ANNUAL R E P O RT 2008

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1 ANNUAL REPORT 2008

2 Acknowledgments Publication, KNCV Tuberculosis Foundation 2008 Text Frank Koelewijn / Totaal Tekstproductie & Redactie, Alphen a/d Rijn, NL Final editing Iris Timmer, KNCV Tuberculosis Foundation, The Hague Translation Josh Dillon, France Design DeLeeuwOntwerper(s), The Hague Printing Marty Rengers B.V., Koudekerk a/d Rijn Graphics Frank van Leth (photos on pp. 3, 4, and 8) Marianne Havermans (photo on p. 22) Netty Kamp (photos on pp. 16, 17, 18, 19, and 25) Rob Beuse (photos on pp. 1, 4, 10, 14, 15, and 33) Roy Beusker (photo on p. 24) STOP TB Partnership (photos on cover and on pp. 2, 12 and 13) To obtain additional copies of this annual report, please contact KNCV Tuberculosis Foundation by calling +31 (0) The contents of this annual report may be reproduced in publications, provided that the source is clearly and accurately stated.

3 Who We Are and What We Do 2 Contents Partnerships 5 Management Report 6 The Netherlands 8 Worldwide 10 Africa 12 Asia 14 Eastern Europe 16 Latin America 18 Tuberculosis Coalition for Technical Assistance 20 Human Resources 21 Facilities 22 Communications and Fund-raising 23 Donors 24 Finance, Planning, & Control 25 Financial Results 26 Key to Abbreviations 32 KNCV Tuberculosis Foundation KNCV Tuberculosis Foundation s mission is to eliminate tuberculosis worldwide by developing and implementing effective control strategies. We subscribe to the worldwide goals for TB control defined by the World Health Organization (WHO): achieving a case detection rate of 70 per cent and a treatment success rate of 85 per cent. We also endorse the United Nations Millennium Development Goals to reverse the TB epidemic by We coordinate TB control in the Netherlands and work with over forty countries in Europe, Africa, Asia, and Latin America to fight tuberculosis.

4 Who We Are and What We Do KNCV Tuberculosis Foundation Royal Dutch Association for the Fight Against Tuberculosis KNCV Tuberculosis Foundation fights tuberculosis all over the world. We are a Dutch organization of deeply passionate experts and professionals, including doctors, researchers, training experts, and nurses, all specializing in TB control. Over the years, we have built up a wealth of knowledge and expertise, particularly by fighting tuberculosis successfully in the Netherlands. We share our knowledge and expertise with the rest of the world to the greatest extent possible. Tuberculosis has no borders, and, judging by the number of its victims, it is the world s second infectious disease unnecessarily so, since patients can make a full recovery thanks to relatively inexpensive treatment. We find it unacceptable that there are still thousands of people who die of tuberculosis every day. Since it was established in 1903, KNCV Tuberculosis Foundation has thus ensured that tuberculosis patients are identified at an early stage, receive treatment, and recover from the disease. And with success. In the forty-two countries in which we work, nearly 3 million patients are identified each year, of whom over 85 per cent recover. This is largely attributable to the international TB treatment method that was developed with our support. Local Support In order to reach everyone, we work with all levels from governments to health-care workers in forty-two countries in Europe, Africa, Asia, and Latin America. We aim to capitalize on the population s individual strengths and responsibility, and thus focus our efforts mainly on establishing and improving local and national TB control programs. We train local health workers, for example, in recognizing, identifying, and treating TB patients, and educate local researchers through projects for doctoral students from various project countries, among other initiatives. In this way, we ensure that the country, and thus the population, can ultimately fight tuberculosis without outside assistance. Broad Approach Beyond this, we provide a full range of services to both national TB programs and worldwide platforms for policy development. These encompass providing advice on and support of detection and treatment, an approach to fighting drug-resistant tuber culosis, managing the risk of infection, improving laboratory capacity, working with HIV/AIDS programs, policy development, professional development, and social mobilization. PAGE ANNUAL REPORT

5 Tuberculosis: The Facts Tuberculosis is a highly contagious and deadly infectious disease. The disease can occur anywhere in the body, but the commonest form is pulmonary tuberculosis. Tuberculosis is transmitted through airborne droplets of saliva from the coughs or sneezes of an infected person, for example. Symptoms in the early stages are usually coughing, fatigue, fever, and loss of appetite. If patients do not receive treatment, their condition may continue to worsen until death ultimately ensues. It is estimated that approximately one-third of the world s population carries the tuberculosis bacterium. But not everyone infected falls ill. Worldwide, 9 million people contract tuberculosis each year, over 1.5 million of whom die of the disease. Tuberculosis, along with AIDS and malaria, is one of the world s three deadliest infectious diseases. Research We also conduct scientific research. Using TB prevalence studies, we map out the TB situation and its cause in a particular country. Since the current treatment method is long-term and hard on patients, we also conduct intensive research on more effective control strategies. In addition, we work hard in the area of prevention, producing educational materials for patients and conducting preliminary studies on the efficacy of a vaccine against tuberculosis. Partnerships KNCV Tuberculosis Foundation maintains a large network, working with the World Health Organization (WHO), among others. In addition, we are a co-founder of the Stop TB Partnership, a worldwide coalition of TB control organizations. We are considered one of the world s leading players in TB control. Poverty Reduction Ultimately, it is not just the TB patient who benefits from treatment, but the entire family as well. By the same token, the danger of further infection within the community is reduced. If a mother or father dies of tuberculosis, the family often loses its breadwinner. TB control therefore represents a sustainable investment in the future. We fight not only tuberculosis, but also poverty and HIV/AIDS, and thus reinforce a country s overall health system. We also ensure that the disease does not return to the Netherlands. After all, as long as tuberculosis continues to occur throughout the world, the disease still presents a real threat to the Netherlands. It is for this reason that we must not and cannot relax our TB control efforts, not even in the Netherlands. PAGE ANNUAL REPORT

6 Transparency We attach great importance to transparency, which we take to mean actively focusing attention on information relating to our work, the Board of our organization, and the results of our expenditure, even in times of reduced funding. In addition to revenue from institutional donors, our own fundraising initiatives ensure continuity in our work, providing us with opportunities for making our own choices about allocating funds and for devoting our energy to new and existing projects for which donors have not yet been located. The Fight Goes On In the Millennium Development Goals, the United Nations has stated that the global TB epidemic must be stopped by KNCV Tuberculosis Foundation is making every effort to achieve this goal. As an ambassador for quality TB control, we continue to emphasize the seriousness of the disease and the urgency of control. After all, we know that the goal is realistic: Tuberculosis is under control in the Netherlands now there s just the rest of the world to go! STOP TB Strategy TB patients can be cured by undergoing a course of treatment that involves a combination of various antibiotics. During treatment, patients take their medication each day under strict supervision. This treatment is part of the WHO s STOP TB Strategy, recommended throughout the world, and it constitutes the most cost-effective strategy for fighting TB. The Dutch doctor Karel Styblo developed the method in the 1970s with the support of KNCV Tuberculosis Foundation. Drug-Resistant Tuberculosis Of great importance in treating tuberculosis is the fact that patients follow a strict schedule when taking their medication. Failing that, the medication will not work effectively, and drug-resistant, multidrugresistant tuberculosis (MDR-TB), or even extensively drug-resistant tuberculosis (XDR-TB) can develop. The treatment of MDR-TB requires other, more expensive drugs that have other side effects; furthermore, the course of treatment is longer. In patients with XDR-TB, the bacterium hardly responds at all to drugs. Good laboratory research is therefore crucial to the fight against MDR-TB and XDR-TB. For that reason, we are working to strengthen and expand our laboratory network in the project countries. We are also developing better, affordable tests and are providing training to laboratory staff. Tuberculosis and HIV/AIDS A major cause of the TB epidemic is HIV/ AIDS. HIV infection weakens the body s immune system. Consequently, people with a latent TB infection run a great risk of developing active tuberculosis. Conversely, tuberculosis further undermines the already compromised immune systems of those infected with HIV/AIDS. In fact, the two illnesses reinforce each other. The only solution to this is for both diseases to be treated simultaneously. Over the last few years, KNCV Tuberculosis Foundation has achieved a great deal in bolstering collaboration between local TB and HIV/ AIDS control. TB patients are tested for HIV, and if they have been infected, they are given AIDS inhibitors. Conversely, HIV patients are tested for tuberculosis. If they are infected with TB, they undergo a preventative course of treatment with isoniazid (a drug often used to treat TB). If it turns out that they have already developed tuberculosis, they undergo a complete course of treatment for TB. We also devote much energy to training new staff, and we teach health workers how to protect themselves from becoming infected with HIV. PAGE ANNUAL REPORT

7 Partnerships National RIVM/CIb The Center for Infectious Disease Control (Netherlands) of the National Institute for Public Health and the Environment plays a coordinating role in preventing and controlling infections. RIVM/ CIb partly acts as a commissioning agency in respect of KNCV Tuberculosis Foundation. Dutch Municipal Health Service (GGD en) The implementation of TB control which involves surveillance, detection, treatment, and vaccination is entrusted to the seven Municipal Health Service regions in the Netherlands. KNCV Tuberculosis Foundation supports them in these efforts. The Municipal Health Service reports its patient information to the Netherlands Tuberculosis Register (NTR), which is administered by KNCV Tuberculosis Foundation. GGD Nederland GGD Nederland is the national Municipal Health Service association in the Netherlands and as such is an important partner to KNCV Tuberculosis Foundation in establishing and maintaining quality TB control and the expertise of Municipal Health Service employees. NVALT The Netherlands Association of Physicians for Pulmonary Diseases and Tuberculosis is a member of KNCV Tuberculosis Foundation. We work closely with the association in developing new policy and creating conditions conducive to quality diagnostics and treatment. NVMM The Netherlands Society for Medical Microbiology (NVMM) is also a member of KNCV Tuberculosis Foundation. Together with the society, we work to promote and safeguard the quality of laboratory diagnostics. AMC KNCV Tuberculosis Foundation works with the Academic Medical Center of the University of Amsterdam in the field of research, education, and the supervision of PhD students. We also have partnerships with other universities. International TBCTA KNCV Tuberculosis Foundation and seven international partners have joined efforts to form the Tuberculosis Coalition for Technical Assistance, a global collaborative partnership providing support to national control programs in Africa, Latin America, and Asia. The Union The Union is our traditional partner in the fight against tuberculosis and in advocating the DOTS strategy (the WHO s Stop TB Strategy). The Union's aim is to support TB control throughout the world. Its main areas of emphasis are training and health services research. WHO KNCV Tuberculosis Foundation works closely with the World Health Organization. We take part in technical working groups at the WHO headquarters in Geneva and in all six regions. We have also made important contributions to the creation of the STOP TB strategy. STOP TB Partnership We are a co-founder of the Stop TB Partnership, a worldwide coalition of organizations devoted to achieving the WHO goals for TB control. KNCV Tuberculosis Foundation sits on the partnership board and is active in all working groups. USAID The United States Agency for International Development is the American directorate for international cooperation which supports TB control throughout the world. From 2005 through 2010, TBCTA is receiving a five-year project subsidy from USAID for the purpose of expanding and bolstering the STOP TB strategy. CIDA The Canadian International Development Agency is a Canadian development organization that provides financial support to our projects in Kenya, Tanzania, Zambia, and Angola which focus on technical assistance for national control programs. DGIS KNCV Tuberculosis Foundation has enjoyed a fruitful collaboration with the Directorate-General for International Cooperation (Netherlands) for many years. From 2006 through 2010, we are receiving a TMF Program Subsidy from DGIS in support of our international activities. LSHTM Since 2005, KNCV Tuberculosis Foundation has been working with the London School of Hygiene & Tropical Medicine in the TARGETS Research Programme Consortium. The objective of this consortium is to develop and apply tools for fighting infectious diseases. Developing and evaluating strategies for reaching poor and vulnerable groups with TB control interventions is a special area of focus. Aeras Global TB Vaccine Foundation The aim of Aeras is to develop a vaccine against tuberculosis. KNCV Tuberculosis Foundation has long worked with Aeras to establish field sites for testing this vaccine in South Africa (since 2001), Kenya (2005), Uganda (2006), and in Cambodia (from 2008). PAGE ANNUAL REPORT

8 Management Report At a global level, the TB epidemic appears to be stabilizing. KNCV Tuberculosis Foundation is making a substantial contribution to this effort. We are now active in forty-two countries and have a broader range of responsibilities and more consultants. We have also trained more health workers and researchers. In 2008, we opened an office or an agency in a number of countries and will be opening even more offices in We have successfully used our influence to make the need for intensified TB control a higher political priority. TB control in the Netherlands was positively assessed by external experts in Internally, we have focused on the ongoing professionalization of our organization. We are launching a new fund-raising campaign in 2009 which we expect to raise our public profile and generate more donations. The support we provide to international TB control increased in The number of project countries grew to forty-two, and more projects were implemented. In addition to our offices in Indonesia and Kazakhstan, we have opened offices and agencies in Nigeria, Namibia, Ethiopia, Kenya, and Botswana. We will be expanding our presence to other countries in From these offices, we can intensify our activities with local staff and develop TB programs more quickly thanks to the support of our partner USAID (the United States Agency for International Development). For the purpose of equipping the offices properly, we began creating guidelines for employment terms and conditions and ICT support in Successful Advocacy Efforts In 2008, we frequently called attention to the fact that HIV programs must address the problem of TB, for instance while taking part in the Dutch Foreign Affairs delegation to the UN in New York in June. Partly as a result of our efforts, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF) is now considering a proposal for the GF meeting in April 2009 to require HIV programs to incorporate the three I s of TB/HIV control: intensified case finding, isoniazid preventive therapy, and tuberculosis infection control for people living with HIV. Infection control was also a key objective of our program-based approach to multidrug-resistant tuberculosis (MDR-TB) in the project countries in 2008 and will continue to be in In 2008, we also emphasized the importance of the EU s assuming a proactive role with respect to TB control in Europe and along its borders. In June 2009, a meeting will be convened between the fifty-three member states of the WHO region. We welcome this development and will continue to call attention to the necessity of the EU taking the initiative, even outside its own region Training and Research In 2008, we trained more local health care workers and researchers, and are currently supervising nine PhD students from various countries in doctoral research on MDR-TB and prevalence studies. Such research is vital: Our prevalence research in Vietnam indicates that the number of TB patients is much higher there than was initially thought. There remains much work to do if we are to achieve the Millennium Goals for In 2008, the chairman of our Supervisory Board, Rob Beuse, accompanied our consultant for Vietnam on a mission. He was very impressed with our work, noting in his travel report that an effective TB consultant is not only an experienced, competent physician, but also a skilled, empathic communicator. KNCV Tuberculosis Foundation is extremely successful at combining these two elements knowledge and communication. International Evaluations An international team assessed Dutch TB control positively in Its recommendations have been integrated in the plan for From left to right: Ms. G.T.M. Schippers, Finance and Organization Director, and Prof. M.W. Borgdorff, Executive Director

9 eliminating tuberculosis which our National Unit, together with the Center for Infectious Disease Control (Netherlands) and other national TB control organizations, drew up in We received our third visit from the Internationale Adviesraad [International Advisory Council] in Their advice is helping us to improve our plans and working methods. In 2009, we will be enlisting the council s aid in developing our new strategic plans for A Fund-raising Boost A new head was appointed to the Communications and Fund-raising (C&F) Unit on January 1, 2008, which gave a boost to our fund-raising efforts. Preparations for introducing a new fundraising brand were made in The launch is scheduled for March 24, 2009 on World TB Day. As a result, we hope to bring the issue of tuberculosis to the fore again and obviously to revitalize giving among private individuals. The effects of the financial crisis are not yet clear. We are still assured funding from current contracts in 2009 and But it is still unknown whether institutional donors TB control funding policies will change. In 2008, we began drawing up an inventory of required funding and possible scenarios so that we will be ready to submit proposals for donor contributions at the end of Organizational Developments Our director Martien Borgdorff left the organization on January 1, 2009, after having been appointed head of a research department at the Academic Medical Center (AMC). We would like to thank him for the work he has done for KNCV Tuberculosis Foundation and wish him every success in his new position. Peter Gondrie is the organization's newly appointed director and will assume this position on May 1th, We have further developed our organizationwide monitoring and evaluation (M&E) system, aimed at continually improving the organization. An initial report was recently published which we will be including in the new strategic and unit plans in The growth of the organization s international activities, the number of foreign offices, and the number of staff led to our developing organizational modifications for the International and the Finance, Planning, & Control units in 2008 which we will introduce starting in Our new ICT policy plan was completed in April 2008 and is currently being implemented. In 2009, we will be replacing much of our ICT equipment. Additionally, working conditions of employees abroad have been the focus of much attention, and an International HR Handbook is being prepared. Lastly, we were once again awarded the Central Bureau on Fund-raising s (CBF) seal of approval in More information on the management structure, the application of the Good Governance Code for members of the Association of Fund-raising Organizations, the detailed financial annual report, and detailed information on countries can be found at Management Structure KNCV Tuberculosis Foundation is an association. It has a two-member Executive Board charged with day-to-day management and assisted in this respect by the management team. A sevenmember Supervisory Board assesses the performance of the Board and the organization. The Supervisory and Executive Boards are both accountable to the highest association body, the General Membership Meeting, to which the Supervisory Board reports on matters concerning its supervisory duties and the Executive Board on management. The operational structure of the organization is composed of units representing the organization s core activities on the one hand and the facilitating part of the organization on the other. The core activities are carried out by the - National Unit, - International Unit, - Africa Unit, - Research Unit, - Communications and Fund-raising Unit, - Data Management Unit, and - TBCTA Unit (Project Management Unit for the USAID project). A facilitating role is played by the - Finance, Planning, & Control Unit, - Facilities Unit, and - Executive Support Unit, including HR. PAGE ANNUAL REPORT

10 What We Do in The Netherlands As in 2007, the number of TB patients in the Netherlands remained under 1,000 in 2008, necessitating a reassessment of control policy. KNCV Tuberculosis Foundation is firmly committed to eradicating tuberculosis in the Netherlands but does realize that there is still a long way to go to achieve this goal. For this reason, we established a new TB control plan for in We also published the Handbook for TB Control in the Netherlands and the new Tuberculosis HIV Guidelines. TB Control Highly Successful In April 2008, a team of international TB experts evaluated TB control in the Netherlands, judging the quality of Dutch TB control to be excellent. Their recommendations focused mainly on improving cooperation between KNCV Tuberculosis Foundation and the Center for Infectious Disease Control, on better laboratory diagnostics, and on a further integration of TB and HIV/AIDS control. Work on the last issue is currently under way (see Guidelines ). For the most part, the recommendations have been incorporated into the new TB control plan for On the Road to Elimination It is expected that, by around 2015, the Netherlands will have approximately 800 TB patients per year. In light of this development, we formulated our new TB control plan, entitled Op weg naar eliminatie [ On the Road to Elimination ] in The plan ensures a series of measures for maintaining adequate TB control in the Netherlands from These measures consist of - technical and concrete improvements (e.g., intensified TB case finding among risk PAGE ANNUAL REPORT

11 groups, a shortening of the course of treatment for latent TB infection), - organizational improvements. (e.g., accelerating the regionalization of TB control by the Municipal Health Service, designating a TB coordinator at every hospital; strengthening the laboratory function by introducing a layered structure for TB diagnostics on the basis of safety and quality requirements), and - improvements in the TB control parameters. This mainly involves the cooperation between KNCV Tuberculosis Foundation and CIb. Discussions about a reallocation of duties and responsibilities were initiated in TB Control Handbook In 2008, KNCV Tuberculosis Foundation published the Handbook for TB Control in the Netherlands, intended for all professionals who deal with tuberculosis and TB patients from Municipal Health Service staff to individuals working with the homeless. The handbook contains all applicable legislation, guidelines, procedures, and working practices for TB control. Allart Vis presented to his GP with chest and back pain and constant fatigue. I was 33 and working very hard at the time, often abroad. I had felt ill for months but just didn t have time to go to the doctor. I thought I was on the verge of burnout. But it turned out to be drug-resistant tuberculosis. Allart did not immediately realize how serious the illness was: I was just relieved it wasn t cancer. I had become a father only three weeks before, so I was afraid I d infected my baby girl. But it soon became clear that I wasn t yet contagious. The treatment lasted two years and was very hard on me. The pills made me tired, and the pain in my legs was unbearable. But Allart made a full recovery. The good that s come from this is that I see life differently now. I work less hard, am more physically active, and eat a healthier diet. That means a great deal to me. Tuberculosis HIV Guidelines The Committee for Practical Tuberculosis Control (CPT) developed the new Tuberculosis HIV guidelines in 2008 for the purpose of contributing to improved prevention, diagnosis, and treatment of HIV patients with TB and TB patients with an HIV infection. The CPT recommends that newly identified HIV patients should be offered a tuberculin skin test as standard practice and that newly identified TB patients should always be tested for HIV. The guidelines are based on the principle of evidence-based guidelines development. The various scientific associations and partnerships active in the areas of TB and HIV/AIDS control have validated the guidelines. Research in the Netherlands We concluded various studies in The results of the study Immigranten en hun reisgedrag [ Immigrants and Their Travel Behavior ], which examined the origins of TB among immigrants, will be made available in Our predictive study of immigrants who have (or have had) contact with infectious TB patients shows that the new blood tests (IGRA) are no more effective in predicting which people will develop TB than regular tuberculin skin tests are. Because the TB risk among the immigrants examined appeared considerably high, we think it advisable to test immigrants for both active tuberculosis (X-ray) and a latent tuberculosis infection (tuberculin skin test or blood test). In 2009, we will be assessing whether we should modify our current TB guidelines in this respect. A new study on the predictive value of the IGRA blood test was begun in 2008 involving 1,500 immigrants who since having entered the Netherlands have been called on by the Municipal Health Service to undergo the required screening for active tuberculosis. A Learning Organization KNCV Tuberculosis Foundation aspires to be a learning organization. As part of Human Resource Development (HRD), we thus worked hard to improve knowledge management in We want HRD staff to learn from their experiences so that they will continually be improving themselves and their professional skills. In pursuance of this vision, the HRD Department has also given its support to the introduction of the monitoring and evaluation system aimed at improving our entire organization. This work will be continued in Tuberculosis in the Netherlands In January 2009, according to provisional data, 957 patients were entered in the Netherlands Tuberculosis Register in Approximately one in seven TB cases is the result of a recent transmission within the Netherlands. The remaining cases are traceable to infections in the past or were imported from other countries with a high incidence of tuberculosis. Groups in the Netherlands with a relatively high incidence of tuberculosis are individuals who are in contact with TB patients, individuals from sub-saharan Africa, asylum seekers, those infected with HIV, the homeless, and drug addicts. The Municipal Health Service is investigating the incidence of tuberculosis within these so-called risk groups. In 2000, nearly one in four TB cases (23 per cent) was identified at an early stage thanks to such active case finding, thus preventing the risk of new infections. PAGE ANNUAL REPORT

12 KNCV Tuberculosis Foundation is active in forty-two countries throughout the world. In 2008, a total of 3, 287, 425 TB patients were identified an estimated 54 per cent of all new patients with an infectious form of tuberculosis. Of them, 85 per cent have been cured. What We Do Worldwide At a global level, the TB epidemic appears to be stabilizing. Treatment results of TB patients are good: The World Health Organization s (WHO) worldwide goal of an 85 per cent cure rate was reached by a wide margin in A point of concern, however, is that the increase in the number of patients identified is leveling off. In 2008, an increase of 2 per cent was observed. In particular, big countries with a high level of tuberculosis, like India and China, are underperforming. There is a good chance that the WHO s global goal of a 70 per cent detection rate will not be achieved in the coming years. Even the Millennium Goals in 2015 are in danger. More Active Case Detection The international TB control community is worried about the inadequate detection of tuberculosis patients worldwide. For that reason, we will be looking to identify even more actively TB patients in risk groups such as HIV patients, prisoners, drug users, and the homeless. We are intensifying our collaborative efforts with private medical care in public-private partnerships (PPPs). TB care must be institutionalized in the general health care system: Doctors must routinely ask the patients in their hospitals or clinics if they have a cough and provide them with a TB test if necessary. We are also intensifying our social mobilization efforts and will be providing still more information on tuberculosis. Tuberculosis and HIV/AIDS The problems of TB/HIV represent an obstacle to effective TB control. Consequently, we tested many TB patients for HIV in 2008 and offered them AIDS inhibitors where necessary. In Tanzania, Kenya, and Zambia, 80 per cent of TB patients are tested. The combined treatment of tuberculosis and HIV/AIDS has been further developed. The new approach PAGE ANNUAL REPORT

13 includes intensified case finding among HIV patients, the prescription of the drug isoniazid to HIV patients with a latent tuberculosis infection, and improved control of TB infection risk. We try to differentiate as much as possible between HIV and TB patients. Hospitals are adapting their facilities with this in view and are providing patients and staff with better protection against infection. We are supporting them in these efforts. In 2008, we distributed demonstration kits and provided infection control courses not just to senior staff but also to architects building hospitals, for instance. We are continuing these initiatives in We are also defining infection control guidelines. Together with our technical partners, we presented the new internationally agreed approach also known as the three I s (intensified case finding, isoniazid preventive therapy, and tuberculosis infection control) at the United Nations General Assembly Special Session on HIV and AIDS (UNGASS) in June Drug-Resistant Tuberculosis Multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis represent a threat to quality TB control. Good lab diagnostics are required for effective detection and patient treatment. In 2008, we thus successfully worked toward improving the capacity and quality of the laboratories in our project countries. We are launching a project for strengthening national reference laboratories in 2009 to provide ongoing improvement of lab diagnostics. We hope to open a center of excellence in East Africa for diagnosing and treating MDR-TB, a center that will set the benchmark standard in the region. The program-based approach adopted in the fight against MDR-TB in Indonesia made great progress in 2008, partly as a result of our efforts to improve the quality of laboratories. We also provided training on MDR-TB detection. In China, Kazakhstan, Vietnam, Kenya, and Namibia, we also launched a program-based approach to fighting MDR-TB. A large-scale conference on the approach to fighting MDR-TB in countries in Asia, Eastern Europe, and the former Soviet Union is scheduled to take place in Beijing in April Public-Private Partnerships We encourage national tuberculosis control programs (NTPs), as well as private clinics and local hospitals, to work more closely with public-private partnerships (PPPs). In this way, we make TB care more accessible to the local population and can detect and treat more TB patients. This approach has been very successful in Indonesia for years, and we extended it to Mexico, Nigeria, Cambodia, and the Philippines in As a member of the Stop TB Partnership PPP working group, we contributed to writing the PPP guidelines. PPP training initiatives have been scheduled in various Asian countries in Capacity Building To improve local research capacity, we are enabling nine PhD students to do doctoral research in areas including MDR-TB and to carry out prevalence studies. The students (three of whom are from Vietnam, two from South Africa, and the remaining four from Bangladesh, Kenya, China, and Uganda) are all active in TB control in their own countries. In our project, they are working to become senior researchers so that they can carry out research themselves in their home countries in order to improve TB control there. Human Resource Development (HRD) The annual platform meeting for HRD employees active in international TB control was held in The Hague in June Also in The Hague, we gave a five-day training course for HRD consultants in 2008, during which twenty participants from various developing countries were able to gain further proficiency in international consultancy and HRD in TB organizations with the aim that, in the long term, they will be able to work as independent HRD consultants. They first go on a mentored field visit as junior consultants accompanied by a supervisor. We carried out three such visits in Also in 2008, we continued to provide support to the regional training centers in Indonesia, Nigeria, and Georgia which currently organize international TB training courses in their regions, or will be doing so in the coming years. Because of the conflict in Georgia, the project there has unfortunately been delayed, but everything is going according to plan in Indonesia and Nigeria. KNCV Tuberculosis Foundation provides support for the development of training curricula and instruction for trainers. We also give organizational advice on how to develop a well-functioning, financially sound organization. A key component of this advice is a communications policy: How does one raise the profile of an organization with an international outlook which provides quality training of which countries in the region will want to avail themselves? We will be continuing to provide this kind of support in PAGE ANNUAL REPORT

14 KNCV Tuberculosis Foundation is active in twenty-two African countries: Angola, Benin, Botswana, Egypt, Ethiopia, Gambia, Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, Namibia, Nigeria, Uganda (Research Unit only), Rwanda, Sierra Leone, Sudan, Swaziland, Tanzania, Zambia, and South Africa. In 2008, a total of 1,060,382 TB patients were identified in the twenty-one countries supported by the International Unit. Of them, 75 per cent have been cured. What We Do in Africa KNCV Tuberculosis Foundation carries out the majority of its activities in Africa. Tuberculosis is a major problem here, but we are achieving more and more success in the fight against the disease. In 2008, the integrated control of dual TB/HIV infections was given a powerful boost. We also intensified the control of multidrug-resistant tuberculosis (MDR-TB) to reduce the threat of extensively drug-resistant tuberculosis (XDR-TB). As part of Human Resource Development (HRD), we support countries in formulating strategic plans and train health workers. We also conduct epidemiological research. Kenya Achieves Goals In Africa, the number of tuberculosis patients identified has decreased for the very first time. Yet that doesn t mean they aren t there. For this reason, we plan to intensify our detection efforts. In Tanzania, we started with individuals presenting with a chronic cough in prisons and elsewhere. The results were immediate: A demonstrably higher number of TB patients were identified. Further, we developed strategies in each project country for controlling MDR-TB to prevent the spread of XDR-TB. An application for MDR-TB drugs from the Green Light Committee (GLC) for Namibia and Tanzania has been granted. With Swaziland now a project country, we are active in all of eastern and southern Africa. The good news is that in 2008, Kenya was the very first African country to achieve the global WHO goals of 70 per cent detection and 85 per cent recovery. Because of this success and our long involvement in Kenya, Kenya s national control program was awarded the KNCV Tuberculosis Foundation Award for Eminence in Tuberculosis Control (Styblo medal). The award was presented during the thirty-ninth Union World Conference on Lung Health in Paris. PAGE ANNUAL REPORT

15 Our Offices We are delighted to have been able to open five offices in Namibia, Nigeria, Botswana, and Ethiopia under the flag of TB CAP (Tuberculosis Control Assistance Program) in We opened our own office in Kenya, which is run by a former employee of the Kenyan and Malawian NTP. From this office, we are working with the Kenya Association for the Prevention of Tuberculosis and Lung Disease (KAPTLD), a non-governmental organization. The KAPTLD provides administrative support, manages KNCV Tuberculosis Foundation funds in Kenya, and oversees a public-private partnership (PPP) project in Kenya. We are currently providing technical assistance but will eventually be turning over that component to the KAPTLD. Strategic HRD Plans We support NTPs in ten African countries in the area of HRD. The support we provide particularly involves formulating and implementing staffing plans, and promoting health workers development through training, supervision, and coaching in the workplace. This is possible only if HRD has been made a main priority on the relevant NTP s political agenda. In 2008, we were able to start formulating HRD plans in Kenya, Tanzania, Malawi, and South Africa. As it is important for NTPs to have an insight into staff make-up and development, we have provided training courses on HRM information systems and are helping Nigeria, Malawi, and Tanzania to develop and introduce their own HRM information system. We have trained local HRD staff in Kenya, South Africa, and Tanzania for TB control work. Workload Research We have carried out a pilot study in Zambia on the TB control workload. The research protocol and required gauges are now ready. We will be carrying out the study in Tanzania in 2009, and interest has also been expressed in Kenya. The effective recording and reporting of patient data are essential not only for individual patients but also for acquiring a clear understanding of the overall TB situation in a particular country. For this reason, we developed an instrument in 2008 which assesses the strengths and weaknesses of health care workers when entering data in the register and which reveals where improvements can be made. Major Incidence Study In 2008, we prepared a study on the incidence (the annual number of new cases) of tuberculosis among children in Kenya and Uganda. We are starting to screen 2,000 to 7,000 newborns and adolescents in We will be employing both active and passive detection methods, as active detection has proved more effective in identifying many more patients. Within the context of our partnership with the Aeras Global TB Vaccine Foundation, we have written a research protocol for a field study in Mozambique on the efficacy of a new vaccine that will be available in several years time. In Tanzania, we studied patient preferences for the provision of drugs during TB treatment. Daily hospital visits put quite a strain on patients, most of whom would rather take their medication at home, preferably under the supervision of a spouse or family member. We are carrying out a pilot project to evaluate whether this is feasible. KAP study in Angola As part of Advocacy, Communication, and Social Mobilization (ACSM), we have carried out our first Knowledge, Attitude, and Practice (KAP) study in Angola. By assessing people s knowledge of tuberculosis and using that to create local strategies for developing health information, we intend to effect the greatest behavioral change possible with respect to tuberculosis. Interviews with members of various population groups show that people understand that tuberculosis is dangerous but that many do not know what the symptoms are. If clinics fail to establish a diagnosis after one or two consultations, many seek to relieve their symptoms in the informal or traditional sector. The challenge now is to ensure that we detect tuberculosis at an early stage by providing better educational information and health care. PAGE ANNUAL REPORT

16 KNCV Tuberculosis Foundation is active in ten Asian countries: Afghanistan, Bangladesh, Cambodia, China, the Philippines, Indonesia, Iran, Nepal, Pakistan, and Vietnam. In 2008, a total of 1,871,373 TB patients were identified in the eight countries supported by the International Unit. Of them, 92 per cent have been cured. What We Do in Asia Tuberculosis claims the majority of its victims in Asia. Multidrug-resistant tuberculosis (MDR-TB) and dual TB/HIV infections are on the rise. The positive trend observed in 2007 decreased somewhat in 2008: The detection of TB patients in China hardly increased at all, and Indonesia even dropped below a detection rate of 70 per cent. Nevertheless, the national control programs (NTPs) are still making progress. With the aid of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF), we are launching a project in the Philippines in Vietnam and Cambodia are also performing well. In addition, we are delighted about our new projects in Pakistan and Iran. China: TB Care for the Poor We have been continuing work on our World Bank project in China, the aim of which is to help TB care also reach the poor, of major importance in meeting the Millennium Goals in As success continues to be limited, we will be teaming up with a number of Chinese universities in 2009 to examine whether we can improve the identification of TB patients among the poorer population groups by involving the insurance system in TB control in rural areas. The international TB control community has high expectations for the project. The Philippines: Numerous Activities In the Philippines, we supported external evaluations of the NTP in a general sense with special emphasis on Human Resource Development (HRD) and in the area of public-private partnership (PPP). The latter project was financed by USAID (the United States Agency for International Development). We will be continuing to provide support in We also conducted a mission to ascertain the quality of the data collected for GF, which awarded this project to KNCV Tuberculosis Foundation a great result! PAGE ANNUAL REPORT

17 Indonesia: Goal Not Reached Unfortunately, Indonesia failed to achieve the WHO goal of 70 per cent detection in 2008 because the GF temporarily suspended its aid in Fortunately, aid has resumed and a new project proposal accepted. With the support of USAID, we have drawn up a new five-year strategic plan. We were also able to appoint an interim country representative, an individual with a great deal of management experience. In 2009, we are initiating MDR-TB treatment throughout the country. For this purpose, we are providing a technical coordinator and forty local staff members with training and the necessary tools. Supervision in Cambodia and Vietnam In 2008, we trained Cambodian NTP staff in analyzing data for the recording and reporting (R&R) system. Our HRD consultant also provided a training course in supervision. In a country like Cambodia, quality supervision is difficult, as employees see it as an inspection rather than as a way to learn from their mistakes. The HRD training course teaches employees and supervisors alike to work on supervision in an open, constructive environment. An HRD follow-up course has been scheduled for The NTP in Vietnam analyzed all TB training courses and curricula for staff in We are supporting the NTP in developing a system to assess and further improve the effectiveness of these courses. During the supervision of doctors, nurses, and laboratory technicians, an evaluation is made as to whether they are applying what they have learned in the courses in a practical setting. If this is not the case, they are coached on the job or given further training. With the support of USAID, we have also launched a project in Vietnam for improving lab infrastructure, equipment, and capacity, as well as the quality of laboratory staff. In addition, we have examined whether it was possible to identify TB patients according to the level of exhaled nitric oxide, which occurs in TB patients in higher than normal concentrations. Our breath test was meant to determine whether the difference was great enough for a reliable test. This proved not to be the case an unfortunate outcome, as it would have been a fast, inexpensive test for use in prevalence studies. New Project Countries In 2008, Pakistan and Iran were added to the project countries in which we are active. Thanks to the support of USAID, we provided training courses, supervision, and lab support, and have begun preparations for a prevalence study. We also supported an evaluation mission there. We are opening our own office in 2009 and will be recruiting local staff, crucial for a successful partnership with the NTP. In Iran, we carried out an exploratory mission, entered into a partnership agreement with the National Research Institute for Tuberculosis and Lung Disease (NRITLD), and gave training courses in TB/HIV cooperation. In 2009, we will be overseeing various health services research projects and providing regional training courses in health services research. We also carried out an exploratory mission in Afghanistan in Starting in 2009, we will be focusing on infection control and staff training and coaching as part of a USAID and TB CAP (Tuberculosis Control Assistance Program) project. New Test for Resistance In June 2008, the Strategic and Technical Advisory Group for Tuberculosis (STAG-TB) granted its approval of a new test for measuring resistance to isoniazid and rifampicin, two important TB drugs. What makes this test so special is that the results are available the next day, a process that used to take two months! It is a molecular test that shows genome mutations in the tuberculosis bacillus which are different for each country. That is why the test also has to be evaluated separately for all countries. We are currently working on testing and validation for Vietnam and Indonesia, and are examining whether the faster diagnosis leads to better treatment results. The results will be available in Expectations are high: If the test proves to be widely applicable, it will have an enormous impact on the control and treatment of MDR-TB. PAGE ANNUAL REPORT

18 KNCV Tuberculosis Foundation is active in eight countries in Eastern Europe and Central Asia: Armenia, Georgia, Kazakhstan, Moldavia, Ukraine, Romania, Russia, and Tajikistan. In 2008, a total of 331,151 TB patients were identified. Of them, 68 per cent have been cured. What We Do in Eastern Europe and Central Asia Health care in Eastern Europe and the former Soviet republic is still functionally inadequate. As a result, the incidence of dual TB/HIV infections, multidrug-resistant tuberculosis (MDR-TB), and extensively drug-resistant tuberculosis (XDR- TB) continues to rise. This situation represents such a threat to Europe that in 2007 the decision was taken at a high political level to turn the tide. We deeply regret that this letter of intent did not lead to a shared strategy to fight tuberculosis in It thus remains to be seen whether Europe will succeed in achieving the WHO goals for Berlin Follow-up An initial follow-up to the European Ministerial Forum held in Berlin on October 22, 2007, dominated the 2008 Wolfheze Conference. During the conference, it emerged that the European Partnership for TB control was no longer viable. The affiliated countries and organizations are no longer able to free up sufficient funds to keep the Partnership going. This is a regrettable outcome, as it eliminates the possibility of cross-coordinating the TB control plans presented by the countries at the conference. Although the plans are of excellent quality, in the absence of a shared approach to TB control, Europe will not reach the Millennium Goals in 2015 the very purpose of the European Ministerial Forum. One glimmer of hope is that a committee is to be set up in 2009 to replace the European Partnership. Regional Office for Central Asia Our office in Kazakhstan was assigned a regional function for Central Asia in From this office, we support the national tuberculosis programs (NTPs) in Kazakhstan, Tajikistan, and Turkmenistan. PAGE ANNUAL REPORT

19 A large number of projects are currently under way. In order to oversee these properly, we will be expanding the staff employed by this office in In Kazakhstan, we have pursued TB control in prisons. This has been so successful that the government has asked us to support the NTP as well, an initiative that we have now undertaken. In 2009, we are initiating a project for detecting and treating MDR- TB, paired with a project for improving the laboratories. In Tajikistan, too, we supported TB control in prisons at the request of Caritas Luxembourg. Our donor organization USAID (the United States Agency for International Development) is undertaking MDR-TB control and social support initiatives in the five Central Asian countries. Our plan for this has been approved and starts in We are working with the AIDS Foundation East West (AFEW) on tuberculosis and HIV control in prisons. To improve detection within the project, we will be adopting a more active approach to risk groups in At a conference in Kazakhstan, we were able to present our experience in TB control in prisons to important players in the region. Various countries expressed an interest in potential partnerships. Activities Suspended in Georgia During the first six months of 2008, we enthusiastically began preparations for the regional training center in Georgia which is supposed to organize international TB training courses in the region. In an implementation plan, we set out the mission of the center, the target groups and training needs, and suitable courses, and created a financial framework for all of this. Unfortunately, we were unable to carry out the implementation plan, owing to the conflict that broke out between Russia and Georgia in August. The political situation has forced us to suspend all our activities in the country, but we hope to resume them in Warsaw Training Course Well Attended Our annual Warsaw Training Course in management for TB control organizations in Eastern Europe was again a great success in This course is primarily intended to teach skills necessary for organizing and managing an NTP. In practical terms, however, the medical and technical side of TB control has proved to be a special focus for participants. We are trying to adapt this to a more management-oriented approach, but this is a long-term process. In 2009, the course will be moved to Latvia, as the work visits in Poland do not give the participants a good overview of well-organized TB control according to WHO guidelines. Successful Roma Project Thanks to a donation from Achmea, we were able to initiate a three-year project among the Roma population in two Romanian districts in The Roma have a strictly organized community with their own values and standards, which require a special approach. By promoting greater knowledge of tuberculosis, we are trying to involve the Roma actively in TB control with the aim of identifying and treating more and more patients at an early stage. We provide training to health care intermediaries and female leaders within the Roma community, and train schoolchildren to act as health promoters within the family unit and in their surroundings. Eighty people were trained in A system for recording and reporting was also set up. The project is intended to be a model for other districts and Roma communities in Romania and surrounding countries. PAGE ANNUAL REPORT

20 KNCV Tuberculosis Foundation is active in five Latin American countries: Cuba, the Dominican Republic, Mexico, Peru, and Suriname. In 2008, a total of 24,519 TB patients were identified (excluding Peru). Of them, 80 per cent have been cured. What We Do in Latin America The identification and treatment of TB patients in Latin America have not yet achieved the World Health Organization s global goals, but various countries are making great progress. KNCV Tuberculosis Foundation pursued its activities in Cuba, Mexico, and the Dominican Republic in In Peru, we carried out a mission for the first time in years with the aim of evaluating the implementation and control of multidrug-resistant tuberculosis (MDR-TB). As a member of the regional technical advisory group for Latin America, we take part in the regional TB meeting each year. The Threat of MDR-TB At 77 per cent, TB treatment results in Latin America are very disappointing. One reason is that many TB patients still do not finish their course of treatment. This increases the chances of MDR-TB, detected in 2.4 per cent of all new TB patients. According to the WHO, the TB epidemic is taken too lightly at the political level and is believed to be under control. Nothing could be further from the truth, however. For this reason, we plan to further intensify our efforts in the area of Advocacy, Communication, and Social Mobilization (ACSM) in the project countries over the coming years. MDR-TB Treatment off to a Good Start We provided support to the control program (NTP) of the Dominican Republic in 2008, and MDR-TB treatment got off to a flying start. Following an external evaluation, the Green Light Committee (GLC), a supplier of MDR- TB drugs, has held up the NTP as an example of an organization that has succeeded in developing a plan and implementing it in a short time. We will be expanding this joint approach with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GF) in PAGE ANNUAL REPORT

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