Control and Prevention of Tuberculosis (CAP-TB)

Summary Report 

Control and 

Prevention of 

Tuberculosis 

(CAP-TB) 

October 2012 to 

September 2015 

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

1

Overview 

Background 

TB/ MDR-TB Risk Groups 

MMP: migrant and mobile population 

ps 

PLHIV: people living with HIV 

population 

DM: diabetes mellitus 

NTION IV AND EDUCATION CAP-TB Elderly: > 65 years old Model 

cess 

Infection control 

ity mobilization 

control 

f trainers and physician mentoring 

The U.S. Agency for International Development Control and Prevention- 

Tuberculosis (USAID CAP-TB) project has been funded in Myanmar from 

October 2011 through December 2015. The overall goal of the CAP-TB 

project is to develop a model for multi-drug resistant tuberculosis (MDR-TB) 

control and prevention in the Greater Mekong Sub-region (GMS) of Myanmar, 

China, and Thailand, with impact on incidence and mortality from MDR-TB in 

these countries. The CAP-TB model is a patient-centered, community-driven 

approach to strengthen health systems with the overall goal to impact MDR- 

TB control and prevention. 

PREVENTION AND EDUCATION 

DOTS success 

PREVENTION AND EDUCATION Community mobilization 

DOTS success 


Community mobilization 

Training of trainers and physician mentoring 





DM: diabetes mellitus 

Elderly: > 65 years old 

TREATMENT SUCCESS 

DOTS success 

Directly observed therapy (DOT) 

Community-based DOT 

RISK GROUPS 

MMP, PLHIV, 

Patient education DIAGNOSIS Infection control 

DM, Elderly 




ENT SUCCESS DM: diabetes mellitus 

served therapy (DOT) Elderly: > 65 years old 

ty-based DOT 

RISK GROUPS 

Living Support PackageChest X-rays 

DIAGNOSIS MMP, PLHIV, 

ucation 

Early case detection 

DM, Elderly 

port Package 

Chest X-rays 

Build TB lab capacity 



GeneXpert 

Microbiology studies 

TREATMENT SUCCESS 

GeneXpert 

Directly observed therapy (DOT) 


Community-based DOT 

TREATMENT SUCCESS Patient education 

Directly observed therapy Living (DOT) Support Package 

Community-based DOT TREATMENT INITIATION 

RISK GROUPS 

Patient education Second-line drug availability MMP, PLHIV, 

TREATMENT INITIATION 

DM, Elderly 

Second-line drug availability 

MDR-TB treatment guideline 

Package of services 

Living Support Package 





Chest X-rays 




GeneXpert 



DOTS success 




DIAGNOSIS 

RISK GROUPS 

MMP, PLHIV, 

DM, Elderly 

DIAGNOSIS 

Chest X-rays 



GeneXpert 


DIAGNOSIS 

Chest X-rays 



GeneXpert 


Existing Services 

Strengthened Services TREATMENT INITIATIONAdded Services 


Strengthened Services 

Added Services 


TREATMENT INITIATION 






Existing Services 

Strengthened Services 


The cornerstone of the project is the development of mobilization to support patients was done using 

a Existing comprehensive Services prevention to care model Strengthened for MDR- Services both standard and Added innovative Servicesmethods: by engaging 

TB, based on the foundational building blocks for 

tuberculosis (TB) control. 

Effective MDR-TB control is a challenge for TB 

platforms and health systems, as evidenced by the 

large diagnosis and treatment gaps reported from 

global data. Despite progress since 2009, fewer 

than 41% of estimated MDR-TB cases worldwide 

were diagnosed in 2014, and the global success 

rate remains at 50%. Starting in 2012, the CAP-TB 

project developed a model for MDR-TB control using 

a “patient-centered” perspective to identify gaps in 

the health system. The CAP-TB model starts with 

finding presumptive TB and MDR-TB patients in the 

community; linking presumptive patients with the 

national TB system for early diagnosis and initiation 

of treatment; and supporting those diagnosed 

throughout their 20-24 month regimen. Community 

community volunteers and outreach workers to 

provide support and accountability through a bundle 

of patient-support interventions; as well as through 

technology and innovation, introducing Myanmar’s 

first mobile health application for TB control. CAP- 

TB’s implementation has been led by FHI 360, 

working in close partnership with local implementing 

agencies as well as with the Myanmar National 

Tuberculosis Program (NTP). The Myanmar Medical 

Association (MMA), the Myanmar Health Assistant 

Association (MHAA), Pyi Gyi Khin, and the Myanmar 

Business Coalition on AID (MBCA) successfully 

implemented the CAP-TB model in Yangon, Mandalay, 

and Monywa over the course of the project’s lifetime. 

This report summarizes highlights from the USAID 

CAP-TB project over the three primary years of 

implementation. 

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

Partners 

Myanmar Medical 

Association (MMA) 

As the largest academic body of general practitioners (GP) in Myanmar, the 

MMA CAP-TB team focused on improving screening and case finding of 

MDR-TB patients through strengthening referral linkages between private 

and public sectors. MMA developed a training curriculum for programmatic 

management of drug-resistant tuberculosis (PMDT) to GPs (private medical 

doctors) in accordance with national guidelines working with the NTP. The 

trainings were then conducted in high priority MDR-TB townships in close 

collaboration with the NTP. 

The MMA CAP-TB team also piloted the country’s first community volunteers 

to provide directly observed therapy (DOT) for MDR-TB patients. These 

community volunteers were also trained to provide health education and basic 

counselling services not only to the patients but also to the family members 

in pilot townships. This community DOT model is currently being scaled up by 

The Three Millennium Development Goals Multi-Donor Trust Fund (of which 

USAID is also one of seven donors). Technology integration was also piloted 

through “DOTsync”, an m-Health application with case management features, 

the first m-Health application for TB in Myanmar. 

Pyi Gyi Khin (PGK) and 

Myanmar Health Assistant 

Association (MHAA) 

PGK is a local community-based organization which was 

originally founded to work with the HIV population using selfhelp 

groups and networks. This background among people 

living with HIV was an asset for the CAP-TB project in reaching 

its target populations as the PGK CAP-TB team worked among 

PLHIV networks, conducting health education sessions and 

referring presumptive TB cases to Yangon township health 

centers. 

MHAA contributed its strengths in coordination with 

government counterparts and proven strong experiences 

in field implementation. MHAA’s strengths in community 

outreach also contributed to the CAP-TB strategy for providing 

comprehensive home-based care (infection control, side 

effect monitoring and household contract tracing). This 

comprehensive package was designed to ensure continuity of 

care for MDR-TB patients, with the overall goal to maximize 

treatment success. 

Myanmar 

Business 

Coalition on 

AID (MBCA) 

Under the CAP-TB project, MBCA utilized its existing strengths 

in engagement with the business sector to advocate for 

workplace policies on TB. In the Monywa industrial zone and 

businesses, MBCA conducted health education sessions and 

recruited volunteers with the goal to improve case finding. 

These volunteers were trained as ‘TB Champions’ to serve as 

focal points within their workplace for referring presumptive TB 

patients and other TB related services. 


3

Timeline 

FY12 

FY13 

FY14 

FY15 

January 2013 

March 2013 

May 2013 

June 2013 

August 2013 

March 2014 

October 2014 

November 2014 

April 2015 

Community based activities 

Launched 3 phases of Organizational Capacity Development: Technical and 

Organizational Capacity Assessment Tool (TOCAT) 

Launched package of support and community based activities 

Launched TB Champions for workplace 

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

Launched Community based MDR-TB DOT by community volunteers 

Installed solar panel to power GeneXpert machine 

Launched Cover Your Cough Campaign 

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

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

Initiated CAP-TB model scale up 

Geographic coverage 

Yangon Region 

Mandalay Region 

Sagaing Region 

11 townships in Yangon region 

7 townships in Mandalay region 

2 townships in Sagaing region 


Project Implementation 

Community 

engagement 

Increasing early case detection through community engagement, especially 

close contacts of MDR-TB patients and other high risk groups as defined by 

the CAP-TB strategy. 

Individuals Referred 

Sputum Positivity Rate 

Sputum testing done 

Sputum smear positive Positive 

Starting from March 2013, CAP-TB implementing agencies conducted community outreach in project 

townships by providing health education and disseminating information on TB symptoms, diagnosis, 

treatment and available health services. A broad range of activities and strategies were implemented 

including one-on-one counseling, with an emphasis on promoting communication from the community. 

Health education events were also popular, where field staff disseminated information on TB diagnosis and 

treatment services available at township health centers. 

Referral Cascade 

Presumptive cases referred 

Access to diagnosis centers 

Sputum microscopy done 

Diagnosed as TB (All Form) 

Female 

Male 

CAP-TB’s trained outreach workers strengthened linkages between families, communities and the TB teams 

at the township level by coordination among township health centers. This strengthened referral linkages 

between communities and health service providers. 

Population Categories for Presumptive Patients Referred for Diagnosis 

The patient-centered approach for MDR-TB care and prevention improved the efficiency of referral services 

and sputum positivity rates, focusing on those at risk for TB and MDR-TB. 


5

Living Support 

Packages 

Nutrition and 

Transportation 

Package 

Outreach workers and trained community members delivered CAP-TB’s 

“living support package”, comprising a monthly supply of nutrition, 

transportation support to ensure clinic follow-up and monthly home 

visits. Home visits were done to counsel patients on treatment, check on 

infection control and provide accountability and support to ensure treatment 

completion and cure. 

CAP-TB living support package: Gender ratios for three funding years. 

FY13 

223 

43% 

296 

57% 

FY14 

241 

39% 

373 

61% 

FY15 

106 

39% 

169 

61% 

Infection control: 

Accommodation 

pilot during 

intensive phase 

MDR-TB treatment 

In early FY 14, the CAP-TB FHI 360 team gathered the project’s 

implementers to brainstorm on infection control interventions during the 

intensive phase of MDR-TB treatment. The team decided on eligible criteria 

for patients to receive accommodation as well as monitoring, with the goal 

to provide temporary shelter for infectious MDR-TB patients during the 

intensive phase of their treatment. With recommendation from respective 

NTP personnel and township medical officers, 49 MDR-TB patients (from 13 

project townships) were provided with rented accommodation or housing 

renovation in order to meet the needs of infection control standards. 


CAP-TB Myanmar: 

A Patient-Centered, Community-Driven Model for MDR-TB 

Community 

driven solution: 

Directly observed 

Treatment (DOT) by 

community health 

workers 

LOWER MYANMAR MEDICAL CENTER & 

AUNG SAN TB HOSPITAL 

Regional centers for outpatient and inpatient TB 

and MDR-TB care. Oversee diagnosis and treatment 

for largest number of patients in the country 

In FY13, the Myanmar Medical 

Association (MMA), collaborated 

closely with the National TB 

Program and basic health staff to 

pilot community-DOT for MDR-TB 

patients. This model later expanded 

to 12 townships through CAP-TB’s 

3 Implementing agencies, MMA, 

MHAA, and PGK. 

Community volunteers were 

recruited from existing community 

networks in the focus townships. 

They worked alongside basic health 

staff to conduct daily home visits to 

MDR-TB patients for evening DOT, 

providing psychosocial support and 

health education to patients and 

family members. 

These were the country’s first 

community volunteers to provide 

DOT for MDR-TB patients, and the 

community-driven DOT model was 

recognized by the international 

sector for its potential for scale-up. 

The NTP also valued the potential of 

this model to support rapid scaleup 

of PMDT through expansion 

to other project townships. With 

support from the Three Millennium 

Development Goal (3MDG) Fund, the 

CAP-TB model has now been scaled 

up to 43 townships in Yangon. 

TOWNSHIP HEALTH CENTER 

Township Medical Officers and Basic Health Staff 

oversee treatment once patients are at home. 

Strengthening capacity at the township level is a 

top priority for decentralization so that patients 

can get care close to home 

COMMUNITY & HOME 

Comprehensive package of 

support: home visits, 

infection control, 

psychosocial support, 

DOTsync mobile app 

PATIENT 

HOME 


7

Innovation and 

Technology 

Solar-powered 

Gene Xpert 

machine 

The NTP recognized the underutilization of Gene Xpert machines installed 

at MDR-TB treatment centers where access to the electrical grid and voltage 

stability were major concerns. To provide a solution to this problem, CAP-TB 

procured the country’s first solar powered system for the Gene Xpert machines 

at Yangon’s Lower Myanmar TB Center. The solar panel provides stable, 

continuous power enabling uninterrupted analysis of sputum for MDR-TB. 

This helped to pave the way for the NTP to scale up solar-powered Gene 

Xpert machines in district level and more remote facilities, improving access to 

diagnosis in unreached areas of the country. 

DOTsync: 

Integration of 

Mobile Technology 

in MDR-TB 

response 

The community volunteers trained by MMA to provide DOT for MDR-TB patients 

were equipped with smartphones that run a powerful data collection and patient 

tracking application. “DOTsync” was built using Dimagi’s CommCare, an opensource 

platform, bringing the fight against dangerous TB strains into the mobile 

technology era. Compared to pre-DOTsync, the identification of presumptive TB/ 

MDR-TB cases was more efficient, with a higher sputum positivity rate. 

• After launching DOTsync in select townships, the number of people reached 

for health education increased by 40% (from 324 to 452). 

• At the start of DOTsync, 29 presumptive TB/MDR-TB cases had sputum 

tested of which 28% were smear positive. 

• After DOTsync, 39 of 65 (60%) presumptive cases had sputum tested with a 

smear positivity rate of 33%. 

DOT provision was monitored through daily data uploads, enabling timely 

follow-up for missed doses and quality control for community volunteers. Data 

on treatment outcomes for 30 MDR-TB patients supported with DOTsync are 

promising, with a treatment success rate of 93%. 


7 Days Daily 

NO:1234 /11:12:2014 

NO:1234 / 1:12:2014 

Public transportation 

Bus stop 

Used to promote public awareness for following good 

cough etiquette when using public transportation. 

Community engagement 

? 

? 

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

Stickers 

posted inside the 

public buses and 

taxis in Yangon 

Posters 

posted in the waiting 

areas at highway bus 

terminals 

T-shirts 

distributed to 

transportation workers 

Public quiz shows 

at selected hot spots 

49 at markets 

96 events 

34 at bus stops 

5 at highway bus terminals 

2 at railway stations 

4 at other public places 

Mass media 

Radio 

Health talk in collaboration with national 

TB program through City FM & Mandalay 

FM radio stations with live feedback 

during popular spots on the air. 

Social media 

Cover your 

cough Facebook 

Television 

Skynet health TV channel: 

broadcasted campaign launching 

ceremony and field activities 

CONTEST 

Celebration of the campaign achievements including awards 

to winners of social media contests and contributors. 

THE 

THE 

7 Days Daily 

NEWS 

NEWS 

Printed media 

A big 

community event 

Tools: over 7,000 IEC materials distributed 

Campaign activities posted in 5 popular journals and 

newspapers (7 Days Daily, Daily Eleven newspaper, Health 

Digest Journal, The street view journal, Myanmar Post Global 

News journal) in Myanmar 

Like & share 

photo contest 

Total likes: 5,539 for FB page 

a simple 

message with 

life-saving impact 

when you cough, 

cover your mouth 

and nose using 

a cloth, tissue 

paper, or mask. 

Social and mass media for 

effective communication: 

Cough campaign 

Leading up to World TB Day 2014, the CAP-TB “Cover 

your Cough” campaign used creative social and mass 

media to reach patients, families, and communities on 

simple methods to reduce TB and MDR-TB transmission. 

Through effective partnership with Myanmar’s top hip 

hop celebrity, publicizing over the airwaves on FM radio 

stations, and working with event organizers and different 

stakeholders, CAP-TB conducted public quiz shows at 

selected hot spots on TB and infection control-related 

health messages. Radio listeners’ live feedback through 

the FM radio station was also solicited during popular 

spots on the air. Thousands of stickers with photos of 

the campaign’s celebrity spokesperson demonstrating 

good cough etiquette were posted on hundreds of buses 

and taxis on the crowded roads of Yangon. Many of 

these methods were innovative and to our knowledge, 

some had never been done in the country before— 

demonstrating the impact of social and mass media 

communication to teach a simple, life-saving message. 


9

Building technical 

capacity for 

Programmatic 

Management of 

Drug-resistant 

Tuberculosis 

(PMDT) 

The NTP’s plan for PMDT covered 22 townships in 2011, 38 townships 

in 2012, 53 townships in 2013, 68 townships in 2014 and 108 

townships in 2015. To strengthen the human resource capacity for 

PMDT, CAP-TB supported “Training of Trainers” for clinicians from 

the public sector in 2012. The training curriculum was in line with the 

NTP PMDT training guidelines and approved by the NTP. Trainers and 

facilitators were drawn from NTP, WHO, FHI 360 and MSF-Holland 

(the only organization which supports MDR-TB management outside 

the NTP). Along with the expansion of MDR-TB treatment townships, 2 

PMDT trainings were conducted in Yangon and Mandalay during 2014, 

with participation from clinicians in expanded townships. 

In addition to MDR-TB treatment training, CAP-TB addressed the gap 

of case finding from the private sector through MMA’s trainings for 

280 general practitioners (179 men and 101 women) from 18 PMDT 

townships (Figure, left, showing townships and approximate number 

of participants). This was done in collaboration with the MMA Public- 

Private Mix project with the objective of strengthening referral linkages 

between private and public sectors. 

Given the high priority focus on children as a risk group for TB, CAP- 

TB supported the National Workshop on Childhood TB Management 

organized by the NTP in August 2013. Professor Stephen Graham from 

the University of Melbourne carried out field visits and reviewed the 

NTP guidelines on childhood TB management. A total of 75 participants 

from the country (3 chest physicians, 41 pediatricians, 19 staff from 

the NTP, 4 from WHO and 8 from NGOs) drafted an action plan with 

recommendations resulting from the group discussion. 

In October 2012, TB REACH training laid the groundwork for the CAP-TB- supported training strategy. This 

training covered the standard diagnosis of TB and the chest X-ray recording and reporting system (CRRS). 

Clinicians from the government and private sectors were targeted to build capacity in clinical reporting 

of chest radiographs to identify TB. These trainings were conducted in Mandalay and Yangon by the NTP 

and the Union, with support from CAP-TB. Attendees included a total of 57 clinicians (26 In Mandalay and 

31 in Yangon) including public sector township medical officers and NTP TB Team leaders from 22 project 

townships as well as private sector general practitioners (32 Public and 25 Private). 


Evidence based planning and 

implementation 

Community survey 

on health seeking/ 

purchasing 

behavior for TB 

diagnosis and 

treatment 

In March 2013, during the initial phase of designing CAP-TB’s patient-centered, 

community-driven model, the project launched the “TB Trends” survey within 

target communities to clarify health seeking/purchasing behavior for diagnosis 

and treatment of TB. Communities were also asked where they purchased 

their medication, to better understand access to quality assured TB drugs. The 

CAP-TB team trained field staff to conduct this module in the community. Data 

were collected over one month from March 25 to April 26, 2014 and a total of 

1,022 beneficiaries (410 MBCA, 410 MHAA and 202 PGK) in Yangon, Mandalay, 

and Monywa completed the survey. Results from this survey helped the CAP- 

TB team to design strategies for patient support. 

Money is a barrier for seeking care 

Time traveled to nearest health facility 

Treatment outcomes and cost-effectiveness analysis for the CAP-TB model 

Avg Cost per Patient 

by Group 

Description 

(Group #) 

Treatment Success 

Rate (%) † 

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

Total # of 

Patients 

$ 223.11 Minimal support (Home visit only (1)) 38.5% 329 26 

$ 846.52 Home visit +Pkg of Support (2) 85.4% 510 485 

$ 1,902.30 Home visit +DOT (3) 85.7% 110 14 

$ 2,508.78 Home visit +Pkg of Support + DOT (4) 92.6% 34 94 

Total # of Patients 

with Treatment 

Outcome 

The CAP-TB project developed a patient-centered, community-driven model for MDR-TB support that was 

designed to be a scalable, sustainable, and cost-effective approach for patient support. From April 2013 

through September 2015, the CAP-TB team supported 983 patients for the full duration or a portion of their 

20-24 month long MDR-TB treatment. The main CAP-TB intervention was the monthly “package of support” 

comprising home visits (counseling, infection control, contact referrals); food, and transportation allowance: 

510 patients received this monthly package of support, of whom 485 have completed treatment to date, 

with 85.3% treatment success. The highest level of intervention (Group 4) comprised the monthly package of 

support with the addition of daily, evening DOT by community volunteers: 110 patients received this level of 

support, of whom 94 have completed treatment, with 92.6% treatment success. The “minimal support” group 

(usual care with intermittent home visits) had a total of 329 patients of whom 26 have completed treatment, 

with 38.5% treatment success. These results are still preliminary as most patients in this group are currently 

on treatment and their outcomes will be available in mid-2016. Thus, the results cannot be fully interpreted at 

this time for the minimal support group. The CAP-TB team thanks the Myanmar NTP for the strong support 

throughout the project’s implementation, as well as the USAID Burma Mission for funding this work. 


11

Control and Prevention of Tuberculosis (CAP-TB)

Create successful ePaper yourself

Delete template?

Save as template?