuberculosis Tuberculosis is a major public health problem in Bangladesh. Bangladesh ranks 7 th among the top 22 high TB burden countries in the world. The WHO estimates that there had been 227 new cases (all forms of TB) per 100,000 population in Bangladesh in 2014 and an estimated prevalence of 404 per 100,000 population for the same year, according to the WHO report Global Tuberculosis Report 2015. The estimated mortality rate for the same year was 51 per 100,000 population. With an estimated population of 159 million, these estimates correspond with an annual incidence of about 360,000 all forms of TB cases and about 81,000 deaths annually due to TB. The national TB prevalence survey which was conducted from October 2007 to March 2009 showed an overall adjusted prevalence of smear positive TB 79.4 per 100,000 adult population aged above 14 years 1. But the WHO estimates on TB disease burden in Bangladesh have not been approved by the NTP in Bangladesh and a joint reassessment of estimates of TB disease burden will be undertaken following completion of the national TB prevalence survey, but final results will not be available before the end of 2016. The country adopted the WHO recommended DOTS strategy in 1993. The country achieved expansion of DOTS strategy throughout the country by 1998. With the financial support from GFATM, since August 2004, the NTP and its partner NGOs expanded and strengthened the overall TB control programme in the country. The service has been expanded to prisons, garments industries / work place, medical teaching institutes, Army hospitals etc. As a result, the national TB case notification (all forms) increased to 124/100,000 population in 2014 from 58/100,000 population in 2000. DOTS services were strengthened through financial support from GFATM, TBCARE II project following after TBCAP by involving new partners in urban areas and also through introducing new technologies (i.e. LED FM system, GeneXpert). USAID funded TBCARE II project managed by URC provided extensive support in expansion of LED FM system (200 microscopes), GeneXpert technologies (39 machines) and cartridges for these machines by the end of 2015. Targets for TB control have been set in line with the Millennium Development Goals (MDGs) to halt and reverse the incidence by 2015. The STOP TB Partnership has set two additional impact targets, which are to halve the prevalence and death rates by 2015 compared to the level in 1990. 2.1 Progress towards case detection and treatment outcome targets: A total of 24,738 TB cases (including 853 not-new smear-negative and EP TB cases) were registered during 2015, of which 56% were smear positive pulmonary TB cases. The remaining (44%) were smear negative pulmonary TB and 1 Health and Science Bulletin vol. 8 No. 4 December 2010; available online at http://www.icddrb.org/publication.cfm?classificationid=56&pubid=11089 08

Extra-Pulmonary TB cases. The table below presents the numbers of the different forms of TB that were diagnosed annually during the period 2001-2015 in all project areas combined. Table: 1 Tuberculosis cases (different type) registered since 2001 Year New smear-pos Re-treatment Smear-neg. & EP Total 2001 8677 1327 1637 11641 2002 9895 1607 2078 13580 2003 10912 1744 2619 15275 2004 11298 1714 3772 16784 2005 12350 1552 4616 18518 2006 14084 1717 6455 22256 2007 13899 1501 6366 21766 2008 14150 1475 6752 22377 2009 14611 1746 8096 24453 2010 13805 1566 9233 24604 2011 13268 1435 9722 24425 2012 13966 1418 9348 24732 2013 13115 1314 10145 24574 2014 12683 1321 10476 24480 2015 12194 1148 11396 24738 Registration of TB cases (all forms) has increased over time but remained almost stable for the last several years. Additionally, the proportion of re-treatment patients among the positive cases has remained at 9%, as shown in graph 1. The increase in numbers of smear-negative pulmonary and extra-pulmonary patients has contributed to the overall increase in TB case detection. This increase (shown above in table 1) is mainly due to the focus given to enhance the diagnosis and treatment of all forms of TB including smear-negative and EP TB since 2006 through establishing collaboration with Chest Diseases Clinics, medical colleges and specialists and by conducting training for doctors on x-ray reading. Besides training of the doctors, support to patients was also provided for diagnostic examinations e.g. X-Ray and biopsy costs utilizing GFATM funding. All these efforts have contributed to an increase in smearnegative pulmonary and extra-pulmonary TB patients during the period. Graph 1: Trends in TB case registration, Rett. and sm-ve/ep proportion Trends in Detection, Rett. & Neg/EP prop. 25000 20000 15000 10000 5000 0 50% 40% 30% 20% 10% 0% Total Regd. Rett. +ve -Ve/EP The decreasing trend of re-treatment cases could be explained as a good indicator of programme performances. At start of the project, during the year 1995 most of the re-treatment cases registered by the project were treated previously outside the NTP by the private providers, as such the proportion of re-treatment cases among all smear positives at that time was 29%. Over the years this proportion has come down to and remained at around 10% which 09

rate / 100,000 pop. Rate/100000 pop. explains the good referral linkage with the private sectors and better accessibility & acceptability of NTP services. Almost all of them are from NTP regimen s failures, relapses and defaulters who returned back for re-treatment. The DF projects achieved an average case notification rate of 90 per 100,000 population for all forms and 49 per 100,000 population for smear positive forms in 2015. The notification rate has been almost stable with very little variation over the last several years and thus difficult to conclude on the reflection of real current epidemiological situation in the project area. Graph 2: Trends in TB notification rate per 100,000 population Trends in TB notification rate since 2003: DF 100 90 80 70 60 50 40 30 20 10 0 85 87 86 72 79 81 85 91 89 90 88 64 59 54 60 56 56 58 49 49 54 51 56 54 51 52 42 43 48 51 51 52 49 48 50 46 46 44 49 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 New Sm+ve All Sm+ve All form However, the steady case notification since 2006 might indicate that the optimal case detection has been achieved and the same level of notification might be expected for the coming few years in the project area. TB case notification varies significantly among the different regions. In the Northern region (greater Mymensingh) the notification rate of new smear positive cases has always been higher (63 per 100,000 population) then in the other two (greater Rajshahi around 35 and greater Faridpur around 30/100,000 pop) regions. This difference might indicate low level TB prevalence in these regions of the country. Graph 3: Region wise new sm+ve TB notification rate per 100,000 populations 80 Regionwise New Sm+ve Case notification rates per 100,000 pop. 70 60 58 59 62 69 66 66 68 63 63 65 60 58 63 50 40 30 20 30 30 25 27 36 30 37 37 34 35 36 37 34 34 35 32 36 39 33 34 34 34 30 34 35 30 10 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Gr. Faridpur Gr. Rajshahi Gr. Mymensingh 10

Suspects/100000 pop. New Sm+ve/100000 pop. Analysis of data shows, despite significant increase in suspects in the south and in the northwest regions of the project, the case notification did not increase significantly - only very little in fact as shown in graphs 4 and 5. Graph 4: Region wise trends in TB suspects per 100,000 populations Trends in TB suspects per 100,000 pop. 1200 1000 800 600 400 535 354 543 374 432 665 404 986 687 680 966 964 787 761 613 583 1046 765 664 933 892 691 662 556 549 832 684 612 862 724 588 995 916 782 781 741 687 320 306 200 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Gr. Faridpur Gr. Rajshahi Gr. Mymensingh Graph 5: Trends in TB suspects and cases per 100,000 populations in greater Faridpur region Trend in suspects and new sm+ve cases in Gr. Faridpur region 900 100 800 700 687 761 787 765 662 691 684 724 782 90 781 80 600 500 400 300 200 404 320 295 25 27 30 37 34 36 37 35 36 39 34 30 30 70 60 50 40 30 20 100 10 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 0 Suspects Cases Taking into account the good quality of microscopy services in the project area and standardized screening system of suspects, it could be concluded that TB is not equally distributed all over the country. WHO thus recommends use of notification trends to assess performances of TB control programmes and does no longer recommend using national estimates for the sub-national level. Special emphasis has been given to detecting female TB cases. Efforts were made at improved sputum collection from female presumptive TB cases. Female ratio among smear positive TB cases remains low in Bangladesh for several years. Analysis of data showed that among TB suspects male female ratio is 1.6:1 but 3:1 among diagnosed TB cases. A community based house-tohouse survey was carried out in previous years to find out eventual barriers for females in producing good quality sputum and whether there is any need in intervening. The survey results showed that the routine low female TB case 11

suspects new sm+ve cases rate/100000 pop. detection does not indicate their lesser accessibility to the health services and supported the routine TB case finding among females. The graph 6 below shows the case detection trends among male and female in the working area. Graph 6: Gender-wise new smear positive TB case notification rate Trends in gender wise New Sm+ve TB notification rate 80 70 60 50 40 30 20 10 0 Male Female 2.2 TB control activities in workplace (Dhaka Export Processing Zone) TB, a highly communicable disease, spreads fast in crowded conditions. At least 10% of the infected people bear lifelong risk of developing the disease. Progression of infection to the development of the TB disease mostly depends on the individual s nutritional status and HIV infection status. Like other developing countries, there has also been the rapid urbanization in Bangladesh leading to the development of several factories both in organized and nonorganized ways. Poor people from rural areas migrate to work in those factories where the working condition is often unhealthy with poor ventilation. These poor workers are often paid low and several workers share a small room for their living. Such living and working conditions are the most favourable environment for easy transmission of TB. Considering the situation DF started TB control activities in 2004 in Dhaka Export Processing Zone (DEPZ), a government controlled workplace, located near Dhaka where more than 100,000 workers are engaged in processing export goods and most of them are young female workers. Since the start of the programme in DEPZ, DF has observed a higher TB incidence among the workers compared to the general population. The female ratio among detected TB cases in this workplace is almost three times compared to the general population. The graphs below show the trends in TB suspects and cases per 100,000 workers and female ratio among the detected TB cases: Graph 7: Trends in TB suspects and new sm+ve cases per 100,000 population in DEPZ Trends in TB suspects and cases per 100,000 pop. in DEPZ 2000 1500 1000 500 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 140 120 100 80 60 40 20 0 Suspects Cases Considering the growing expansion of industrial factories, DF planned to strengthen TB activities in newly industrialized DF border districts involving the private sector. Situation analysis involving the workers who got admitted in DF hospitals indicated their unawareness about the availability of TB services near their workplaces. As a result they first seek care from private pharmacies and return home when they do not improve. In order to increase 12

Rate Rate awareness on TB among factory workers, DF has been organizing orientation sessions for them in these border districts with the support from Challenge TB. As a result 3,153 workers from these DF bordering districts workplaces attended for sputum examination during 2015. Among them, 461 (14.62 %) smear positive cases were diagnosed and put on treatment. It has been observed that the positivity rate and the notification rates are higher among these worker populations compared to the general population. The TB treatment success rate has been maintained above 85% since 1995 with a low death (<5%) and low failure (<3%) rates. The ability to detect a good proportion of failure cases is a good indicator of sputum smear microscopy quality. The average success rate for all the projects was 90% with a death rate at 4.3% for the cohort 2014. The graph below shows the trends in TB treatment success rates since 2009. Graph 8: Treatment outcome in new smear positive cases Trends in New Sm+ve TB Treatment Outcome 100% 50% 0% 2009 Success 2010 Died 2011 2012 Defaulted2013 Failure 2014 4% 3% 2% 1% 0% 2.3 Tuberculosis in children: Child TB diagnosis is a global concern given the continued under-detection of TB among the child population. Children remain the most vulnerable in contracting TB from adults. Diagnosis of TB in children remains very challenging, especially in Bangladesh where there are inadequate diagnostic facilities and specialists for detecting Child TB cases. Presentation of symptoms of childhood TB is different compared to adult TB. Children cannot produce good sputum. Microscopy of sputum smear often cannot detect the bacilli as the number of bacilli is few in the sputum of children. Analysis done by the DF project in the past showed a sputum positivity rate among children suspects for TB of 1% compared to > 7% among adult symptomatic TB. Estimating the incidence of TB among children is difficult and the published estimates vary 2 / 3. The study conducted in one DF upazila during 2009 in collaboration with ICDDR,B showed a child TB prevalence of 52 per 100,000 children. This study seems to have provided important evidence on under-detection of child TB cases in Bangladesh which helped the NTP Bangladesh to adopt strategies to increase child TB cases throughout the country. In order to improve child TB case detection the Damien Foundation in collaboration with the Centre for Women and Child Health (CWCH) conducted a study to evaluate the effectiveness of algorithm for detection of child TB and effectiveness of community awareness in enhancing diagnosis of child TB which also support the above findings 4. An increase in child TB detection in the study clinics was also observed. Efforts at improving diagnosis of TB among children were continued in 2015 through coordinating with government doctors on diagnosis of childhood TB. A total of 80 doctors were trained involving the eminent national level child 2 Epidemiology and disease burden of tuberculosis in children: a global perspective. Infect Drug Resist, 7:153 65, null 2014. 3 World Health Organization. Global tuberuclosis report 2014. World Health Organization, Geneva; 2014. (WHO/HTM/TB/2014.08). 4 Intervention to increase detection of childhood tuberculosis in Bangladesh; INT J TUBERC LUNG DIS 16(1):70 75 13

Number specialists on diagnosis of child TB since 2008. As a result, diagnosis of TB among children has been higher (6%) in DF area compared to the other parts of the country (3.3% national average). The graph below shows the number of child TB cases diagnosed in the DF project area. Graph 9: Child TB detection Child TB 1000 800 600 400 200 0 792 885 6% 658 673 581 583 4% 4% 504 4% 403 3% 3% 3% 3% 144 156 157 133 151 152 134 166 156 2007 2008 2009 2010 2011 2012 2013 2014 2015 New Pos. Neg. & EP % child among Total 0.06 0.05 0.04 0.03 0.02 0.01 0 Chemoprophylaxis using Isoniazid tablet 5 mg per kg body weight for 6 months is being recommended for children aged below 5 years not suffering from TB who are close contacts of a TB patient. The preventive therapy prevents two severe forms of TB in children, namely milliary TB and TB meningitis. A total of 16,268 children received chemoprophylaxis during the last 5 years, of which 4050 in 2015. Chemoprophylaxis completion rate among children enrolled during 2014 was 86%. 2.4 TB in prisoners and other vulnerable groups It was found from several surveys that the prevalence of TB is higher in prison compared to the general population. The reason of this higher prevalence is due to the fast spread of TB in poorly ventilated, densely crowded living conditions in the prisons. Prisoners often have limited access to the health care services and the health care service providers also have limited access to the prisons as the prisons are restricted places. For this reason, very little is known about the severity of TB in the prisons of Bangladesh. The foundation in collaboration with the NTP Bangladesh organized a survey in the 4 jails of Rajshahi, Noagoan, Nawabganj and Tangail districts in 2003. The findings were that the TB prevalence in the surveyed jails is 152/100,000 population compared to 79.4/100,000 population among the general population. Since then DF has established a referral linkage with the local jail authorities and health personnel through which DF staffs are informed on identification of TB suspects and sputum samples are collected by prison health staff. DF staffs regularly visit the prisons to collect sputum samples. During 2015, a total of 198 TB suspects sputum samples from 11 prisons of DF working area were examined and 25 TB cases (21 smear-positive, 2 smear-negative & 2 extra-pulmonary TB) were diagnosed and started treatment. The prison health staffs are engaged in providing DOT inside the prison and DF staff is informed when a prisoner is released for further arrangement of treatment engaging a DOT provider from the resident upazila. 2.5 TB HIV co-infection TB remains the most common opportunistic infection among HIV infected people in high TB burden countries like Bangladesh. TB-HIV co-infection leads to rapid progression to TB disease and earlier deaths. Luckily HIV prevalence among Bangladeshi adult population and TB patients is still low (<0.1%) but rising, and the prevalence is higher in high-risk groups such as intravenous drug users (5.3%). To measure the burden of TB-HIV co-infection among TB patients, DF undertook an HIV prevalence survey among hospitalized TB patients since May 2009, with financial support from Family Health International (FHI360). A total of only 6 TB-HIV co-infected cases were detected in DF area through screening 3.860 TB patients till July 2014. This survey showed a very low HIV prevalence (0.2 %) among TB patients in the DF working area of Bangladesh. The study conducted by FHI360 with other TB organizations (e.g. BRAC) showed similar findings. The other 3 limited surveys conducted in the past in other settings also showed very low (0.1%) TB-HIV co-infection among the adult population in Bangladesh. 14

Though the prevalence of HIV among adult population is still low in Bangladesh there are significant high level risk behaviours among some groups that makes Bangladesh vulnerable to HIV/AIDS. 2.6 MDR - TB Since 1997 DF started to treat MDR-TB patients using a succession of standardized regimens under strict operational research conditions, which led to the identification of a highly efficient, safe, short and relatively cheap regimen initially resulting in close to 90% cure with minimal bacteriological failure or relapse, and without amplification of second-line drug resistance. Results have deteriorated slightly over the last years due to increasing levels of secondline drug resistance (mainly fluoroquinolnes, because of their wide use for general infections) among newly presenting MDR-TB. Over the years efforts at improving the care for severely resistant TB have also included earlier detection (through slide DST) and their treatment using new drugs such as bedaquiline and linezolid since 2011. Additionally DF has developed locally appropriate, low cost, simple and safe laboratory screening and drug susceptibility testing methods (FDA vital staining; slide DST) which has led to an increasingly early screening, diagnosis and treatment of such cases. Currently 4 very simple laboratories in DF areas are capable of delivering min. 95% correct diagnoses of TB resistant to rifampicin, fluoroquinolones (high or low level) and 2 nd -line injectables, besides its differentiation from non-tb mycobacterial disease, and this within 2 weeks. The more efficient but very costly molecular diagnosis of rifampicin resistance by GeneXpert machines were installed in 5 DF laboratories (donations from NTP/USAID) but most of them showing disturbances (equipment errors) most of the time leading to dependence on DF developed DST testing methods. For these achievements in the field of drug resistant TB, DF Bangladesh received intensive support from the Mycobacteriology Unit at the Institute of Tropical Medicine in Antwerp, Belgium, with gradual transfer of capacity to its reference laboratories (the main one at its own hospital in Netrakona) 5. DF takes care also of MDR-TB patients referred to its services from other areas, and since 2008 it has been given the responsibility by the NTP to organize MDR-TB management for the entire Rajshahi Division. This has been achieved through training, organization and continuous collaboration and service delivery of the NGOs and Government institutions working for TB in this Division. Besides, the DF support in this field has also led to the creation of 40 MDR beds as well as a TB referral laboratory for the division, capable of rapid diagnosis of MDR- and XDR-TB. In 2015 enrolment of MDR TB patients on shorter 9-month regimen was continued. A total of 1,522 MDR TB patients have been enrolled under 9-month shorter regimen since 2005 and the enrollment during 2015 was 200 (155 from DF area and 45 from non-df area in Rajshahi division). Among 814 patients enrolled since 2005 till end of 2013 from DF Bangladesh working area, 707 proven MDR TB cases were analyzed: 589 (83.3%) success, 47 (6.7%) died, 55 (7.8%) lost to follow up and 16 (2.3%) failed treatment. Among 16 failure cases, 12 were tested for fluoroquinolone resistance: 9 (56.25%) had high level, 3 (18.75%) had low level fluoroquinolone resistance and 1 (6.25%) had resistance to kanamycin. Out of 475 patients successfully treated and followed for 24 months, 5 (1%) relapsed: 3 had high level, 1 low level resistance and one sensitive to fluoroquinolone. Treatment success rate from non-df area of Rajshahi division is found to be improving during the recent years (79% success rate among 328 patients analyzed) as a result of intense monitoring from Rajshahi laboratory based DF staffs. 2.7 Tuberculosis Infection control Infection control (IC) aiming at protecting healthy people from the sick remains an important step in TB control programme especially when M/XDR TB is posing threat to the achievements made so far in this disease programme. Infection control measures were established in DF hospitals since its inception through ensuring separate rooms for MDR TB patients from non-mdr TB patients, smear positives from smear negatives and Extra-pulmonary TB patients. Adequate ventilation and fresh air mixing in hospital ward rooms have been ensured in all the DF hospitals through keeping the doors and windows open and installing adequate ceiling fans. Besides, DF also installed UV 5 At present the DF Netrakona hospital works independently, with ITM Antwerp supporting only for data management, quality assurance particularly for the MDR DST, and advanced tests needed for study documentation and/or management of the most complicated cases (fingerprinting; DNA sequencing of resistant genes and tests on a wide range of second-line drugs). 15

lights in all the MDR TB wards. Health education among hospitalized patients on safe sputum collection (in 2-5% phenol solution containing buckets), cough hygiene and cough etiquette is being continued routinely. Surgical masks are routinely supplied to all hospitalized patients in DF and Rajshahi Chest disease hospitals and their regular use and cleaning have been ensured by the nurses. In the clinics, the infection control measures have been ensured through arranging the different assets (cupboard, tables, chairs etc.) and through modifying the sitting arrangements taking the airflow into account. Practice of ensuring infection control measures have been incorporated in routine supervision visit checklist. 3. Leprosy Following the achievement of the elimination status 6 in 1998 at national level, leprosy is no longer considered as a major public health problem in Bangladesh. Since then the interest in leprosy by public health care providers decreased significantly resulting in a sharp decline in leprosy case detection in the country, e.g. a decrease of about 63% in 2014 compared to 2002 (Weekly Epidemiological Record 7 ). The new leprosy case data from DF area shows a decrease of 45% only, indicating adequate efforts taken by DF in finding leprosy cases. Despite the elimination status, Bangladesh remains one of the countries worldwide detecting around 4.000 new leprosy cases annually. About 40% of the geographical area in Bangladesh is covered by leprosy NGOs whereas the government provides services for the remaining 60%. It has been observed that among the total new cases detected in Bangladesh more than 70% cases are detected in the NGO covered area. It thus seems that there is a serious underdetection in the area covered by the government. Among the 372 new leprosy cases detected in 2015 in the DF area, 53% were MB leprosy and 38% of them were skin smear positive. The proportion of children among new cases was 4% in 2015. This low proportion of children among new cases might indicate the decrease in the ongoing transmission of leprosy in the community. Among these new cases 155 cases (42%) were female which indicates the efforts made at detecting women affected by leprosy. The proportion with disability grade 2 amongst newly diagnosed leprosy patients remains high (13%) indicating late diagnosis, because of dwindling attention, decreasing awareness and lack of diagnostic skills among health care providers i.e. delayed referrals by health care providers. Internal migration from rural to urban areas for seeking income generation is a big problem in Bangladesh. Poor people return from urban working area to their home village for care seeking when they become sick. This is because health services in rural areas are much cheaper - low cost village doctors and private chambers as well as easily accessible UHCs as compared to services in urban areas with huge expensive private providers. This might also explain the higher disability grade 2 rates among new detected cases in the DF working rural areas. Graph 10: New Leprosy Detection, Proportion of MB & disability grade 2 in DF Bangladesh, 2004-2015 Trends in New Leprosy, MB & Dis. Gr. 2 Prop. 800 700 600 500 400 300 200 100 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 70% 60% 50% 40% 30% 20% 10% 0% New Total MB% Gr. 2 % Contact checking (active case finding) remains an important part in sustaining leprosy case detection in situations where the leprosy endemicity is low. Sustaining the level of community awareness (indicating voluntary reporting) is 6 Defined as <1 case per 10.000 population. 7 http://www.who.int/wer/2015/wer9036/en/ 16

absolute number also a difficult task in such low endemic situation. The graph below shows the trends in leprosy case reporting indicating the sources. Graph 11: Trends in leprosy case detection and registered prevalence in DF Bangladesh projects Leprosy Mode of Detection 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2006 (628) 2007 (692) 2008 (696) 2009 (701) 2010 (516) 2011 (579) 2012 (487) 2013 (415) 2014 (384) 2015 (372) Vol. Vol. = voluntarily Con. = contact Ref. = referral Oth. = other High treatment success (above 90%) has been maintained for both PB and MB leprosy cases in DF Bangladesh project during the last several years. These rates for PB was 97% and for MB 91% during 2015. 3.1 Care of Leprosy patients (POD): Leprosy, being a disabling neurological disease, leaves affected persons with permanent disabilities if not detected early and treated properly. Disabilities and deformities require lifelong care to prevent further deformities and disabilities. Hence prevention and care of deformities and disabilities are the most important aspects of leprosy management. This could be achieved by early diagnosis and judicious treatment both of the disease and of any reaction/neuritis that occurs. Every step is taken to prevent further development of new disabilities through routine follow up, early diagnosis and prompt management of nerve-function-impairment (NFI), supply of protective footwears, teaching of self care etc. The main objective of POD activities is: No disability apart from that which was irreversible at diagnosis. Since the beginning (1972), DF has been providing passive care to limit further disability and deformity by asking them to report voluntarily for any problem after completion of MDT. Additionally from the year 2008, DF took the special initiative for prevention of disability and deformity by active surveillance of all patients whether new or completed MDT by means of observing POD DAY in every clinic once a year. The main objectives of POD DAY are to promote self care by the patients and to optimize the skills of all field staff to limit the disability due to leprosy. To organize a successful POD Day, all clinic staffs are informed for their presence in the clinic about the Pre-POD visit by the physio-technician (PT), visit by PT one month prior to the POD Day. During Pre-POD visit, PT sits with all the field staff including the TLCO to make a good planning of all activities essential for POD Day including the listing of patients under care, checking the stock of POD materials, prepare list of patients for community based rehabilitation (CBR), vocational training (VT) & Reconstructive surgery. All the POD listed patients are invited on the scheduled POD Day by home visits during other field activities of the field staff. General counseling on self care to limit further disability through Peer Education by the selective patient is performed on the POD day. Individuals are taught on self care, ulcer care and active & passive exercises. A Self Care Kit box containing all the basic materials for simple ulcer care, anesthetic hand and foot care, is provided to all patients to take immediate care at home when necessary. Protective footwear is also distributed on POD day. Con. 17

TLCAs gain more confidence and improve their skill on patient management through this POD day. For the care of patients having anesthetic feet, a total of 2,207 pairs of MCR shoes were supplied during 2015. During the year 2015, a total of 414 leprosy cases were hospitalized for the management of different types of complications in the three DF hospitals, 62% of them were due to ulcer management and for special type of shoes and 15% of the hospitalized leprosy cases received septic surgery as a management of ulcer care. 4. Leprosy Integration Project (LIP) Damien Foundation is providing combined TB & Leprosy services in 102 upazilas, under 13 districts, in addition, only Leprosy service is being provided in 05 upazilas (all upazilas Sherpur Sadar, Jhinaigati, Nakla, Shribordi and Nalitabari) of Sherpur district and 4 upazilas (Mymensingh Sadar, Phulpur, Muktagacha, Trishal) of Mymensingh district in Bangladesh. Among 09 upazilas under Sherpur & Mymensingh districts only 3 clinics under Sherpur sadar, Shribordi & Mymensingh sadar upazilas were running as daily clinic and other 7 clinics were run as Drug Delivery Point (DDP). Also there were no visible community awareness activities in the above 9 upazilas. To run the daily clinic of the above 09 upazilas (10 centers) for providing daily patients service and awareness activities to the community, in June 2014, Damien Foundation started an intensive awareness activity under the Leprosy Integration Project (LIP) for two years (2014 to 2015), which was implemented in the above nine (9) upazilas. The title of the project was 2015 and Beyond: Poverty Reduction through through strengthened health systems. To achieve the project goal Damien Foundation determined two objectives as follows: i) Objectives-1: to develop capacity of health service providers through organizing training of Medical Officers, Private Practitioners, Government Health staff aiming to ensure early case detection and to reduce disability. ii). Objective-2: to mobilize communities to increase awareness and utilization of Leprosy services through organizing training of Village Doctors and advocacy meeting with person affected by Leprosy (PAL) and community elites to improve referral of suspects. 18

To achieve the above two objectives, DF performed all foreseen activities/sessions within the project period. The following activities were performed and outputs achieved during the project period from 2014-2015 against the objective-1: SL.No Name of the Activities / Events Total Sessions done in 2014 Achievement in 2014 & 2015 Total Participant & 2015 Male Female Total 1 Advocacy meeting with government health officials at district level 2 35 5 40 2 Advocacy meeting with health service provider at UHC 6 172 83 255 3 Orientation for Medical Students/Nurse 4 10 110 120 4 Attend monthly UHC meeting 9 0 0 0 5 Annual conference with person's affected by leprosy 4 129 64 193 6 Complicated patient Ref. to Rf. Hospital 24 15 11 26 7 Training for service delivery team 17 170 80 250 8 Health assistant orientation at UHC. 18 333 232 565 9 House hold extended contact survey 216 22484 29933 52417 10 Orientation on project activity for all respective staff. 3 32 19 51 And the following activities were performed and outputs achieved during the project period from 2014-2015 against the objective-2: SL.No Name of the Activities / Events Achievement in 2014 & Total Sessions 2015 done in 2014 Total Participant & 2015 Male Female Total 1 Conduct IEC and group health education 194 3295 245 3540 2 Arrange school health education 72 1394 1315 2709 3 Arrange orientation with others local NGO's 33 385 119 504 4 Folk song 36 8147 1020 9167 5 Leprosy information sign board at UHC 9 0 0 0 6 Observation on World Leprosy Day 2 346 232 578 7 Form multi stakeholders support team/local advisory team 24 416 272 688 8 Meeting with media people & print media coverage 2 38 1 39 9 Orientation on leprosy among local VD/pharmacist. 18 260 7 267 Folk song Group Health Education 19

Outcome of the LIP project: Before starting the Leprosy Integration Project (in the year 2012 & 2013), 65-70 Leprosy cases were being diagnosed from the project areas. Among the detected cases grade-2 disability was more than 15%. With this project, we expected an additional new 100 Leprosy cases with grade-2 disability below 10%. After implementation of the project activities during the project period (in the year 2014 & 2015) we found the following results: Sl.No. Output 2012 2013 2014 2015 Suspect flow 1 Total number of suspects examined 1808 1821 2553 4257 2 Number of male suspects 740 687 1125 1437 3 Number of female suspects 703 730 1064 1715 4 Number of child suspects 365 404 364 1105 Registered patients 5 Total number of confirmed leprosy patients registered 69 68 66 80 6 Number of registered male patients 46 38 27 36 7 Number of registered female patients 20 21 30 36 8 Number of registered child patients 3 9 9 8 9 Number of registered PB patients 57% 44% 65% 66% (39) (30) 43% 56% 10 Number of registered MB patients (30) (38) Grade 2 disability among registered patients Total number of grade 2 disability patients 15 9 11 among newly diagnosed cases in the (22%) (13%) reporting year 12 13 14 Number of male patients with grade 2 disability Number of female patients with grade 2 disability Number of child patients with grade 2 disability (43) 35% (23) 4 (6%) (53) 34% (27) 8 (10%) 12 7 3 6 3 2 1 2 0 0 0 0 As per above result in the project period (2014 & 2015) community awareness, knowledge of GOB Health personnel and their involvement in the program has been increased. Suspects increased almost up to the double. Suspects and Cases increased from Voluntary and referral by GOB health staff. As per the expectation, we could not achieve an additional 100 new Leprosy cases within the project period (2014 & 2015) but after the program intervention the case detection trend was raised. Grade-2 disability rate among newly diagnosed Leprosy cases also decreased from 15% to 8%. Female cases detection increased from 30% to 50%. Child Leprosy case detection remains same with initial disability grade-2 rate 0%. Though the project period was 2 years, the actual intervention period was one and half year. Leprosy is a chronic disease with a long incubation period. But this project showed a satisfactory achievement even though this was only a short-term project intervention. 5. BASIC Project Bangladesh has already achieved the World Health Organization (WHO) Leprosy Elimination goal at national level in December 1998. But there are still about 4000 new cases being detected each year. And still there are some new leprosy cases with disability grade 1 and 2. In addition, there are about 12,000 people disabled by leprosy in the country, who have already grade 2, with visible deformity at end of treatment. This group certainly needs a broad range of services. The main principles of leprosy control are based on timely detection of new cases and their treatment with effective chemotherapy. The emphasis will remain on sustaining the provisions for quality patient care that are equitably distributed, affordable and easily accessible. However, there is an urgent need to bring about decisive and innovative changes to the organization of leprosy control and the working arrangements among all partners, as well as to influence the attitude of health-care providers, persons affected by leprosy and their families, and the general public. 20

The National Leprosy Elimination Program of Bangladesh focuses its activities mainly on medical cure of the disease. There is no organized routine program for supporting people with disabilities/deformities. However, there is a great need to ensure quality of life for those who end up with permanent disabilities. The World Health Organization (WHO) initially provided rehabilitation and vocational training support but this support was stopped once leprosy elimination status was achieved. Damien Foundation started to provide support to leprosy affected deformed people in order to improve their living conditions. Damien Foundation Bangladesh detected and treated more than 20,000 leprosy cases since 1972. About one-fifth of the diagnosed cases have already disability grade 2 limiting their routine income generating activities. Most of them already completed their treatment meaning that they were declared cured medically but physically having the same disability. Most of them are unable to continue normal activities due to their deformities and disabilities. Disabilities cause long term or lifelong unfavorable socio-economic consequences to the affected persons and to their family members. Realizing the global and regional burden of deformed and disabled leprosy affected persons, rehabilitation as part of leprosy care activities is considered as a basic concept and guiding principle of the Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy (Plan period: 2011 2015) which also highlights integration, innovative approaches in case finding, improving quality in diagnosis and management along with sustaining political commitment in leprosy related activities. In compliance with the global and regional strategies the Damien Foundation enhanced its activities towards early diagnosis and treatment of leprosy affected persons and emphasized Community Based Rehabilitations (CBR) of people having permanent disabilities. In April 2009 Damien Foundation started a pilot project as Basic Project for CBR program in the area of Mymensingh, Kishoreganj and Netrakona districts, located in the northern region of Bangladesh where Leprosy control activities have been carried out since 1972. The Main objective of this project is to support the most vulnerable, disabled and poor leprosy patients including their children to improve their livelihood, which will be a living example for other cured patients to survive with dignity through reducing leprosy associated stigma in the community. And the specific objectives are i). to support leprosy patients through income generating activities (IGA), ii). to develop technical skills of leprosy affected persons through vocational training, iii). to ensure educational support for children either affected by leprosy or belonging to leprosy affected families, and iv). to provide houses for abundant leprosy patients. A total of 219 (male 149 + female 70) deformed Persons Affected by Leprosy (PAL) and their children benefited from this intervention through five phases from August 2009 to December 2015. Among them, 125 PAL received a GRANT under this Basic project to start an Income Generating Activity (IGA). Support from a local NGO SABALAMBI UNNAYAN SAMITY (SUS), expert in the field of micro-credits and micro-enterprise, has been received for assuring an intense supervision of 40 clients and other 85 clients are directly supervised by DF. All these beneficiaries started diverse small-scaled enterprises: business with Rickshaw, a three wheeler local transport system, Milking cow, land lease for Cultivation, Mobile shop (Hawker), Rice husking machine, and Grocery shop. Most of them are running their income generating activities satisfactorily. Besides this, houses were built for 19 leprosy affected persons, 17 received Vocational Training (VT) along with support to run their businesses and 58 children from leprosy affected persons families received support for their education including school dress, tuition fee, private tutor fee, books and other educational materials. Phases Income Generating Technical activities (IGA) Skill Housing Education Total 1st Phase: starting from August 2009 25 9 0 11 45 2nd Phase: starting from August 2011 25 1 4 14 44 3rd Phase: starting from January 2013 25 5 5 15 50 4th Phase: starting from March 2014 25 1 5 10 41 5th Phase: starting from January 2015 25 1 5 8 39 Total 125 17 19 58 219 21

Among the above five phases we have evaluated three phases (1 st, 2 nd & 3 rd phases) on the basis of the following income parameters and found the below results of several activities: Income parameters are: i). Sustainable: Able to contribute 100% to family expenses, ii). Medium: Able to contribute 50% - 70% to family expenses, iii). Low: Able to contribute less than 50% to family expenses iv). Failure: Capital lost or moved away. Income Generation Activities (IGAs) Income parameter Grocery Shop + Milking Cow + Ricksha w Rice Husking Machine Tea Stall Mobile Shop Beef Fattening+ Land lease Running business Sustainable 23 05 08 03 01 - - 03 02 01 (31%) Medium 27 04 13 01 01-01 05 02 - (36%) Low 12 02 05 02-01 01 01 - (16%) Failure 13 06 04 01 - - - 01-01 (17%) Total 17 30 07 02 01 01 10 05 02 75 Totals IGA support-2015 Technical Skill Development program Income Tailoring Electric Electric Haircutting Shoemaker Maso Total Parameter Welding wiring (Saloon) (Cobbler) n Sustainable 02 01-01 - - 04 (27%) Medium 02-01 - 01 04 (27%) Low 04 - - - - - 04 (27%) Failure 02 - - - 01-03 (20%) Total 10 01 01 01 01 01 15 Education Support No. of Students Enrolled Intervention Completed (Passed HSC exam) No. of Students running with progress Drop out/excluded 40 09 24 07 Remarks Got married-03, Failed two times in JSC/HSC exam-04 Housing Support No. of clients housing support received 09 Present status Living in the house Died 07 02 22

Housing Support-2015 Education support-2015 6. HOSPITAL ACTIVITY Besides 160 field clinics for about 32 million population in Bangladesh, DF also runs three hospitals with a bed capacity of 255 to take care of complicated leprosy and TB, including MDR TB cases. These hospitals are situated in Jalchatra - Madhupur, Raghurampur Shambhugonj and Anantapur (Baluakanda) under districts Tangail, Mymensingh & Netrakona respectively. During the year 2015 a total of 1,621 patients (TB: 1,202, Leprosy: 399 & General 20) received care from DF hospitals. As the complicated and very weak patients are normally referred to hospitals for intensive care, the death rate among hospitalized cases are likely to be higher than the patients treated ambulatory from the field clinics. But the death rate among hospitalized TB patients was lower (2.91%) compared to the overall death rate among all TB patients including those treated in the field (5.59) which indicates the high quality services provided by DF hospitals or the timely referral. The average bed occupancy rates foreseen per disease category and duration of stay in different DF hospitals are shown in the table below: Table 2: Bed Occupancy and duration of stay TTLCP MTLCP NTLCP Leprosy TB General Leprosy TB Leprosy TB Subtotal 45% 60% 7% 87% 49% 68% 47% Total 54% 60% 51% Duration of stay in days Average 27 22 4 40 18 25 17 Overall bed occupancy in Jalchatra, Mymensingh and Netrakona hospitals was 54%, 60% and 51% respectively during 2015. There has been a decrease in hospital bed occupancy during the last years. The reasons might be the reduction in admission of TB patients because of early case detection (less complication) and management at upazila health complexes. Graph 12: trends in hospital bed occupation 100% 80% 60% 40% 20% 0% Trends in bed occupation (2004-2015) 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 TTLCP MTLCP NTLCP 23

Admission rate among the smear positive cases registered during the year ranges from 5% to 13% among the three hospitals. Table 3: Reasons of TB admission 2015 Hospital Complication Poor Gen. Drug DOT MDR Other Total health reaction TTLCP 109 162 (40%) 81(20%) 0 44 12 (3%) 408 (27%) (0%) (11%) MTLCP 60 203 (23%) 31 0 (0%) 83 81 (9%) 458 (7%) NTLCP 38 (7%) 203 (39%) (4%) 23 (4%) Table 4: Reasons of Leprosy Admission- 2015 Reaction & Eye Ulcer Hospital neuritis complication (10%) 0 (0%) 32 (6%) 40 (8%) 336 Reconstructive Surgery Other Total TTLCP 28 (35%) 37 (47%) 1 (1%) 4 (5%) 11 (14%) 81 MTLCP 39 (19%) 162 (79%) 6 (3%) 4 (2%) 21 (10%) 232 NTLCP 2 (2%) 71 (56%) 5 (4%) 4 (3%) 4 (3%) 86 Total 69 (17%) 270 (66%) 12 (3%) 12 (3%) 36 (9%) 399 The organization runs an OPD for general patients from Jalchatra hospital (TTLCP) to serve the local community and ensures twenty four hours emergency service for the general patients. During the year 2015, a total of 19,737 general patients came for consultations at the OPD and a total of 565 patients received emergency care, out of which 436 were out of office hour. 7. Advocacy Communication & Social Mobilization (ACSM) ACSM addresses key barriers to accessing TB care and completing treatment, and thus support the achievement of organizational as well as national TB programme goals and objectives. ACSM is increasingly being acknowledged as an essential strategic component of TB control. The Global plan to stop TB 2006-2015 and the Stop TB Strategy launched by WHO positioned ACSM as an important component of the TB control programmes for wider use to address four key challenges like, improving case detection and treatment adherence, combating stigma and discrimination, empowering people affected by TB and mobilizing political commitment and resources for TB. The importance of ACSM is still remains same in the End TB Strategy planned for the period from 2016 to 2035. The objectives of ACSM are to increase awareness, bring about behavioral change, influence social norms, and expand community support in TB control programme. In line with the Global and National strategy the Damien Foundation Bangladesh (DF) is actively involved in disseminating TB & Leprosy related health messages through a variety of communication channels to improve and sustain TB & Leprosy related safe behavior among the individual and community. These are as follows: - Community health education - Training of village doctors - Meeting with cured TB patients/elites of the community (TB club meeting) - Meeting/orientation with different NGO staff/govt. health service providers - Health Education in out-patient and indoor department of health service providing institutes - Folk song/popular theatre in the community - Patient to patient education for self care - Observance of World TB & Leprosy Day - Training and refresher course for own staff 24

Table below shows ACSM activities in 2015 at a glance- Training/Orientation and other ACSM activities conducted in 2015 Activities Session Conducted Participant Attended Training/Orientation/Refresher Training for Village Doctors, Pharmacy Holders (1 day) 204 5,033 Review meeting/ orientation with Govt. Health & Family Planning staff 21 1,940 Orientation for Medical Doctors (Public-Private) 26 591 Training for other NGO staff 20 493 Other orientation (for Women groups, MDR, TB/HIV, Multipurpose, 46 3,483 Factory) Other ACSM Events TB Club Meeting 502 Pts.- 11,028 Elite- 1,890 Total-12,918 Health Education session at community level 150,895 1,165,542 Health Education in Out Patient Department (OPD) of Upazila Health 93,347 1,311,962 Complex, Sadar Hospital, Medical College, Sub Center, Community Clinic Health Education session in Indoor of Upazila Health Complex, Sadar 17,418 293,605 Hospital, Medical College Health Education session in Damien Foundation clinic/treatment center 192,775 642,604 Folk song/popular theatre 116 Miking for disseminating health message on TB/Leprosy 96 Celebrated at National, District and Upazila World TB and Leprosy Day celebration level The impact of several ACSM activities and dense network of services ultimately plays an important role in the promotion of TB service facilities in the community, which leads to early diagnosis. As a result, the main duration of diagnostic delay (patient delay plus health service delay) for TB is decreasing. The overall delay is less than 2 months in 2015, except for TTLCP area. The delay in case of females to total cases is almost similar as the delay for males. Graph 13: Diagnosis delay in 2015 - project and gender wise Engaging all care providers and community 7.1.1 Public-public and public private mix approaches Engaging all care providers through public-private mix (PPM) approaches is an important core component of TB Control Programme. The engagement of all relevant health-care providers is essential to meet the TB-related Sustainable Development Goals and reach the targets for TB Control Programme. In the project area, Damien Foundation successfully involved all health institutions belonging to public sector health care networks, such as public hospitals, health care providing facilities at rural levels, medical college hospitals, prison health facilities and workplaces. 7.1 25

MO-GP Orientation MO (Bangladesh Army) Orientation Besides, a large number of non graduate private practitioners (village doctors), graduate medical practitioners, private hospitals and NGO health facilities were involved in referral of presumptive cases and providing DOT. Multipurpose Orientation Factory worker Orientation Graph 14: The graphs below shows contribution to referral of presumptive and case detection by different providers and sources. Mode of referral of TB presumptive and detection of TB case in 2015 26

Graph 15: Mode of Leprosy suspects Graph 16: Mode of Leprosy cases 27

7.1.2 Partnership with the Village Doctors Over the period, the Damien Foundation partnership with the Village Doctors (VD) has been proven as one of the most effective and sustainable approaches; and thus during the year 2015, this effort to further strengthen the partnership with the VDs was continued. The Village Doctors continued their important role in referring suspects, as well as contributing to case detection and providing DOT services to the community as in previous years. Village Doctors in 2015 DF Efforts in 2015 with VDs Contribution by Village Doctors Session Participants Presumptive Cases Training (1 TB (Number) 23,534 1,617 204 5,033 day) % among all 09% 12% In addition to the referral- the Village Doctors were involved as DOT providers for 14,788 TB cases, which is 60% of total DOT in the year. Graph 17: Trends on Contribution from village doctor during last 5 years 14% 12% 14% 14% 14% 13% 12% 12% 11% 11% 12% 10% 9% 8% 6% 4% Suspect referral % Case detection % 2% 0% 2011 2012 2013 2014 2015 Though the graph shows a slight decrease in contribution in referrals and case detection from VDs in compare to last year, this was probably be due to increase referral from Government Medical Officers, Graduate Private Practitioners and Govt. Health staff. It is to be mentioned here that 28

Village Doctor (VD) Orientation there was an emphasis for enhanced linkages with them in recent years in order to detect more PulmonarySmear Negative and Extra-pulmonaryTB cases. Last two years report shows that referral of TB presumptive by Govt. MO and GP has been increasedfrom 18% to 20% and their contributionin TB case detectionalso increasedfrom 31% to 33%. Moreover, referral of TB presumptivecases by Govt. Health staff has been increased from 23% to 27% and their contributionin TB case detectionincreasedfrom 16% to 18%. Followinggraphs shows the trend of case detection in last three years (2013 to 2015) - Graph 18:Comparison of rend t oftb presumptivereferral fromvd, GoB Staff and GP-MO 27% 22% 18% 23% 18% 20% Patie nt p resumpti ve referral (%) VD presumpti ve referral 11% 11% 9% GP & MP presumpti ve referral 9% 9% 8% GoB Health Staf f presumpti ve referral 2013 2014 2015 Annual Report 2015 29

Graph 19: Comparisonof trend of contributionfrom VD, GoB Staff and GP-MO for TB case detection 35% 30% 25% 29% 31% 33% Patient contribution to case detection (%) 20% 15% 10% 05% 0% 16% 16% 18% 14% 13% 12% 11% 11% 10% 2013 2014 2015 VD case detection GP & MO case detection GoB Health Staff case detection This increasing trend of involvement of GoB MOs and field health staf f seems a positive sign for sustainability. 7.1.3 Working with the Government Health & Family Planning staff and General Physicians DF partnershipwith the GovernmentHealth Personnelis another cost-effective approachfor case finding and case holding. During last year, this partnership approach has been strengthened. Govt. Medical Doctors and General Practitioners in 2015 Govt. Health & Family Planning staff in 2015 30 Annual Report 2 015

DF Efforts in 2015 with Govt. Health & Family Planning staff Contribution by Govt. Health & Family Planning staff Review meeting/ Orientation (1 day) Session Participants Presumptive Cases TB (Number) 65,742 2375 21 1940 % among all 27% 18% Leprosy (Nr.) 1207 22 % among all 6% 5% Besides referral, Govt. Health & FP staff play an important role in DOT Monitoring. A total of 3,464 TB patients received DOT under their supervision in 2015, which is 14% contribution to the total DOT monitoring. Their involvement increased the DOT expansion in the community, which is very much important to improve patient friendly access to the services and enabling community participation in TB control. 7.2 Empowering patients and communities Considering the pivotal role of Advocacy, Communication and Social Mobilization (ACSM) in the field of TB control and Leprosy elimination the ACSM activities have been continued in collaboration with the Government (NTP & NLEP), with the financial support from the Belgian Government & Damien Foundation, GFATM, CTB and WHO. The effect of several ACSM activities and dense network of services has been revealed through sustaining the referral of presumptive cases and increasing trend among certain group of people as well. The clinic staffs were involved with several ACSM activities besides routine activities on diagnosis, treatment and follow-up. 7.2.1 Working with the Former patients and Elites (TB Club Meeting) The objective is involving cured patients from the community to increase the case finding and to encourage them to send presumptive TB cases and to detect early relapse. Since 2000, DF has emphasized involving former patients in the identification of presumptive TB cases from the community and for referring them to health centers. This involvement was extended to organizing TB clubs of former patients at the union level (a union is a small administrative unit with a population of about 20,000). The vast majority of the cured TB patients are from the poorest segment of the society, but their role in TB & Leprosy control activities has given them an identity as the best advocate to the community in terms of referral of presumptive TB & Leprosy cases. 31

DF Efforts in 2015 with Cured Patients and Local Elites Contribution by Patients and Local Elites Session Participants Presumptive Cases TB Club meeting TB (Number) 19,427 1,367 at union level Patients- % among all 8% 10% (1 day) 11,028 Leprosy (Nr.) 1,556 48 502 % among all 8% 12% TB (Number) 6,512 337 Elites- 1,890 % among all 3% 3% Leprosy (Nr.) 453 5 % among all 2% 1% Each cured patient is a living example for the community that TB is curable. Graph 20: Contribution of former TB patients and Elites in referring presumptive TB cases and smear positive case detection during last five years (2011-2015) TB Club meeting (Cured patients gathering) 32

7.2.2 Working with other NGOs: During the year 2015, training/orientation sessions were conducted with the participation of other NGO staff. They were also involved in referring presumptive cases of TB and Leprosy. DF Efforts in 2015 with NGO staff & Contribution by NGO staff & volunteers volunteers Training for other NGO staff (1 day) Session Participants Presumptive Cases 20 493 TB (Nr.) 4,117 175 % among all 2% 2% Leprosy (Nr.) 140 0 % among all 1% 0% 7.2.3 Health Education Activities in Community and Govt. Health Facilities: Health education events do create greater social commitment and support behavioral change in order to ensure access to treatment and care for all, particularly the poor, vulnerable and hard-to- reach populations. The activities include disseminating accurate information on the diseases and dispelling myths about TB/Leprosy, educating and encouraging people with their family members to be more actively involved. Several events of health education were conducted in the year 2015. Details are in following table: Health Education Activities in 2015 Health education session in community HE session in OPD (UHC, SH, MC, FWC, SC, CC) HE session in INDOOR (UHC, SH, MC) HE session in DF clinic Folk song/ popular theatre Contribution from Health Educational Activities Session Participants Presumptive Cases 150,895 1,165,542 93,347 1,311,962 17,418 293,605 TB (Number) 65,308 2,353 % among all 26% 17% 192,775 642,604 Leprosy (Nr.) 12,302 159 116 Miking 96 Total 454,647 3,413,713 % among all 66% 38% Health education activities helps to enhance community participation which leads to increased awareness, promote health-seeking behavior, inspire dialogue, and heighten community concern and action for TB/Leprosy control. 33

7.2.4 Community participation in DOT expansion In compliance with the components of the STOP TB STRATEGY: Pursue High-Quality DOTS Expansion and Enhancement, Damien Foundation Bangladesh since initiation of the TB control programme has decentralized DOT to the community level to make it more patient friendly by involving VDs, GOB Health and Family planning staffs, other NGO staffs, cured patients, school teachers, religious leaders and local elite. In each Union, there are 5 to 6 Fixed DOT Providers (FDP) to provide DOT to the patients, this next to other Non-Fixed DOT Providers. The graph bellow shows the involvement different categories of DOT providers in TB Control Programme, where about 60% of them are Village Doctors in DF project areas. Graph 21: DOT Providers in 2015 Village Doctors (VDs) contribution as DOT Providers in 2015 Graph 22: Fixed and Non-Fixed DOT Provider in DF project areas in 2015 34

8. Operational Research in Damien Foundation Bangladesh Damien Foundation Bangladesh has been conducting several operational researches next to its routine activities aiming at defining/establishing cost-effective means of diagnosis & treatment, documenting/validating different research findings/publications from other countries and to provide input to the national and international Health Agencies (WHO, IUATLD) to develop/recommend new tools and strategies for different NTPs based on study results obtained in DF Bangladesh. 8.1 Diagnosis and Management of MDR TB Since 1997 DF started to treat MDR-TB patients using a succession of standardized regimens under strict operational research conditions, which led to the identification of a highly efficient, safe, short and relatively cheap regimen initially resulting in close to 90% cure with minimal bacteriological failure or relapse, and without amplification of second-line drug resistance. Results have deteriorated slightly over the last years due to increasing levels of secondline drug resistance (mainly fluoroquinolnes, because of their wide use for general infections) among newly presenting MDR-TB. Over the years efforts at improving the care for severely resistant TB have also included earlier detection (through slide DST) and their treatment using new drugs such as bedaquiline and linezolid since 2011. Additionally DF has developed locally appropriate, low cost, simple and safe laboratory screening and drug susceptibility testing methods (FDA vital staining; slide DST) which has led to an increasingly early screening, diagnosis and treatment of such cases. Currently 4 very simple laboratories in DF areas are capable of delivering min. 95% correct diagnoses of TB resistant to rifampicin, fluoroquinolones (high or low level) and 2 nd -line injectables, besides its differentiation from non-tb mycobacterial disease, and this within 2 weeks. The more efficient but very costly molecular diagnosis of rifampicin resistance by GeneXpert machines were installed in 5 DF laboratories (donations from NTP/USAID) but most of them showing disturbances (equipment errors) most of the time leading to dependence on DF developed DST testing methods. For these achievements in the field of drug resistant TB, DF Bangladesh received intensive support from the Mycobacteriology Unit at the Institute of Tropical Medicine in Antwerp, Belgium, with gradual transfer of capacity to its reference laboratories (the main one at its own hospital in Netrakona) 8. DF takes care also of MDR-TB patients referred to its services from other areas, and since 2008 it has been given the responsibility by the NTP to organize MDR-TB management for the entire Rajshahi Division. This has been achieved through training, organization and continuous collaboration and service delivery of the NGOs and Government institutions working for TB in this Division. Besides, the DF support in this field has also led to the creation of 40 MDR beds as well as a TB referral laboratory for the division, capable of rapid diagnosis of MDR- and XDR-TB. In 2015 enrolment of MDR TB patients on shorter 9-month regimen was continued. A total of 1,522 MDR TB patients have been enrolled under 9-month shorter regimen since 2005 and the enrollment during 2015 was 200 (155 from DF area and 45 from non-df area in Rajshahi division). Among 814 patients enrolled since 2005 till end of 2013 from DF Bangladesh working area, 707 proven MDR TB cases were analyzed: 589 (83.3%) success, 47 (6.7%) died, 55 (7.8%) lost to follow up and 16 (2.3%) failed treatment. Among 16 failure cases, 12 were tested for fluoroquinolone resistance: 9 (56.25%) had high level, 3 (18.75%) had low level fluoroquinolone resistance and 1 (6.25%) had resistance to kanamycin. Out of 475 patients successfully treated and followed for 24 months, 5 (1%) relapsed: 3 had high level, 1 low level resistance and one sensitive to fluoroquinolone. Treatment success rate from non-df area of Rajshahi division is found to be improving during the recent years (79% success rate among 328 patients analyzed) as a result of intense monitoring from Rajshahi laboratory based DF staffs. The drug cost per patient treated with this 9 month regimen is around 225 Euro which is much lower than the WHO recommended regimen. Considering the cost, treatment duration and higher treatment success, several countries have 8 At present the DF Netrakona hospital works independently, with ITM Antwerp supporting only for data management, quality assurance particularly for the MDR DST, and advanced tests needed for study documentation and/or management of the most complicated cases (fingerprinting; DNA sequencing of resistant genes and tests on a wide range of second-line drugs). 35

already adopted this regimen under operational research conditions following the WHO recommendation. The Union is coordinating TREAT TB initiative in conducting a clinical trial using a modified version of this 9 month regimen in South Africa, Vietnam, Mongolia and Ethiopia. Though the result of stage 1 of STREAM trial is expected to be available in late 2017, it is being continued with stage 2. In stage 2, two new regimens are included with stage 1: Kanamycin is replaced by new drug bedaquiline (BDQ) in one regimen and kanamycin given for first 2 months in the other. The duration of new regimens with BDQ is 9 months while the other with kanamycin is 6 months. The Union is also coordinating an operational research in 9 francophone African countries in testing this 9 month regimen. NTP Bangladesh planned to gradually scale up this short regimen throughout the country starting from 2014. Following the achievements of this shorter regimen in DF Bangladesh projects and in other countries, NTP Bangladesh planned for expansion of this regimen phase wise throughout the country. The UNION supported the NTP through appointing one advisor at NTP. NTP Bangladesh has obtained approval from the ministry of health and is now in process of selection of principal investigator and obtaining ethical clearance. USAID is in process of providing required drugs to NTP Bangladesh for 250 patients for initial evaluation on safety and treatment success of this regimen in Dhaka and Chittagong divisions under clinical trial conditions. 8. 2 Drug resistance monitoring Monitoring the TB drug resistance in DF Bangladesh projects is in place since end of 1995, mainly through systematic referral of sputum from defaulters, relapse and failure cases, besides the random surveys done in 1995 and 2001. From May 2002 onwards, most primary cultures were handed over by Antwerp to the reference lab in Bangladesh (Netrakona). Netrakona lab started LJ DST in 2008 and since 2010 this lab is performing LJ DST independently under the direct supervision and control of Antwerp lab. Selective strains are sent for quality control to Antwerp lab besides the routine participation in proficiency testing. The total number of inoculated cultures has risen considerably during the years. Annually more than 3,000 sputum samples are processed in Netrakona lab, most of which belong to follow-up samples of MDR TB cases. Since 2004 following the introduction of rifampicin throughout intermittent regimen in the country, an increase in MDR TB rate was observed. The analysis of trends in RMP and Ofloxacin resistance incidence for all DF districts expressed per 1000 smear positive cases (new+rett.), show at least that there is no increase in rifampicin resistance over the last 5 years. Considering only RIF-resistant isolates, fluoroquinolone resistance has reached 20%, and the trend seems to be increasing. Apart from MDR followup specimens, XDR and 2 nd -line injectable resistance are virtually absent. Most alarming is that the rising prevalence of fluoroquinolone resistance seems to be accompanied by an increasing proportion of high-level resistance, responsible for the deterioration of MDR short-course treatment results in recent years. However, as shown further the results often differ between LJ and slide DST, and totals tested by this system are still rather few. Drug resistance monitoring among late converters and retreatment cases, Damien Foundation Bangladesh 1997-2012, all project districts RMP resistance 12 10 8 6 4 2 Switch to 6-month R- throughout regimen Ofloxacin resistance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 0% RMP-resistance per 1000 registered smear+ %OFX-resistance among RMP-resistant tested 36

8. 3 FDA staining and slide DST Since mid-2008, slide culture and (FDA) vital staining are used decentralized by all DF Bangladesh projects, except for FTLCP where the lab is still suitable only for FDA. FDA staining was installed in 8 clinics of Greater Mymensingh, preparing for the OneRIF clinical trial on earlier detection of MDR-TB and effect of double dose RIF first-line treatment. FDA results at 2 weeks treatment was used as screening on which samples should be referred for further tests (GeneXpert, slide DST). FDA staining of sputum smears is now being used for declaration of failure of MDR regimen: FDA result at least 1+ in 2 occasions one month apart from 5 months onwards. Slide DST is performed to detect 2 nd line drug resistance. This test provides information on Kanamycin and ofloxacin results at different concentrations besides rifampicin in 2 weeks time. 8.4 Six months MDT Regimen trial For MB Leprosy Patients In 2002, WHO recommended to launch trials of a uniform MDT of six-month duration for all the leprosy cases (PB and MB) with the regimen given to MB cases. As the current regimen for PB cases is adequate, Damien Foundation in collaboration with Danish Bangladesh Leprosy Mission undertook this study on MB patients during 2005 2006. MB patients under this study are being followed up annually for 10 years to assess relapse rate. After exclusion of those withdrawn from the study, the number of patients eligible for analysis are 562 and 773 for twelve months and six months cohort respectively. Among them respectively 44% and 38% were skin smear positive, 20% and 23% were with Grade 2 disabilities at enrollment. Their mean Nerve Function Impairment (NFI) score was 83 for both groups at the time of diagnosis. Regarding gender distribution, 30% and 27% were female in twelve and six month cohort respectively while the average age of male was 40.12 (range 16-88 years) and for female it was 41.19 (range 16-80) for both groups together. Despite some errors and data missing from the yearly routine follow-up, respectively 96% and 98% cases completed their treatment in twelve and six months cohort. No significant difference has been observed in NFI score from start to current follow-up among the regular cases. It stays 83 to 84 out of 90. The decreasing trend in maximum BI is observed in both cohorts, from 1.59 to 0.03 in twelve months and 1.30 to 0.18 in six months after the follow-up in 2015. No confirmed relapse has been diagnosed till end of 2015. 8.5 Optimization of TB treatment regimen (OneRIF study) Several studies are currently ongoing globally to find new regimens for the treatment of TB. Most of these studies focus on finding new/more efficient drugs for both drug- susceptible and - resistant TB. The DF project focuses on optimizing the current TB regimen by doubling the dose of rifampicin for drug susceptible TB. This new clinical trial using double dose rifampicin for smear positive TB patients aged 15 years and older in the intervention group, was started in 2014 in 8 clinics with a high patient load, in collaboration with the clinical trial unit of the Institute of Tropical Medicine, Antwerp - Belgium. Early follow-up of sputum smear by FDA vital staining at 2 weeks along with Xpert testing of slow responders (speeding up diagnosis of MDR and start of MDR treatment) was used as screening tool. Enrollment was completed by the end of September 2015: 476 under intervention arm and 471 under control arm. No significant increase in hepatic enzymes with double dose rifampicin among those enrolled was observed. A total of 24 failure cases (14 intervention arm and 10 control arm) have been observed. Follow up sputum smears (microscopy and culture) from all cured, treatment completed and lost to follow up patients will be examined after one year period to assess relapse rates. This interesting pilot study aims at future larger study and hopeful reduction in TB treatment duration to 4 months in fast responders. 9. Human Resource Management & Development 9.1 Overview A total of 574 (male-371 and female-203) local staffs and an expatriate are involved at different levels of Damien Foundation (DF) Bangladesh to ensure the smooth functioning of the 160 field clinics, and 3 DF hospitals - with a capacity of 255 beds - and for the financial and administrative management. Out of this total, 374 staffs are involved in carrying out the field activities under the supervision of 35 Supervisors (TLCOs, Sr. TLCO, Monitoring & 37

Evaluation Officers and Field Coordinators) and 8 Medical Doctors. Next to DF staff, one volunteer for each of the 261 sputum collection centres has been selected from the respective communities. These volunteers have been trained to identify TB & Leprosy suspects and to make smearing. In 2015, total staff turnover was 7% (42). On the other hand, DF recruited 28 new staff to fill-up the vacant positions at the different levels. Among them a Medical Coordinator, Finance Manager and Data Entry Officer have been recruited for Damien Foundation Coordinating Officer in Dhaka. 9.2 Training organized by DF throughout the year 2015 TOT on Leprosy: DF organized three days TOT course on Leprosy from 18/04/2015 to 20/04/2015 at DF Training Center, Jalchatra Hospital compound, Madhupur, Tangail funded by LNEP. A total of 30 participants (Govt. TLCA, PO CS office, DF TLCOs, DF Sr. TLCO & FC) were present. Training on POD: DF organized three days POD training from 21/04/2015 to 23/04/2015 at DF Training Center, Jalchatra Hospital compound, Madhupur, Tangail funded by LNEP. A total of 23 participants (Govt. TLCA, PO CS office, DF TLCAs & TLCOs) were present. Light Emitting Diode (LED) training: in continuation of the initiative to introduce/install LED microscopy since 2011. In this year, a total of 15 staffs (TLCA/CA) were oriented in the technology to be used at field clinic level for improving the quality of TB diagnosis. Training on Good Clinical Laboratory Practice (GCLP) and QA for OneRIF study: On 05/06/2015 and 25/06/2015 DF conducted two training sessions for OneRIF study on GCP & QA for DF Medical Officer and field staffs and total participants were 14 and 19 accordingly. 9.3 Participation in different training courses within the country 2015 To develop skills in different fields, DF staff members attended different training courses in-country in 2015, organized by NTP/The Union /BRAC. A detailed schedule of the participants is given below: Course Name Participants Duration Clinical Leprosy-A basic course for Dr. Md. Zobair Hossain, Medical Officer-RTLCP 1 week doctor organized by TLMI-Nilphamari Refresher course on Financial Mr. Bappy Policarp Palma, Accounts Officer- 1 week Management organized by BRAC FTLCP Basic Laboratory training on LED Total 15 participants (CAs and TLCAs) from 1 week Microscopy organized by URC different projects Basic Training on Computer, Dhaka Total 12 participants (TLCAs) from different 2 weeks Bangladesh organized by NTP projects Refresher training on ZN Microscopy Several TLCAs from different projects 1 week organized by NTP Training on TB mhealth Application organized by URC Several TLCAs from different projects 1day 9.4 Participation in International training courses/meetings/conferences 2015 With a view to update knowledge and to share experience, DF staff members regularly participate in different international training courses, meetings, conferences, workshops and seminars. In 2015, the following DF staff attended conferences, meetings and training courses as per below schedule: Conference/ Meeting/Training course Participants Place & Duration Meeting on ILEP (International Federation of Anti-Leprosy Associations) Congress Mr. Bart Rombaut, Country Director, DF Bangladesh Wuerzburg, Germany from 24 th to 27 th March, 2015 Training course on Gain a better understanding of molecular Tuberculosis (TB) diagnostic GeneXpert machines and how to test airflow and service a biosafety cabinet Md. Anwar Hossain Akram, Laboratory Coordinator, DF Bangladesh Institute of Tropical Medicine (ITM), Antwerp, Belgium from 8 th to 19 th June, 2015 38

10. Visiting Group Communication Department Damien Foundation (DF) Bangladesh had the pleasure to receive visiting groups from Belgium every year. Those visits have this characteristic in common: all visitors are volunteers in the network of the Communication Department. With their relentless support DF Belgium manages to raise, year after year, the necessary funds for the worldwide programmes. During the visits the volunteers obtain a clear insight into: (1) The many-sided tasks of a programme, fighting against TB and leprosy & (2) The challenges and realities specific to this country. The groups have different objectives and can be grouped as follows: i). Volunteers participating in "Construction Camps/Building Camp" ii). Cycling groups who discover the DF activities and Bangladesh by cycle. iii). Network volunteers who witness the DF work during an immersion journey. iv). Business groups, sponsoring DF Bangladesh. v). Regional Belgian TV stations, accompanied by students and teachers from their own broadcasting area. As such, in July 2015 a total of 10 Volunteers came to Bangladesh, to help DF in the realization of much needed construction. The volunteers stayed for around one month from 19/07/2015 to 15/08/2015, out of which they worked 3 weeks together with the local laborers to extent the Boundary wall (upper level) and Garage renovation including store room at Mymensingh DF hospital. The remaining week they travelled and observed DF activities at Jalchatra & Netrakona hospitals as well as visited some touristic attractions (Dhaka, Chittagong, Bandarban and Cox s Bazar). The interest is mutual: the volunteers experience a unique way to discover a new country, its friendly population and the Tuberculosis (TB) and Leprosy work of the DF. On the other hand, DF can realize needed reconstruction works with the support of volunteers and financial input by City councils from Belgium. After arrival in Bangladesh, the group received an overview of the Damien Foundation Bangladesh through a presentation at Damien Foundation Coordination Office (DFCO), Dhaka. Visitors from Left: 1. Martine Marie Jan-Teacher, 2. Janne Koentje A.-Student, 3. Heleen Veroniek L.-Student, 4. Andrey Osipov-Photographer, 5. Paul Marie J.-Teacher, 6. Oona Elisa Jakobe Marion-Student, 7. Evie Anne S.- Student, 8. Emilie Christine N.-Student, 9. Robbe Alois Dirk-Student & 10. Sophie-Teacher 39

After that they visited the DF Jalchatra hospital and stayed two nights. On the way to Jalchatra they visited a government hospital (Upazila Health Complex-UHC), meet with local government health authorities, admitted general patients, visited a DF clinic inside the UHC and meet with DF paramedic staff and patients; on the road side they visited a Rice mill (rice production), brick oven and talked to local people. During their stay in Jalchatra hospital they visited hospitalized patients, observed the laboratory work, visited a local tribal (Mandi/Garo) community and observed their culture. During their three week stay in Mymensingh, they participated in construction works with local labourers, visited DF clinics, laboratory work, and meet with hospitalized patients, government local health authorities, field clinics, Health education programme, DOT providers, Community Based Rehabilitation (CBR) programme, local slum etc. During the weekend they have visited local historical places, meet with local communities. Also, they visited DF Netrakona hospital and meet with hospitalized patients. Before returning to Belgium, the group visited touristic places in Bangladesh (Bandarban, Cox s Bazar) and a few historical places in Dhaka. In the course of the visit, the participants received a full disclosure to all aspects of the TB and Leprosy control programme of DF. They did visit DF-hospitals and labs, DF-clinics within the Upazila Health Complex (UHC), cured patients meetings, Health Education programmes, Community Based Rehabilitation (CBR) program etc. The outcome of this program, both in terms of fundraising objectives as well as in terms of information-transfer to the Belgian population regarding the DF-work in Bangladesh is considered to be very good. 11. Programme Management and Coordination At the project level, overall implementation management of program is done through a team approach by the Management Team (MT). The Management Team is headed by the Project Director with the Hospital/Field Director, Medical Officer/consultant, M&E Officers/Field Coordinators/Senior TLCOs as MT members. The MT discusses the day-to-day management issues on weekly basis and decides on the major issues, including issues referred from TLCO meetings, on quarterly basis. They can also organize the MT meeting at any time to deal with urgent issues. An important process of Programme Management and Coordination is the regular monthly TLCO meeting, where all TLCOs, FCs, M&E Officers/Medical Officers, Hospital/Field Directors and Project Director attend. The TLCOs, in fact, serve as the main bridge between the project office and the field clinics besides the project based supervisors (doctors and M&E officer). In depth analysis of monthly progress reports including performance, achievements, challenges and problems are done through active participation of the participants present, and decisions are taken, recommendations are made or action plans are adapted to improve the situation. Dissemination of information and instruction from national level, exchange of information between field clinic and project/dfco, monthly clinic wise planning, settlement of bills and collection of monthly running / different costs of the clinics take place in these monthly meetings. In order to assess case detection and results of health education activities, a manual geographic information system is maintained in each Upazila. This information helps to identify areas with low case finding and enables the staff to identify the barriers for that specific area and to act accordingly. 40

Information / instruction flow takes place mostly through emails between national level office and the project offices on a regular basis. Besides, mobile phone communications are used for urgent matters between national & project levels, and field clinics. In this way, the national office is kept updated on what is happening at any point at field level. For facilitating better coordination representative/s from Damien Foundation Coordination Office at Dhaka also participated in some project level meetings of Management Teams and TLCO meetings and guided them. 12. Monitoring, Supervision & Evaluation 12.1 Internal monitoring, supervision & Evaluation Monitoring of case detection, sputum conversion, results of treatment and quality control of smear microscopy are routinely done and evaluated quarterly. In addition, drug resistance surveillance is continued through routine sputum culture and DST of failure and relapse cases. Monitoring MDR TB treatment through regular updating of MDR files are routinely done by DFCO. The quarterly collected data from the projects are being used to monitor the performances. Cross checking between different datasets allows assessing the quality of the data and feedback is given to the projects in order to improve the performances. Reports are cross-checked with registers and cards by supervisors during their supervision visits and feedback is given on the spot to the field staffs. Monitoring of activities and supportive supervision of staff is done through field visits by different types of staff. At the field level, TB & Leprosy Control Officers (TLCOs) are the first line staff for monitoring of the project activities in 3-4 upazilas (Sub-districts) each. They supervise the first line field staff, TB & Leprosy Control Assistants (TLCAs) / paramedics, Assistant TB & Leprosy Control Assistant (ATLCA) and Clinic Assistants (CAs). TLCOs monitor all the activities implemented at the field level, provide need based support and build/strengthen the capacity of the field staff for better implementation or improvement. A TLCO regularly visits each TB clinic/lab/uhc under his/her mandate to monitor and supervise at least once a week and check/cross-check the clinic documents including registers, reports, treatment cards and other records. S/he monitors case detection, sputum conversion, treatment results, quality control of sputum microscopy, and drug resistant and failure and relapse cases. S/he also pays need-based visits to the community and discusses with patients, DOT providers and other stakeholders to cross check status of DOT implementation, patient follow up, social mobilization and presumptive referral activities. Monitoring and follow-up of project performances is carried out through analyzing the achievements realized, compared to the planned activities and results. Quarterly and annual reports are used to monitor the project performances. M&E Officer (M&EO), Medical Officer (MO) and Field Coordinator (FC) pay monitoring visits to a TB clinic/lab/uhc at least once in 3 months (quarterly) as well as additional visits based on the needs of the program/project. During the monitoring visits they supervise the activities of TLCO and other field staff, guide them, provide technical supports and build or strengthen their capacities through on-the-job training. The Project Director, who is the overall responsible person of a project, and the Hospital Director/ Field Director are the management staff at the project level of DF, and they also monitor field activities on a sample basis as well as according to the needs. From the Damien Foundation Coordinating Office (DFCO), the Medical Coordinator and Medical Specialist visit the field especially for programmatic monitoring to provide professional and technical support. Admin & HR Director (AHRD) and Finance Director (FD) visit the field for need- based monitoring purposes. The Country Director of DF also pays visits based on the needs of project management (HR, finances), and to discuss strategic issues (program/project). 12.2 Supervision from NTP & NLEP: Routinely field clinics were visited by the different representatives of the NTP & NLEP. The supervisors include: Director MBDC, PM, DPM, NTP MOs, GFATM supported TB Consultants posted at the divisional level, a designated Medical Officer (TB/Leprosy) based in the Civil Surgeon s office at the district level, a junior consultant at the district chest clinic. 41

Program Manager-Leprosy of NLEP visited DF Jalchatra Hospital 12.3 Supervision by DF Brussels and other visitors: DF Bangladesh project is also closely monitored through regular communications and analysis of statistical & financial reports by DF Brussels. The Programme Manager and the Medical Advisor of DF Brussels pay visits to DF Bangladesh projects at least once annually. Visitors from ITM, Antwerp, Belgium In addition, from 04/06/2015 to 10/06/2015 Ms. Celine Schurmans, Clinical Research Scientist, from Institute of Tropical Medicine (ITM), Antwerp, Belgium came to Bangladesh to oversee and monitor One RIF study s clinic in DF Bangladesh program. 42

Government Health Infrastructure in DF-areas Annex Table -1 District / Square Population Hospitals Upazilla Health Health TB Clinics TB & Leprosy Control TB beds Lep. beds Project km Complexes Centers Assistants (TLCA) Tangail Project 6,810 7,519,262 3 24 1,078 2 21 0 0 Tangail 3,414 3,755,142 1 12 545 1 12 0 0 Jamalpur 2,032 2,371,673 1 7 332 1 7 0 0 Sherpur 1,364 1,392,447 1 5 201 0 2 0 0 Mymensingh Project. 7,052 8,433,791 4 23 958 2 19 48 0 Mymensingh 4,363 5,384,141 2 11 593 1 8 48 0 Kishoreganj 2,689 3,049,650 2 12 365 1 11 0 0 Netrakona Project. 2,810 2,333,286 1 9 290 0 7 0 0 Netrakona 2,810 2,333,286 1 9 290 0 7 0 0 Rajshahi Project 7,546 7,161,268 14 24 1,106 2 24 150 0 Rajshahi 2,407 2,728,773 9 9 389 1 7 150 0 Naogaon 3,436 2,688,109 4 11 489 0 12 0 0 Nawabganj 1,703 1,744,386 1 4 228 1 5 0 0 Faridpur Project 7,008 6,613,355 7 22 1,002 3 31 24 0 Faridpur 2,073 1,973,392 3 7 257 1 11 24 0 Gopalganj 1,490 1,186,673 1 4 275 1 8 0 0 Madaripur 1,145 1,179,333 1 3 166 1 4 0 0 Rajbari 1,119 1,082,044 1 3 168 0 5 0 0 Shariatpur 1,181 1,191,913 1 5 136 0 3 0 0 Total DF 31,226 32,060,962 29 102 4,434 9 102 222 0 Annual Report 2015 43

Supportive activities over 2015 1/1/201512/31/2015 TB General surgery / ulcerreaction / otherretreatments Others consultations 5 2,475 3 54 23 50 84,633 0 4 0 40 69 0 13 655 31 1,388 *1 Community HE : in the villages, OPD HE, UHC indoor HE and organisation (microcredit or other groups), informal group HE during field visit, HE with the patient's attendants etc. *2 Village Doctors, Fixed DOT provider and Pharmacy hoders training. *3 Seminar in Medical college, sadar hospital *4 Opinion leader, scout and girls guide, NGO workers, review workshop at Upazilla level and DOT committee meeting. *5 MTLCP made shoe for NTLCP, FTLCP & RTLCP Hospitals, physiotherapy, shoemaking and health education Project no. of beds on Hospitalizations: no. of bed-days for no. of Lep. patients admitted TB admissions for TTLCP 95 95 3,295 15,175 158 57% 41 40 44 364 19,737 MTLCP 100 100 8,880 12,966 0 60% 175 60 130 328 815 NTLCP 60 60 2,740 8,492 0 51% 71 11 98 337 425 RTLCP No hospital, not applicable FTLCP Total projects 255 255 14,915 36,633 158 57% 287 111 272 1029 20,977 Project Plastic / Spring MCR Plastazote shoes supplied Folk Miking song Skinsmears Training / Orientation / ref. / seminar: no. of sessions for Community SchoolsSchools GoB H & *1 FP staff VD / FDP*2 TB club Seminar / Openion leader/ workshops *3 scout / NGO *4 Total done Positives sessions OPD Physiotherapy TTLCP 817 14 0 35 42 50,224 0 6 5 38 79 2 17 193 33 374 MTLCP * Average bed Leprosy occupation Shoes made (pairs) HE activities: no. of sessions No hospital, not applicable Annex Table -2 NTLCP 0 0 6 0 0 20,302 96 2 0 20 31 0 3 114 18 165 RTLCP 0 0 10 31 12 56,691 4,537 10 0 51 145 0 9 1,270 153 21 FTLCP 0 0 0 13 12 48,479 600 10 0 54 174 0 6 253 16 4 Total projects3,292 17 70 102 116 260,329 5,233 32 5 203 498 2 48 2485 251 1952 44 Annual Report 2015

Personnel and infrastructure 2015 over Numbers of personnel, transport, equipment Department: Administrative + Hospital Project Personnel Transport Theatre Doctors Paramedical AdministrativeSupport/Techn. Cars Motorcycles Bicycles X-Ray Microscopes Shoe Units in use workshops TTLCP 1 23 3 21 1 1 2 1 sterile 1 4 1 MTLCP 1 19 3 20 1 4 6 1 septic 1 2 1 NTLCP 1 15 1 15 0 1 0 1 septic 1 2 0 RTLCP 0 0 2 12 0 0 0 not applicable, no hospital 0 0 FTLCP 0 0 2 7 0 3 0 not applicable, no hospital 0 0 DFCO 2 0 6 8 2 0 0 not applicable, no hospital 0 0 Total projects 5 57 17 83 4 9 8 3 3 8 2 Department: Field Project Personnel Transport Doctors TLCO TLCA Assis. TLCA Clinic Assis. Cars Motorcycles Bicycles Annex Table -3 Microscopes Combined in use TB/Lep clinicleprosy clinic TTLCP 1 7 61 22 3 1 11 34 35 35 5 MTLCP 0 8 64 24 6 1 11 44 34 34 5 NTLCP 0 4 22 10 2 1 4 13 12 12 0 RTLCP 1 7 58 16 4 2 10 36 34 32 0 FTLCP 1 9 65 9 8 2 9 40 37 37 0 DFCO 0 0 0 0 0 0 0 0 0 0 0 Total projects 3 35 270 81 23 7 45 167 152 150 10 Annual Report 2015 45

CONSOLIDATED REPORT LEPROSY 2015 Evolution of casefinding and caseload Annex Table -4 NUMBERS RATES Year Project Districts & New cases New Disabled On treatment New Lepr. / Lep. preval. / Proportion Prop. new Prop. new population PB MB Total children new cases at end (Year) 100.0000 pop. 10.000 pop. MB new Lep. children L. disabled L. 2009 TTLCP TG+JM+SP 107 87 194 13 26 155 2.58 0.21 45% 7% 13% 7,516,649 MTLCP MM + KS 84 62 146 11 24 107 1.82 0.13 42% 8% 16% 8,039,367 NTLCP Netrakona 14 18 32 2 9 29 1.40 0.13 56% 6% 28% 2,287,297 RTLCP (RA) + NG + NW 131 140 271 23 31 211 3.87 0.30 52% 8% 11% 6,997,298 FTLCP FP+GP+MP+RJ+SR 22 36 58 13 53 0.84 0.08 62% 0% 22% 6,930,460 TOTAL 31,771,071 358 343 701 49 103 555 2.21 0.17 49% 7% 15% 2010 TTLCP TG+JM+SP 38 64 102 6 21 86 1.34 0.11 63% 6% 21% 7,588,121 MTLCP MM + KS 56 52 108 2 25 84 1.33 0.10 48% 2% 23% 8,131,350 NTLCP Netrakona 15 18 33 1 9 22 1.42 0.09 55% 3% 27% 2,317,226 RTLCP RA + NG + NW 106 95 201 10 26 178 2.83 0.25 47% 5% 13% 7,107,893 FTLCP FP+GP+MP+RJ+SR 21 51 72 6 16 69 1.03 0.10 71% 8% 22% 7,008,579 TOTAL 32,153,169 236 280 516 25 97 439 1.60 0.14 54% 5% 19% 2011 TTLCP TG+JM+SP 41 58 99 5 9 84 1.36 0.12 59% 5% 9% 7,256,082 MTLCP MM + KS 39 51 90 6 20 69 1.12 0.09 57% 7% 22% 8,022,179 NTLCP Netrakona 13 18 31 2 5 22 1.39 0.10 58% 6% 16% 2,229,642 RTLCP RA + NG + NW 148 122 270 24 36 227 3.95 0.33 45% 9% 13% 6,842,875 FTLCP FP+GP+MP+RJ+SR 42 47 89 8 15 63 1.38 0.10 53% 9% 17% 6,456,938 TOTAL 30,807,716 283 296 579 45 85 465 1.88 0.15 51% 8% 15% 2012 TTLCP TG+JM+SP 41 53 94 7 19 71 1.28 0.10 56% 7% 20% 7,320,769 MTLCP MM + KS 34 37 71 2 21 53 0.87 0.07 52% 3% 30% 8,122,683 NTLCP Netrakona 11 12 23 1 3 21 1.02 0.09 52% 4% 13% 2,255,083 RTLCP RA + NG + NW 122 112 234 25 34 196 3.38 0.28 48% 11% 15% 6,920,960 FTLCP FP+GP+MP+RJ+SR 21 44 65 6 9 55 1.00 0.08 68% 9% 14% 6,495,476 TOTAL 31,114,971 229 258 487 41 86 396 1.57 0.13 53% 8% 18% 2013 TTLCP TG+JM+SP 35 43 78 3 22 78 1.06 0.11 55% 4% 28% 7,386,189 MTLCP MM + KS 42 38 80 7 16 60 0.97 0.07 48% 9% 20% 8,224,766 NTLCP Netrakona 5 16 21 1 4 18 0.92 0.08 76% 5% 19% 2,280,834 RTLCP RA + NG + NW 91 96 187 12 37 170 2.67 0.24 51% 6% 20% 7,000,045 FTLCP FP+GP+MP+RJ+SR 24 25 49 9 4 40 0.75 0.06 51% 18% 8% 6,534,388 TOTAL 31,426,222 197 218 415 32 83 366 1.32 0.12 53% 8% 20% 2014 TTLCP TG+JM+SP 29 48 77 3 12 66 1.03 0.09 62% 4% 16% 7,452,350 MTLCP MM + KS 41 43 84 8 16 62 1.01 0.07 51% 10% 19% 8,328,458 NTLCP Netrakona 7 11 18 1 4 13 0.78 0.06 61% 6% 22% 2,306,900 RTLCP RA + NG + NW 85 72 157 8 24 124 2.22 0.18 46% 5% 15% 7,080,143 FTLCP FP+GP+MP+RJ+SR 24 24 48 3 4 40 0.73 0.06 50% 6% 8% 6,573,679 TOTAL 31,741,530 186 198 384 23 60 305 1.21 0.10 52% 6% 16% 2015 TTLCP TG+JM+SP 36 39 75 2 10 59 1.00 0.08 52% 3% 13% 7,519,262 MTLCP MM + KS 41 38 79 7 9 68 0.94 0.08 48% 9% 11% 8,433,791 NTLCP Netrakona 3 10 13 1 4 11 0.56 0.05 77% 8% 31% 2,333,286 RTLCP RA + NG + NW 76 89 165 4 22 135 2.30 0.19 54% 2% 13% 7,161,268 FTLCP FP+GP+MP+RJ+SR 17 23 40 2 2 37 0.60 0.06 58% 5% 5% 6,613,354 TOTAL 32,060,961 173 199 372 16 47 310 1.16 0.10 53% 4% 13% 46 Annual Report 2015

CONSOLIDATED REPORT LEPROSY 2015 Annex Table -5 Caseholding and results of treatment, workload Annual Report 2015 47

Tangail 6 13 19 0 5 1 8 20 0.51 0.05 68 62 0 5 Jamalpur 6 14 20 0 7 6 2 22 0.84 0.09 70 14 0 30 Sherpur 24 12 36 2 7 15 3 5 17 2.59 0.12 33 42 6 8 Total project 36 39 75 2 7 27 10 15 59 1.00 0.08 52 38 3 13 MTLCP Kishoregonj 7 8 15 0 0 5 1 6 14 0.49 0.05 53 75 0 7 RTLCP 1,744,386 Rajshahi 17 39 56 0 1 25 11 10 43 2.05 0.16 70 26 0 20 FTLCP 1,179,332 Rajbari 1 2 3 0 0 3 0 0 4 0.28 0.04 67 0 0 0 CONSOLIDATED REPORT LEPROSY 2015 Evolution of casefinding and caseload NUMBERS RATES Project Districts & New cases New New New New SSS+ve UT New per Preval. per New (%) SSS+ve New New population PB MB Total child SLPB Women Disab. MB at end 100,000 pop. 10,000 pop. (%) MB among MB (%) Child. (%) Disab. 3,755,142 TTLCP 2,371,673 1,392,447 7,519,262 Mymensingh 34 30 64 7 10 30 8 15 54 1.19 0.10 47 50 11 13 5,384,141 3,049,650 Total project 41 38 79 7 10 35 9 21 68 0.94 0.08 48 55 9 11 8,433,791 NTLCP Netrakona 3 10 13 1 1 6 4 5 11 0.56 0.05 77 50 8 31 2,333,286 Naogaon 39 26 65 2 14 25 6 14 52 2.42 0.19 40 54 3 9 2,688,109 Nawabganj 20 24 44 2 2 16 5 9 40 2.52 0.23 55 38 5 11 2,728,773 Total project 76 89 165 4 17 66 22 33 135 2.30 0.19 54 37 2 13 7,161,268 Faridpur 6 3 9 0 2 3 1 0 7 0.46 0.04 33 0 0 11 1,973,392 Gopalgonj 2 3 5 0 0 4 0 0 3 0.42 0.03 60 0 0 0 1,186,673 Madaripur 1 4 5 0 0 2 1 0 5 0.42 0.04 80 0 0 20 1,082,044 Sariatpur 7 11 18 2 1 9 0 2 18 1.51 0.15 61 18 11 0 1,191,913 Total project 17 23 40 2 3 21 2 2 37 0.60 0.06 58 9 5 5 6,613,354 All project Total population 173 199 372 16 38 155 47 76 310 1.16 0.10 53 38 4 13 32,060,961 Annex Table -6 48 Annual Report 2015

Tuberculosis: Evolution of case finding and caseload Annex Table -7 Year Project Districts & All Sm+ No smear Sm- PTB Proportion population cases PTB done PTB & EP sm+ / total 2010 TTLCP TG + JM + DEPZ 6,151 4,184 0 1,967 68% 6,120,873 MTLCP MM + KS 6,906 4,344 0 2,562 63% 5,832,696 NTLCP Netrakona 2,586 1,614 0 972 62% 2,287,297 RTLCP (RA) + NG + NW 4,333 2,535 0 1,798 59% 6,954,351 FTLCP FP+GP+MP+RJ+SR 4,628 2,694 0 1,934 58% 6,930,460 TOTAL 28,125,677 24,604 15,371 0 9,233 62% 2011 TTLCP TG + JM + DEPZ 6,087 3,897 0 2,190 64% 5,947,757 MTLCP MM + KS 7,024 4,308 0 2,716 61% 5,819,899 NTLCP Netrakona 2,547 1,523 0 1,024 60% 2,229,642 RTLCP (RA) + NG + NW 4,163 2,365 0 1,798 57% 6,812,592 FTLCP FP+GP+MP+RJ+SR 4,604 2,610 0 1,994 57% 6,456,938 TOTAL 27,266,828 24,425 14,703 0 9,722 60% 2012 TTLCP TG + JM + DEPZ 6,207 4,079 0 2,128 66% 6,004,017 MTLCP MM + KS 7,025 4,450 0 2,575 63% 5,891,337 NTLCP Netrakona 2,642 1,607 0 1,035 61% 2,255,083 RTLCP (RA) + NG + NW 4,245 2,499 0 1,746 59% 6,655,569 FTLCP FP+GP+MP+RJ+SR 4,613 2,749 0 1,864 60% 6,495,476 TOTAL 27,301,482 24,732 15,384 0 9,348 62% 2013 TTLCP TG + JM + DEPZ 5,898 3,718 0 2,180 63% 6,060,941 MTLCP MM + KS 6,905 4,187 0 2,718 61% 5,963,971 NTLCP Netrakona 2,673 1,638 0 1,035 61% 2,280,834 RTLCP RA + NG + NW 4,521 2,458 0 2,063 54% 6,751,823 FTLCP FP+GP+MP+RJ+SR 4,577 2,428 0 2,149 53% 6,534,388 TOTAL 27,591,957 24,574 14,429 0 10,145 59% 2014 TTLCP TG + JM + DEPZ 6,030 3,700 0 2,330 61% 6,118,537 MTLCP MM + KS 6,995 4,044 0 2,951 58% 6,037,824 NTLCP Netrakona 2,765 1,587 0 1,178 57% 2,306,900 RTLCP RA + NG + NW 4,488 2,530 0 1,958 56% 6,801,430 FTLCP FP+GP+MP+RJ+SR 4,202 2,143 0 2,059 51% 6,573,679 TOTAL 27,838,370 24,480 14,004 0 10,476 57% 2015 TTLCP TG + JM + DEPZ 6,044 3,501 0 2,543 58% 6,176,815 MTLCP MM + KS 7,098 3,898 0 3,200 55% 6,112,926 NTLCP Netrakona 2,734 1,540 0 1,194 56% 2,333,286 RTLCP RA + NG + NW 4,658 2,358 0 2,300 51% 6,875,746 FTLCP FP+GP+MP+RJ+SR 4,204 2,045 0 2,159 49% 6,613,354 TOTAL 28,112,127 24,738 13,342 0 11,396 54% Annual Report 2015 49

Faridpur 1,973,392 489 24 6 2 5 228 400 31 1185 41% 25 60 TB case notification, 2015 District Population covered Pulm. Smearnegative New Pulmonary Smear positive cases New cases Relapses Failures R.A.DOther Extrapulmon. New P-ve & Total EP not registration New % of new pulmon.cases sm+ve Annex Table -8 Notification rate/100,000 pop. new sm+ve Gopalganj 1,186,673 326 22 9 1 13 141 215 13 740 44% 27 62 Rajbari 1,082,044 247 18 4 2 5 91 184 20 571 43% 23 53 Madaripur 1,179,332 400 18 15 2 13 150 269 18 885 45% 34 75 Sariatpur 1,191,913 392 18 7 1 6 160 217 22 823 48% 33 69 FTLCP 6,613,354 1854 100 41 8 42 770 1285 104 4204 44% 28 64 Rajshahi 2,252,371 569 25 9 0 3 186 546 29 1367 42% 25 61 RMCH 190,880 53 1 5 0 3 3 23 5 93 57% 28 49 Naogaon 2,688,109 1039 38 37 4 5 286 554 28 1991 52% 39 74 Nawabganj 1,744,386 540 10 9 3 5 244 341 55 1207 45% 31 69 RTLCP 6,875,746 2201 74 60 7 16 719 1464 117 4658 47% 32 68 Tangail 3,755,142 1744 54 25 13 40 491 860 107 3334 52% 46 89 DEPZ 50,000 84 2 0 0 4 15 55 6 166 51% 168 332 Jamalpur 2,371,673 1374 61 58 13 29 336 601 72 2544 54% 58 107 TTLCP 6,176,815 3202 117 83 26 73 842 1516 185 6044 53% 52 98 Netrakona 2,333,286 1397 68 47 1 27 429 595 170 2734 51% 60 117 Mymensingh3,063,276 1570 64 48 7 43 439 837 113 3121 50% 51 102 Kishoreganj 3,049,650 1970 79 63 4 50 809 838 164 3977 50% 65 130 MTLCP 8,446,212 4937 211 158 12 120 1677 2270 447 9832 50% 58 116 DF Bangladesh 28,112,12712194 502 342 53 251 4008 6535 853 24738 49% 43 88 Notification rate/100,000 pop. all forms of TB 50 Annual Report 2015

Treatment outcomes for new smear positive cases, 2014 cohort Annex Table -9 Treatment outcomes (%) Districts RegisteredCured CompletedDied Failed DefaultedTransferredNot Treatment treatment evaluated success (%) NETRAKONA1415 90% 1% 4% 3% 2% 0% 0% 91% TANGAIL 1719 90% 1% 4% 2% 2% 1% 0% 91% DEPZ 59 92% 2% 0% 3% 2% 2% 0% 93% JAMALPUR 1559 87% 1% 3% 3% 3% 2% 0% 88% MYMENSINGH1716 87% 3% 4% 4% 2% 1% 0% 89% KISHOREGANJ 1893 88% 1% 4% 3% 2% 1% 0% 90% NAOGAON 1046 89% 0% 5% 3% 3% 0% 0% 89% NAWABGANJ578 87% 1% 6% 3% 3% 0% 0% 88% RAJSHAHI 601 92% 0% 5% 2% 1% 0% 0% 92% RMCH 79 67% 1% 5% 16% 9% 1% 0% 68% FARIDPUR 476 93% 1% 3% 1% 2% 0% 0% 93% GOPALGANJ390 88% 1% 6% 1% 3% 1% 0% 89% MADARIPUR429 92% 0% 4% 2% 2% 0% 0% 92% RAJBARI 275 92% 0% 3% 3% 2% 0% 0% 92% SARIATPUR 404 92% 0% 5% 2% 1% 0% 0% 92% TOTAL DF 12639 88.8% 1.0% 4.1% 2.8% 2.4% 0.8% 0.0% 89.9% Treatment outcomes for re-treatment smear positive cases, 2014 cohort Annex Table -10 Treatment outcomes (%) Districts Registeredcured Completeddied failed defaultedtransferrednot treatment treatment evaluated success (%) NETRAKONA169 88% 1% 4% 1% 5% 0% 0% 89% TANGAIL 160 84% 2% 5% 1% 8% 1% 0% 86% DEPZ 6 100% 0% 0% 0% 0% 0% 0% 100% JAMALPUR 157 82% 0% 8% 3% 6% 2% 0% 82% MYMENSINGH198 85% 2% 6% 1% 5% 1% 0% 87% KISHOREGANJ 232 85% 2% 5% 3% 3% 1% 0% 88% NAOGAON 93 83% 1% 10% 1% 5% 0% 0% 84% NAWABGANJ58 86% 3% 2% 0% 7% 2% 0% 90% RAJSHAHI 44 89% 0% 7% 0% 5% 0% 0% 89% RMCH 27 89% 0% 0% 7% 4% 0% 0% 89% FARIDPUR 50 88% 0% 8% 4% 0% 0% 0% 88% GOPALGANJ30 87% 0% 3% 3% 7% 0% 0% 87% MADARIPUR21 81% 0% 0% 0% 19% 0% 0% 81% RAJBARI 28 86% 0% 4% 4% 7% 0% 0% 86% SARIATPUR 36 92% 0% 8% 0% 0% 0% 0% 92% TOTAL DF 1309 85.41% 1.30% 5.58% 1.68% 5.27% 0.76% 0.00% 86.7% Annual Report 2015 51

+1 +2 to +6 +1 +2 to +6 +1 +2 to +6 1 log >1 log +1/+2 +3/+4 +5/+6 TTLCP 6 6 42 100% 0% 0% 0% 33% 0% 36% 51% 13% 83% MTLCP 1 20 48 0% 0% 4% 2% 33% 5% 29% 65% 6% 85% NTLCP 2 10 22 0% 0% 0% 0% 0% 0% 22% 56% 22% 84% RTLCP 0 9 114 #DIV/0! 0% 0% 0% 22% 22% 22% 41% 37% 88% FTLCP 2 1 27 0% 0% 0% 0% 0% 0% 25% 75% 0% 92% DF BDESH 11 46 253 55% 0% 1% 0% 23% 5% 28% 52% 21% 87% Table: Summary resutls of External Quality Assurance by project 2015 PROJECTS Nr. Of Microscopy centres Routine smears examined (nos.)smears rechecked by EQA (nos.) EQA rechecking results Total % positive % scanty Pos. Scanty Neg. Nr. HFP slides Nr. HFN slides Nr. Of centres with at least 1 HFP Nr. Of centres with at least 1 HFN HFP% HFN% FTLCP 38 109,042 3.0% 1.0% 214 75 1967 1 5 1 3 0.35% 0.25% TTLCP 34 114,064 5.2% 1.5% 101 54 1954 1 8 1 6 0.65% 0.41% RTLCP 32 109,194 3.8% 1.1% 148 79 1834 1 6 2 2 0.44% 0.33% MTLCP 34 149,704 4.6% 1.5% 221 79 1794 1 4 1 4 0.33% 0.22% NTLCP 12 51,742 4.8% 1.6% 61 27 628 0 0 0 0 0.00% 0.00% DF Total 150 533,746 4.26% 1.31% 745 314 8177 4 23 5 15 0.54% 0.28% DAMIEN FOUNDATION BANGLADESH QUALITY CONTROL OF SKINSMEARS: 2015 Annex Table -11 Annex Table -12 Project Total smears checked in QC Rates of false results Proportions registered results Pos. Neg. False positives False negatives Quantification Pos. Neg. 52 Annual Report 2015

Damien Foundation Hospitals (Mymensingh, Jalchatra and Netrakona) Damien Foundation Bangladesh Core team From left: Dr. Dipak Kumar Biswas-Medical Coordinator, Mr. Mutakabber Hossain-Finance Director, Khondoker Habebul Arif-HR & Administrative Director, Mr. Arif Iftikhar Mannan, Project Director-RTLCP, Mrs. Joshnara Begum, Project Director-MTLCP, Mr. Bart Rombaut-Country Director, Dr. Aung Kya Jai Maug-Medical Specialist Research Training and MDR-TB, Mr. A.H.M. Akram Hossain, Project Director-FTLCP and Mr. Kabir Md. Manirul Azam Khan, Project Director-TTLCP