Met in dit nummer: Geef om Soraya. Succes in Indonesië. Nalaten. Stop Wereld Tuberculosedag. Tbc-bestrijding in het buitenland YEAR

Transcription

1 Met in dit nummer: Geef om Soraya Succes in Indonesië Nalaten Stop Wereld Tuberculosedag Tbc-bestrijding in het buitenland YEAR

2 Colophon Publication KNCV Tuberculosis Foundation, 2007 Tekst Frank Koelewijn / Totaal Tekstproductie & Redactie, Alphen a/d Rijn Translation Frans Kooymans, Maarn Final editing Iris Timmer, KNCV Tuberculosis Foundation, The Hague Design DeLeeuwDesigner(s), The Hague Printing Marty Rengers, B.V. Koudekerk a/d Rijn Illustrations STOP TB Partnership KNCV Tuberculosis Foundation Esther Kop (photo s on cover and page 3) Suzanne Verver (photo s on pages 8 and 9) Els Adams (photo on page 10) Sjon van Veen (photo s on pages 11 and 22) Adriaan Backer (photo s on page 12) Netty Kamp (photo s on pages 14 and 15) Cover photo Basic health worker in Gambia. Copies of this Annual Report are available upon request from KNCV Tuberculosis Foundation by calling international tel. no The contents of this Annual Report may be reproduced in publications provided that the source is clearly and accurately stated.

3 Contents Who we are and what we do 2 Report by the Board 4 The Netherlands 6 Africa 8 Asia 10 Eastern Europe 12 Latin America 14 Tuberculosis Coalition for Technical Assistance 16 Alliances 17 Personnel and Organization 18 Facilities Services 19 Communication and Fundraising 20 Donors 21 Finance Planning and Control 22 Financial Results 23 List of Abbreviations 29 Tuberculosis: The Facts Tuberculose is an infectious disease that is caused by the tuberculosis bacterium (Mycobacterium tuberculosis). Only people with active untreated pulmonary tuberculosis can infect others, via coughing or sneezing. The most common symptoms in the early stage are coughing, fatigue, fever, and loss of appetite. If the tuberculosis is not treated, the patient can become increasingly ill and even die. The tuberculin skin test indicates whether a person has been infected with the bacterium after contact with an infectious patient. It is estimated that one third of the world s population carries the tuberculosis bacterium. However, not everyone who is infected actually develops the disease. The total number of patients is approximately nine million a year. The number of fatalities is over one and a half million a year.

4 Who we are and what we do Royal Netherlands Tuberculosis Association (KNCV) KNCV Tuberculosis Foundation is an international development organization of dedicated professionals, including physicians, public health nurses, and researchers. For 103 years now we have put our heart and soul into the fight against TB. During those years we have built up extensive knowledge and expertise, especially through our successful fight against TB in the Netherlands. We see it as our mission to share this knowledge and expertise with other countries. Our work has meanwhile extended to 35 countries in Europe, Africa, Latin America, and Asia. All of our activities are aimed at effectively fighting tuberculosis. In 2006 alone we were able to reach 2.5 million patients, with a recovery rate of 85%. Unfortunately we still do not reach everyone who needs us. Unnecessary suffering Each year over one and a half million people die of tuberculosis: that is one every 18 seconds. This is totally unnecessary, for with early screening and the right treatment every patient can fully recover. What do we do about this? KNCV Tuberculosis Foundation helps countries to organize the fight against TB and to incorporate it in their medical systems. Our basic requirement is that each country takes its own responsibility. We share our knowledge and expertise, so that the people affected get the right knowledge, medicines, and human resources. After all, the fight against TB involves human effort, both now and in the future. Since we want to reach everyone, even in the remotest corners of a country, we collaborate with the responsible government agencies. We cover a wide range and always tailor our work to the specific situation. In short, we advocate continuing improvement of the fight against TB and call for worldwide attention to this disease. To be able to do our work well, we need the financial contributions and support of our donors, benefactors, and partners. Mission The mission of KNCV Tuberculosis Foundation is to eliminate TB worldwide through the development and implementation of effective strategies to fight the disease. We commit ourselves to the objectives set by WHO, tracing 70% of victims and healing 85% of these, followed by the Millenium development objective of the United Nations to eliminate the TB epidemic by We coordinate the fight against TB in the Netherlands and work with 35 countries in Eastern Europe, Africa, Asia, and Latin America in fighting tuberculosis. The activities of KNCV Tuberculosis Foundation focus on five closely related operating areas: policy development technical assistance and program support research human resource development advocacy, communication, and social mobilization, plus fundraising Policy development KNCV Tuberculosis Foundation contributes to both national and international policy development, often in cooperation with the STOP TB Partnership, WHO and The Union (formerly IUATLD, the International Union Against Tuberculosis and Lung Disease). We advise national governments about control strategies, advocating the STOP TB strategy. We also facilitate or participate in national and international forums for policy development. Technical assistance and program support KNCV Tuberculosis Foundation offers technical assistance and program support to partner countries in nearly all aspects of the fight against TB, from planning, evaluation, and budgeting to laboratory research and drugs management. In addition we offer practical support in the development of plans, guidelines, and funding proposals. Lastly we provide financial support, making this an all-round support package. Research KNCV Tuberculosis Foundation seeks to enhance the fight against TB worldwide PAGE 2 ANNUAL 2006

5 Treatment strategy The STOP TB treatment strategy of the World Health Organization (WHO) is the most cost-effective strategy to reduce tuberculosis. It requires the patient to take the right combination of medicines under continuous supervision. That is a precondition for successful treatment, which takes a minimum of six months. Nearly all patients treated this way are cured. This method was developed in the 1970s by Karel Styblo, a Dutch physician, with the support of KNCV Tuberculosis Foundation. The patient who sticks to the therapy by promoting knowledge about the transmission of tuberculosis and insight into the course of the disease and into the effectiveness of intervention measures. We do this by setting up research projects and by training local researchers in conducting operational and epidemiological research. We also help countries in setting up surveillance systems for multidrug resistant TB and TB/HIV. Human Resource Development KNCV Tuberculosis Foundation supports partner countries in the acquisition of specialized knowledge on how to combat TB. We hire Human Resource Development (HRD) experts, organize seminars and workshops, develop training modules, and establish training centers worldwide to spread our knowledge and expertise. We also support the development and implementation of long-term plans for HRD. Advocacy, communication, and social mobilization, plus fundraising As ambassador for effectiveness in the fight against TB, KNCV Tuberculosis Foundation stresses the urgency of the approach taken in the global TB situation in its contacts with politicians, the media, and the general public. We receive a major part of the funding for our worldwide activities from the Dutch community. We help our partner countries also in getting access to funding sources and support them in the field of advocacy, communication, and social mobilization. PAGE 3 ANNUAL 2006

6 Report by the Board 2006 was an important year in terms of developments in the fight against tuberculosis. The number of cases in the Netherlands again dropped. This raises the prospect of total elimination of TB in this country in the foreseeable future. On the international scene there are also positive signs. The number of identified patients worldwide grew to 5 million. In Africa there are finally signs of success in halting the dual TB/HIV epidemic. Our Public Private Partnership project in Indonesia is particularly successful. Worrisome, however, is the rise of extensively drug-resistant tuberculosis (XDR-TB) in South Africa and Eastern Europe. Keeping this dangerous form of tuberculosis under control is one of the main challenges for International recognition The successes of KNCV Tuberculosis Foundation in 2006 have not gone unnoticed. During the annual meeting of The Union (formerly IUATLD, the International Union Against Tuberculosis and Lung Disease) there was specific mention of the progress made in Africa in the fight against TB and HIV and of the cooperation between the national programs for tuberculosis and HIV/AIDS, which was realized to a significant extent through innovative programs supported by KNCV Tuberculosis Foundation. Our project in Indonesia, aimed at stimulating PPP, also got very positive reactions from our international partners. Altogether, 2.5 million patients were identified in the program countries of KNCV Tuberculosis Foundation, which is 200,000 more than the year before. Treatment results were received from over 1.2 million infected patients. Their rate of cure was 85%. In the field of research there was international recognition for the importance that we attach to measurement of the Millennium objectives. Until now only models were available, but in 2006 several countries actually started to measure progress through population studies. WHO started in 2006 with the development of guidelines for this. These will be published in Conferences and plans The fight against TB in Eastern Europe still leaves much to be desired, due to the high percentage of multi-drug resistant tuberculosis (MDR-TB) and now also XDR- TB. In 2006 KNCV Tuberculosis Foundation presented itself as an advocate of more effective control in the region. We organized a meeting at Clingendael Institute to gain attention for this threat among politicians, policymakers and partnering organizations in the Netherlands. In the fall of 2007 a ministerial conference will be held in Berlin, to be attended by the responsible European and Central Asian ministers, donor organizations, and organizations active in fighting TB. KNCV Tuberculosis Foundation supports WHO in organizing this conference. Another milestone in 2006 was the publication of the Global Plan to Stop TB by the Stop TB Partnership. This plan to combat tuberculosis in the years until 2015 reflects the current worldwide consensus about the need of a successful approach to control the disease. A positive aspect of the plan is that it formulates sharply defined goals for the fight against TB that link up with the Millennium objectives. For KNCV Tuberculosis Foundation, the Global Plan represents the strategy that we intend to follow in our technical support. Elimination of TB in the Netherlands In 2006 there were 1,036 TB patients in the Netherlands, 121 less than in This decline has led TB doctors to ask: should we not aim for total elimination of tuberculosis in the Netherlands? Elimination is certainly to be desired but requires careful planning. After all, a decline in Prof.Dr. M.W. Borgdorff, Executive Director and Ms. G.T.M. Schippers, Director of Finance and Organization PAGE 4 ANNUAL 2006

7 the number of patients presents the risk that TB doctors get to see fewer such patients, and that in the long term can lead to a drop in quality unless the expertise is kept up. KNCV Tuberculosis Foundation is organizing a symposium in 2007 to discuss this issue with its national partners, to come up with a plan for elimination, and to identify the operational bottlenecks and risks. Operations In the fall of 2005 the Fundraising Institutions Association (VFI) enacted the Good Governance Code for organizations that advocate good causes, also called the Wijffels Code. For KNCV Tuberculosis Foundation that was reason to prepare a derivative code: Management and Supervision at KNCV Tuberculosis Foundation Applying the Good Governance Code. We implemented significant changes in We introduced a new system for financial accounting and time recording and installed a new network environment. In the field of Personnel & Organization (P&O) we set the basis for a new social policy by specifically identifying what KNCV Tuberculosis Foundation is and aims to be as an employer and what the organization expects from its employees. This policy will be worked out in further detail in P&O will also work on a revision of employment terms. KNCV Tuberculosis Foundation currently falls under the collective labor agreement for home care, but this agreement no longer meets the characteristics and needs of our current organization, which partly focuses on the international setting. The intention is to develop our own employment terms. In our communications we have repeatedly called for attention to the urgency of the TB problem. A highlight was the Saskia Project in the context of the Rembrandt Year, with an exposition of outsider art in the Old Church in Amsterdam. Rembrandt lost his wife Saskia to tuberculosis. More information about the governance structure and application of the Code of Good Governance for members of the Fundraising Institutions Association, the detailed financial accounts, and country information can be found on the foundation s website at or requested by telephone. Governance structure KNCV Tuberculosis Foundation is an association. Its day-to-day management is conducted by the Executive Board, which is assisted by the management team. The operations conducted by the Executive Board and the organization are reviewed by a seven-member Supervisory Board. This in turn reports to the general members meeting, which is the ultimate association body, on its supervisory activities, while the Executive Board reports on the operating activities. The operations are divided into units. These represent the core activities and facilitating services of the organization. The core activities include the following units: National, International, Research, Project Management, and Data Management. The facilitating units include Finance Planning and Control, Communication and Fundraising, Facilities, and Personnel and Organization, all of which report to the Executive Support Unit. PAGE 5 ANNUAL 2006

8 What we do in... The Netherlands The number of TB patients in the Netherlands dropped again in 2006, provisionally to 1,036. This calls for reassessment of policy for the fight against TB. KNCV Tuberculosis Foundation aims at elimination of tuberculosis in the Netherlands but recognizes the need to keep the knowledge about the disease at a proper level. We bundle and distribute knowledge, support the control efforts, and contribute to the quality of specialized educational programs. We collaborate with Municipal Health Services and maintain the nationwide patient database in the Netherlands Tuberculosis Register (NTR). Plan for elimination of tuberculosis The steady decline of tuberculosis is proof of the success of the fight against TB in the Netherlands. The downside of this is that the level of knowledge about tuberculosis is at risk, as are the efficiency and cost-effectiveness of the control efforts. For that reason we started in 2006 with the project Plan for elimination of tuberculosis in the Netherlands. As part of this project we are developing, along with our partners, a strategy for the future of TB control in the Netherlands. We are organizing a symposium to be held on 1 June 2007, which is to culminate in a number of related underlying plans aimed at eliminating tuberculosis in the Netherlands. New CPT guidelines The Committee for Practical Tuberculosis Control (CPT), which represents all TB professionals in the Netherlands, produces guidelines and protocols for TB control and advises about policy. For immigrants a lung X-ray photo is made upon entry into the country. This is repeated every six months during two years. Following years of research, KNCV Tuberculosis Foundation PAGE 6 ANNUAL 2006

9 PA R K S T R A AT J D D E N H A A G P O S T B U S CC DEN HAAG TELEFOON (070) FAX (070) I N F K N C V T B C. N L W W W. K N C V T B C. N L RICHTLIJN Behandeling Latente Tuberculose Infectie (LTBI) Commissie voor Praktische Tuberculosebestrijding Tuberculosis in the Netherlands The number of patients in 2006 can only be established with certainty sometime in 2007 but is provisionally set at 1,023. That means an incidence of 6.3 per 100,000 inhabitants. That is about 12 percent lower than in 2005 when tuberculosis was diagnosed among 1,157 patients. Of these, 66 percent were born outside the Netherlands; 16 percent of all patients stay shorter than two years in the Netherlands. The number of patients has dropped steadily since 2001, especially due to the declining number of new asylum seekers. As far as we know, 85 percent of patients completed their treatment in and the Municipal Health Services proved in 2006 that this follow-up screening is often unnecessary. The screening instruction has therefore been amended. Starting in 2007 only immigrants from countries that have more than 200 TB patients per 100,000 inhabitants (formerly 50 per 100,000) are still subjected to follow-up screening. The number of X-ray photos by the Municipal Health Services will therefore drop from 155,000 to 125,000. This is more cost-effective and prevents unnecessary radiation. We have also drafted the LTBI guideline, an evidence-based guideline for treatment of latent TB infections. This treatment can prevent a person from actually contracting tuberculosis after being infected. This risk is greater for people with low resistance, such as those infected by HIV or suffering from rheumatism, who use immunity inhibitors. A standard treatment with isoniazid (INH, a tuberculosis medicine) lasts six months, but for risk groups the guidelines prescribe treatment during nine months. In 2007 we hope to introduce a multidisciplinary guideline for the discovery and treatment of patients who are infected by TB as well as HIV. Since the treatment results of tuberculosis among prison inmates in the Netherlands failed to meet the 85% norm, we introduced the Tuberculosis in Prisons protocol in October 2006 together with the Custodial Institutions Service (DJI). This contains guidelines for effective treatment, but also for better collaboration between the parties involved. KNCV Tuberculosis Foundation will assist DJI in 2007 in implementing the protocol. Research Day On 9 June 2006, KNCV Tuberculosis Foundation organized the Research Day for Tuberculosis Control The participants included the Municipal Health Services, the Center for the Fight against Infectious Diseases (CIb), Leiden University Medical Center (LUMC), Academic Medical Center (AMC), and Radboud Hospital. This was the first time that so many participants in the fight against TB in the Netherlands came together to prepare a national agenda for future operational and epidemiological research. Two workshops produced a top ten of research activities, such as in the fields of new diagnostics, treatment, cost-effectiveness, DNA fingerprinting, contact research, and screening. Considering the positive response, plans are underway to hold such a research day again in Paula Hermans Seven years ago Paula Hermans caught a bad cold. It refused to go away. She described it as follows: The lung doctor noted an infection between my ribs and prescribed antibiotics. But it didn t help. When I finally ended up in the hospital, it turned out that I had open TB. I didn t even know what it was! Paula got six months of medicine treatment. She recovered, but her right lung was affected. That was a bad period. Fortunately my husband supported me, and my five kids were taken care of. I ve been lucky, since medicines and good care are within easy reach. In Africa and Asia that is not the case. Many mothers there die of tuberculosis, and their children stay behind all by themselves! PAGE 7 ANNUAL 2006

10 KNCV Tuberculosis Foundation is active in seventeen African countries: Angola, Benin, Egypt, Eritrea, Gambia, Ghana, Kenya, Lesotho, Malawi, Mali, Mozambique, Namibia, Nigeria, South Africa, Tanzania, Uganda, and Zambia. In 2006 a total of 856,614 TB patients were identified, of whom 74 percent have been cured. What we do in... Africa Africa is the continent where most of our activities take place. In particular the integrated fight against the dual infection of TB/HIV has our attention. In 2006 we made significant progress in this area. But a new danger is lurking: the discovery of extensive drug-resistant tuberculosis (XDR-TB) has demonstrated once more that the battle against TB in Africa requires improvement on many fronts. We will continue to commit ourselves to this in Successful approach to TB and HIV In our fight against the dual infection of TB and HIV in Africa we were able to book substantial progress in The collaboration between National Tuberculosis Programs (NTPs) and the HIV/AIDS programs has clearly improved in all of our project countries, owing also to the guidelines of the World Health Organization and the incorporation of new indicators in the current monitoring system to measure this collaboration. In Kenya, Zambia, Malawi, and Tanzania we can now offer nearly all TB patients an HIV test due to the simplified diagnostics. In Kenya 60 percent of all TB patients were tested for HIV in Fifty-three percent of them turned out to be HIV positive, especially many repeat patients, noncontagious patients, and women. Nearly 85 percent of these patients have started with preventive treatment against opportunist infectious diseases. Despite these successes still only 20 percent of all HIV positive TB patients have direct access to antiretroviral medicines. The PAGE 8 ANNUAL 2006

11 challenge for 2007 is to provide such medicines to every patient. Also, the routine screening of HIV positive persons for tuberculosis has to get off the ground. We want to achieve this, for example, by stimulating the process of decentralization of the now centrally organized HIV/AIDS care to smaller clinics, thus bringing it closer to the patient. For it is the small local health clinics where the fight against tuberculosis and HIV/AIDS is properly integrated. New threat: XDR-TB In 2006 some 50 patients with multidrug resistant tuberculosis (MDR-TB) in South Africa were identified to have an extensively drug-resistant form of tuberculosis (XDR-TB). This bacillus is not only resistant against at least two of the common anti-tb medicines but also against two types of anti-mdr-tb medicines. The rise of XDR- TB on various continents corresponds with the overall quality of the fight against TB in a particular country. If the DOTS program (DOTS: Directly Observed Treatment, Short-course, the STOP TB treatment strategy of WHO) does not function well, then the chance of MDR-TB and XDR-TB is that much higher. In 2007 we will conduct MDR-TB surveys in various countries to identify the scope of the resistance problem. We are also helping with the setup of MDR/ XDR-TB treatment programs and with applications for related financial support from the Global Fund. Since MDR/XDR-TB is also a threat to healthcare workers, international guidelines have been prepared in 2006 for the prevention of infections. We have contributed to this in a significant way. Strategic Human Resource Development plan We expanded our Human Resource Development (HRD) activities in Africa further in A focus area in this regard is cooperation in the area of tuberculosis and HIV. In Malawi we provided assistance to the establishment of a five-year strategic HRD plan that was presented in March 2007 as part of the five-year strategic TB elimination plan. It contains descriptions of the tasks and responsibilities of healthcare workers for tuberculosis and HIV/AIDS-related tasks. The intent of the plan is still higher performance on the part of healthcare workers, better cooperation between the programs, and improved incorporation of the fight against TB in the overall healthcare system. In 2006 TB workers in local health centers were trained in TB management. In Nigeria we organized a workshop for the NTP, the HIV/AIDS program, and the TB coordinators in the various states. Subjects covered included task responsibility, supervision, work environment, safety requirements, and infection risks. In Gambia we provided support to the development of a new curriculum for nurses in training, to ensure that they gain the necessary knowledge and skills about tuberculosis during their training. This coming year our support will focus more on the HRD staff in the TB program. In April 2007 we organized a regional workshop to work on an HRD plan by country. There will also be an e-platform so that HRD staff members can interact with each other and submit questions to colleagues in other countries, HRD specialists of KNCV Tuberculosis Foundation, and other international partners. Prevalence survey in Eritrea In 2006 we were also active in African research. In Eritrea we rounded off our study into the prevalence of tuberculosis. This study, conducted among 38,000 persons, provided evidence that the prevalence of infectious tuberculosis in Eritrea is much lower than was assumed on the basis of WHO estimates. This also means that the detection rate in Eritrea is much higher than as calculated by WHO. In 2007 KNCV Tuberculosis Foundation will conduct the same prevalence survey in Tanzania. In Kenya we are holding a tuberculin survey. This involves determining the extent of TB transmission in the population via a tuberculin skin test among 90,000 children. This study will be completed in We are also involved in Kenya in the setup of a vaccine trial site. This is to identify the TB situation among the population in a specific area, so that we can test new vaccines there in the future. These new vaccines must ensure better protection against tuberculosis than the current BCG vaccine. TB choir in Lesotho The objectives of the fight against TB can also be reached through music. This has been proven by the NTP in Lesotho. In their search for new ways to shape health education, communication, and awareness, NTP coordinators came up with the idea of a TB choir. NTP staff members rehearsed a repertoire of songs that have the fight against tuberculosis as their key theme. With a subsidy of 3,000 dollars from a donor of KNCV Tuberculosis Foundation, the choir went into the studio to record and spread their musical message by CD. Beautiful and definitely effective! PAGE 9 ANNUAL 2006

12 KNCV Tuberculosis Foundation is active in seven Asian countries: Bangladesh, Cambodia, China, the Philippines, Indonesia, Nepal, and Viet Nam. In 2006 a total of 1,416,658 TB patiënts were identified, of whom 92 percent habe been cured. What we do in... Asia Tuberculosis is continuing to make the highest number of victims in Asia. Multi-drug resistance (MDR) and dual TB/HIV infections are occurring more than ever. Nonetheless there is reason for optimism about the progress made by the national prevention programs. KNCV Tuberculosis Foundation even got international praise for the way it shaped the collaboration in Indonesia between the National Tuberculosis Program (NTP) and private healthcare. The programs in China and Viet Nam are also doing well. Successful collaboration In 2006 we achieved excellent results in Indonesia. The number of TB patients being treated has again grown by 20 percent, and treatment results continue to be excellent. The collaboration between the NTP and government and private hospitals is continuing to improve. This is important since it has become clear that half of the people with health problems do not visit the public health centers. For doctors and staff members of hospitals we set up DOTS training sessions in 2006 (the STOP TB treatment strategy of WHO). In addition a referral system was set up for patients who live in remote areas. For their daily medicine needs they can now visit local health centers, which are able to monitor the treatment properly. In 2007 we will continue to expand this PPP project. Further distribution of DOTS is another priority, especially in remote areas such as Papua New Guinea and East Timor. In January we organized a meeting in Kalimantan to involve current and former patients in the TB projects, in the context of social mobilization. A basis has been established for the fight PAGE 10 ANNUAL 2006

13 against multi-drug resistant tuberculosis (MDR-TB), with research currently being done into how it is spreading. Also, DOTS+ trial projects are being prepared for the treatment of MDR-TB patients. In addition we will provide PPP training programs for consultants, with the support of the United States Agency for International Development (USAID). Our PPP pilot project in three Chinese provinces, supported by the Canadian International Development Agency (CIDA), was completed in The goal was to realize a better referral system between hospitals and the NTP. New policy has meanwhile been developed, which will be carried out on a larger scale in China overachieved by the end of 2005 the goals of 70 percent detection (actual score 79 percent) and 85 percent successful treatment (actual score 92 percent), which was a tremendous performance. Viet Nam: evaluation and research In Viet Nam we took part in an international evaluation mission. As evidenced by the 100 percent DOTS coverage and the good detection and treatment results, the NTP is performing excellently. Besides China, Viet Nam currently meets the WHO goals. Nonetheless the expected decline of tuberculosis has not been realized. In 2006 we conducted two studies to identify why this was so. The first study showed that tuberculosis among older people is on the decline, whereas it is increasing among young adults. HIV among young people appeared to be the cause of this, but the follow-up study pointed to other causes as well. The NTP is therefore investigating whether the move of young people from the countryside to the cities, where they live in crowded circumstances, plays a role. In September we started with the data collection for a nationwide prevalence survey, which will run until June It is expected that the results of this survey will shed light on the question why tuberculosis is not declining in Viet Nam. The evaluation mission furthermore pointed out that the efforts related to TB/ HIV and MDR-TB in Viet Nam leave much to be desired. The death rate among TB patients with HIV turned out to be high. Treatment of MDR-TB is necessary to prevent further casualties and spread of MDR-TB. We therefore organized a workshop about DOTS+ in April Supervision in Cambodia We took part in an international evaluation mission also in Cambodia. The focus of our contribution lay on the Human Resource Development aspects of the NTP. In particular we looked at the degree to which healthcare workers are being deployed and at their quality, and also at the training in TB care and general basis healthcare. Even though the program in Cambodia is reasonably successful, there is a shortage of clinics and qualified personnel. The weak link in the system is the supervision, which is essential to ensure quality. We are therefore conducting a supervision training program at both national and regional level. The purpose of this is to teach the participants to view their own work through different eyes and to feel responsible for their part of the work. Public Private Partnership in the Philippines In the Philippines, KNCV Tuberculosis Foundation supports the NTP in the development of a five-year program to combat tuberculosis. The support takes place with financial aid from USAID. Our first evaluation of the NTP in 2006 showed that much gain can yet be achieved by improving public private partnership. It is important, for example, that all doctors and clinics get access to a high-quality laboratory network. A plan has been written for this purpose, which the NTP will implement in 2007 with our support. In addition we will examine, along with the NTP, WHO and the Green Light Committee (GLC), how the fight against MDR-TB can be intensified. In this context we will look specifically at the partnership between the public and private sectors. PAGE 11 ANNUAL 2006

14 KNCV Tuberculosis Foundation is active in nine countries in Eastern Europe: Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrzygzstan, Moldova, Uzbekistan, Russia, and Tajikistan. In 2006 a total of 204,853 TB patiënts were identified, of whom 68 percent have been cured. What we do in... Eastern Europe Europe, aside from Africa, is the only continent that will not achieve the goals of the World Health Organization for The TB situation in Eastern Europe and the former Soviet republics is thus a reason for concern. Since the healthcare system functions poorly in these countries, the number of cases of dual TB/HIV infection, multidrug resistant tuberculosis (MDR-TB) and now also extensively drug-resistant tuberculosis (XDR-TB) are on the rise. The accession of Eastern European countries to the EU makes the TB situation a serious threat also for the rest of Europe. High Level Forum of European ministers KNCV Tuberculosis Foundation has alerted for years to the need to tackle the TB problem in Eastern Europe on an international basis. This is finally being responded to by politicians, and a high-level ministerial forum involving European countries will be held on 22 October 2007 in Berlin. The Ministers of Health, Foreign Affairs, and Justice of the 18 European countries that have been hit hardest by tuberculosis will meet there with Western European Ministers of Development Cooperation and with donor organizations. The goal is twofold: putting the fight against TB high on the political agenda and obtaining financial support. KNCV Tuberculosis Foundation, which will chair the steering group that is preparing the forum, is doing everything to ensure a regional approach to the fight against TB both in political and financial terms. Supporting the fight against MDR-TB A major problem in Eastern Europe is MDR- TB. To combat this, countries can apply to the Green Light Committee (GLC) to obtain low-cost drugs that have proved to be of PAGE 12 ANNUAL 2006

15 good quality. In 2006 we supported nine countries in the region in this effort: Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Uzbekistan, Russia, and Tajikistan. We helped with completing the GLC application, determined whether the National Tuberculosis Programs (NTPs) met the stringent GLC standards, supervised the distribution of drugs following approval of an application, and trained healthcare workers in combating MDR-TB. The anti-tuberculosis programs in the region are still in the development phase. They seem to be operating well, even though no concrete results can yet be reported. After Moldova, Georgia is now also about to expand the program from its prison system to the civil sector. Our effort is to make diagnosis and treatment of MDR-TB generally accessible there as from Russia is getting support in the implementation of the system, and in Armenia we are evaluating a first pilot project. Tuberculosis in prisons In 2006 we continued with our projects in the prisons of Moldova and Kazakhstan. We support the screening and treatment of prisoners with tuberculosis both during and after detention, but we also focus on dual TB/HIV infections and on the human rights situation. Even though our financial partners, Cordaid, and the Interchurch Organization for Development Cooperation ICCO are gradually reducing their support in view of other policy priorities, the projects will continue in We do this partly with our own funds and partly with subsidies from local governments and the Global Fund. The cornerstone of our approach is expansion to an integrated fight against TB that encompasses both prisons and the civil sector. In Kazakhstan we have opened up an office, which serves as a basis for cooperation with a partner organization. In Moldova we will be collaborating with a local NGO. At the request of WHO, we addressed the problem of tuberculosis in prisons during a conference in Sinaia in Rumania. A guideline was prepared for this health in prison project, containing minimum requirements for a good anti-tuberculosis program. This document, which is supported by 23 European countries, has been distributed among the Ministers of Justice of all Eastern European countries. Attacking tuberculosis/hiv Together with STOP TB partners, KNCV Tuberculosis Foundation has developed guidelines for the fight against the dual infection of tuberculosis and HIV and for the cooperation between NTPs and HIV/ AIDS programs. In this context we organized two regional workshops in 2006 with a subsidy from the Dutch government: on 31 May in Dushanbe, the capital of Tajikistan, for Tajikistan, Kazakhstan, Uzbekistan, Kyrgyzstan, and Turkmenistan, and on 29 and 30 November in Tbilisi, the capital of Georgia, for Georgia, Azerbaijan, and Armenia. Staff members from the two programs (tuberculosis and HIV/AIDS) were brought together by country to prepare an action plan for cooperation. In 2007 we will assist with the implementation of these plans, along with WHO and with a Dutch subsidy. In May 2007 we will organize training sessions in Kiev, for healthcare workers from the Ukraine, Belarus, Russia, and Moldova, related to operational research into infections of tuberculosis and HIV. Each country will plan its own research project, which we will then help to implement. The research results are exchanged later among the various participants. In Georgia, where we have identified the situation regarding tuberculosis and HIV, we support the development of a national strategic plan to combat tuberculosis and HIV. Human Resource Development Since many years KNCV Tuberculosis Foundation has organized the well-known Warsaw Training, in which NTP managers from Eastern and Central Europe develop management skills in the planning and execution of programs to fight tuberculosis. KNCV Tuberculosis Foundation also provides technical assistance to countries to develop strategies for Human Resource Development in the field of TB control and to share their learnings with network partners. Clingendael conference on Eastern Europe On 15 June 2006 KNCV Tuberculosis Foundation held a seminar at Clingendael Institute about Eastern Europe. The objective was to create awareness among politicians, policymakers, and partner organizations about the threat of tuberculosis in Eastern Europe and to call for action. The seminar, which was also meant to prepare for the high-level ministerial forum to be held in October 2007 in Berlin, was attended by representatives of the Ministries of Health, Welfare and Sport, of Development Cooperation, of Foreign Affairs, and of Justice, the WHO, the STOP TB partner organizations, and ambassadors of various Eastern European countries. A direct result of this seminar was the pledge by Minister Hoogervorst of Health, Welfare and Sport at the end of 2006 that his ministry recognizes the importance of a European action plan to combat tuberculosis and of the intended role of the European Center for Disease Control. PAGE 13 ANNUAL 2006

16 KNCV Tuberculosis Foundation is active in five countries in Latin America: Bolivia, the Dominican Republic, Ecuador, Guatemala, and Mexico. In 2006 a total of 25,438 TB patiënts were identified, of whom 82 percent has been cured. What we do in... Study mission in Indigenous, Guatemala Latin America Latin America is a continent where the problem of tuberculosis is still quite real, but where substantial progress has been made in recent years in combating the disease. KNCV Tuberculosis Foundation is engaged in five countries: Bolivia, the Dominican Republic, Ecuador, Guatemala, and Mexico. We support the national anti-tb programs, train healthcare workers, and work on raising awareness among the population. The Dominican Republic: a success story The Dominican Republic represents the biggest success in Latin America of the Tuberculosis Coalition for Technical Assistance (TBCTA). As a result of the quick implementation of DOTS, the STOP TB control strategy of WHO, the National Tuberculosis Program (NTP) managed in four years to raise the detection rate rom 7.5 to 81 percent. A tremendous performance, to be sure. KNCV Tuberculosis Foundation works together with the WHO-Pan American Health Association on a project that is financed by the United States Agency for International Development. The objective of this program is total DOTS coverage (DOTS: Directly Observed Treatment, Short-course) for the entire country. A start was made in 2006 with a treatment program for multiresistant patients, using medicines supplied by the Green Light Committee (GLC). A study into medicine resistance, a growing problem in the Dominican Republic, runs parallel to this. The first results are expected in To promote the level of expertise among national and provincial healthcare workers, we organized a workshop about PAGE 14 ANNUAL 2006

17 supervision and data analysis. This included an evaluation of the new NTP guidelines for supervision. Research into tuberculosis and HIV that was completed in 2006 provided evidence that 8.6 percent of adult TB patients are infected with HIV. Fortunately the collaboration between NTP and the national HIV/AIDS program has been expanded. Since the guidelines for this were published in 2006, the TB/HIV activities are included in the regular monitoring and reporting cycle. All TB laboratories are equipped to test for HIV. Workshops in Mexico In 2006 we expanded our activities to Mexico. This country has been taking the lead in the fight against TB in Latin America and is working towards elimination of the disease. Our evaluation of the national program in 2005 pointed out that, while much was being done in the areas of advocacy, communication, and social mobilization (ACSM), the strategic planning of these activities needed improvement. The 32 states in Mexico each have their own TB program, including various activities in the field of ACSM, but there is not enough attention for the TB problems that are specific to the various states. For that reason we organized several workshops at the annual nationwide TB forum in Mexico City. Participants from the states worked together in these on improvement of the activity planning for ACSM. The evaluation evidenced that the workshops were much appreciated and that the participants had returned to their separate states with practical plans. Public Private Partnerships In August 2006 we examined Public Private Partnerships (PPP) for USAID in three Mexican states. Public TB control in Mexico is carried out by various government agencies. In addition, numerous private doctors, clinics, and pharmacies are engaged in TB screening. The level of cooperation between the various parties differs significantly by state. Our mission was to identify good practices and to make recommendations for strategic follow-up steps to expand PPP to other states. In 2007 we will work this out into a number of models and a plan of attack for the entire country. Training sessions in the techniques to carry these out, at both national and state level, will be part of this. We hope to be in a position to present measurable results during the course of Social mobilization KNCV Tuberculosis Foundation conducted research in Bolivia, Ecuador, and Guatemala in 2006 into the participation of the native Indian population in fighting and preventing tuberculosis. We did this in cooperation with The Union (formerly IUATLD, the International Union Against Tuberculosis and Lung Disease), in the context of the TBCTA project and with funding by USAID. The purpose of the study was to identify, describe, and spread best practices and to make recommendations for active participation by the population in the fight against TB. Since the native population is quite wary of outsiders due to negative experiences and suppression in the past, we prepared our study in close cooperation with local NGOs and village healthcare workers, who conducted the interviews and group discussions. This indirect approach and the local circumstances made the process cumbersome at times, but it provided much more certainty that it would yield open information about the organization mechanisms and the knowledge about tuberculosis and its spread. The data are currently being analyzed, and results are expected to be available in the course of PAGE 15 ANNUAL 2006

18 Tuberculosis Coalition for Technical Assistance The Tuberculosis Coalition for Technical Assistance (TBCTA) is a unique coalition of leading international organizations for the development and implementation of strategies for TB control. KNCV Tuberculosis Foundation houses its project management office. TBCTA is the principal partner of the United States Agency for International Development (USAID) in the field of technical assistance and is responsible in that capacity for the Tuberculosis Control Assistance Program (TB CAP). This is one of the programs through which USAID funds the international fight against TB until The objective of TB CAP is to improve TB control throughout the world and in specific countries. This is realized by ensuring easier access to controlled diagnosis and quality treatment for all patients, including patients with an HIV infection and/or multidrug resistant tuberculosis (MDR-TB), who are diagnosed and treated in public as well as private healthcare. To achieve these goals, TB CAP focuses on enhancement of the principal aspects of TB control, such as technical execution, organization, policy development, advocacy, communication and social mobilization, and human resource development. International Standard for Tuberculosis Care An important first achievement of TB CAP is the development of the International Standard for Tuberculosis Care. This instrument provides doctors and nurses who work in private healthcare with clear guidelines for diagnosis and treatment and thus promotes the quality of TB care. Just as important was the train-the-trainer education of 86 consultants in the field of MDR-TB, TB/HIV and Public Private Partnership (PPP). Forty-one of these were already able to transfer their knowledge and skills in Active in nine countries TB CAP supported nine countries in 2006, namely Brazil, the Democratic Republic of Congo, Mozambique, Namibia, the Philippines, South Africa, the southern part of Sudan, Zambia, and Kenya. In Mozambique a TB control program was set up in village communities. In addition, a TB/HIV coordination committee was established to enhance the cooperation between the two programs. In Namibia successful treatment rose from 70 to 74 percent. The number of TB patients who were also tested for HIV likewise increased: from 16 to 24 percent. In total, 51 staff employees and 40 volunteers were mobilized after they had been trained in TB care. In Zambia, where 70 percent of all TB patients are also infected by HIV, TB CAP arranged a training for 26 persons; these now provide training in all provinces and districts in the field of HIV testing and TB patient counseling. Supervision and management at district level has also improved through the availability of means of transportation. The registration and reporting system has improved through the introduction of the amended national tuberculosis manual, national tuberculosis registers, and laboratory applications for sputum research. Plans for 2007 In 2007 Cambodia, Djibouti, the Dominican Republic, Ghana, Indonesia, Malawi, Mexico, and Nigeria will be added to the list of TB CAP project countries, with operating plans now underway. In addition, TB CAP will focus in 2007 on intensification of expertise promotion and control of extensively drug-resistant tuberculosis (XDR- TB). In 2006 TBCTA was asked to provide short-term support to countries that experienced problems in the implementation of TB projects financed by the Global Fund against AIDS, Tuberculosis and Malaria (GFATM). Two country visits, to Rumania and Uzbekistan, have been successfully completed, and a visit to Lesotho is planned to take place in Similar visits will take place to Georgia, the Democratic Republic of Congo, and Viet Nam. TBCTA consists of eight TB control organizations under the leadership and management of KNCV Tuberculosis Foundation. These are: American Thoracic Society (ATS) Center for Disease Control and Prevention (CDC) Family Health International (FHI) The Union (formerly IUATLD, the International Union Against Tuberculosis and Lung Disease) Japanese Anti Tuberculosis Association (JATA) Management Sciences for Health (MSH) World Health Organization (WHO) KNCV Tuberculosis Foundation PAGE 16 ANNUAL 2006

19 Alliances Domestic RIVM/CIb The Center for Infectious Disease Control (CIb) of the Dutch Institute for Public Health and the Environment (RIVM) plays a major role in the prevention and control of infections. As the agency responsible for the coordination of TB control in the Netherlands, CIb is one of the principals of KNCV Tuberculosis Foundation. Municipal Health Services (GGD) TB control in the Netherlands (involving surveillance, detection, treatment, and vaccination) is handled by the seven GGD regions in the country. KNCV Tuberculosis Foundation provides support to this. The GGDs enter their patient data in the Netherlands Tuberculosis Register (NTR), which is managed by KNCV Tuberculosis Foundation. GGD Netherlands GGD Netherlands is the national association of Municipal Health Services. In this capacity, it is an important speaking partner for KNCV Tuberculosis Foundation regarding the setup and maintenance of a good system of disease control and the expertise of GGD employees. NVALT The Netherlands Association of Physicians for Lung Diseases and Tuberculosis is a board member of KNCV Tuberculosis Foundation. We work closely with this association in the development of new policy and the establishment of terms and conditions for good diagnosis and treatment. NVMM The Netherlands Association of Medical Microbiologists is likewise a board member of KNCV Tuberculosis Foundation. We work closely with NVMM to promote and guarantee the quality of laboratory diagnostics. AMC KNCV Tuberculosis Foundation collaborates with the Academic Medical Center in Amsterdam in the field of research, education, and advice to PhD candidates. International TBCTA KNCV Tuberculosis Foundation and seven international partners have bundled their efforts in The Tuberculosis Coalition for Technical Assistance. This worldwide knowledge and support network provides support to national TB control programs in Africa, Latin America, and Asia. The Union The Union (formerly IUATLD, the International Union Against Tuberculosis and Lung Disease) is our traditional partner in the fight against tuberculosis and in advocating the DOTS strategy (the STOP TB treatment strategy of WHO). The Union s mission is to support TB control efforts worldwide. Its main focus lies on education and operational research. WHO KNCV Tuberculosis Foundation works closely with the World Health Organization. We participate in technical taskforces at the Geneva headquarters and in all six regions. We have also contributed in a significant way to the establishment of a new control strategy, the STOP TB strategy. STOP TB Partnership We are one of the founders of the STOP TB Partnership, a worldwide coalition of organizations that are dedicated to realization of the WHO goals for TB control. KNCV Tuberculosis Foundation sits on the executive board of the partnership and is active in all taskforces. USAID The United States Agency for International Development is an American development organization that supports TB control efforts worldwide. TBCTA receives a five-year project subsidy from USAID for the period for the spread and enhancement of the STOP TB treatment strategy. CIDA The Canadian International Development Agency is a Canadian development organization that provides financial support for our projects in Kenya, Tanzania, Zambia, and Angola aimed at technical support of the national TB control programs. DGIS KNCV Tuberculosis Foundation has collaborated since many years with the Directorate-General for International Cooperation. For the period we receive a TMF Program subsidy from DGIS in support of our international activities. LSHTM Since 2005 KNCV Tuberculosis Foundation has worked together with the London School of Hygiene & Tropical Medicine (LSHTM) in the TARGETS Research Programme Consortium. The objective of this consortium is the development and application of instruments for infectious disease control. There is special focus on the development and evaluation of strategies to reach poor and vulnerable groups with TB control interventions. Aeras Global TB Vaccine Foundation The objective of Aeras is to develop a vaccine against tuberculosis. KNCV Tuberculosis Foundation has collaborated with Aeras in setting up pilot sites in South Africa where a new vaccine can be tested. Since 2006 there are also pilot sites in Kenya and Uganda. PAGE 17 ANNUAL 2006