Maximize treatment success among Syrian refugees for those remaining in Jordan or moving to other countries. Four activities were undertaken: i) DOTS was instituted using Jordan NTP case management forms; ii) contingency plans for movement to other countries for treatment were developed; however, refugees were counseled to complete treatment in Jordan and to sign a modified World Care Counsel patient charter found in the CDC's Evaluation Tool for Tuberculosis Programs in Resource-limited, Refugee and Post-Conflict Settings, version 2. For consenting patients, WHO and IOM agreed to assist with transfers. At time of treatment initiation, the refugee was given a DOTS card updated with regimen administered, doses given, and pertinent laboratory results, which s/he could take to other treatment locations, either within Jordan or other countries; iii) psychosocial support was provided by the Jordanian Anti TB Association (JATA) to increase treatment success, alleviate fears, and reduce stigma. TB patients often deal with stigma; in addition, refugees have often witnessed traumatic events and struggle with the consequences of displacement adding to their need for psychosocial support; and iv) ongoing monitoring and evaluation. IOM collected TB cohort data and Jordan NTP assessed their governorate and national diagnostic TB centers using CDC's TB program evaluation tool for resource-limited and refugee settings. For the cohort analysis, the objectives were to verify that at least 85 % of the new smear-positive TB cases were cured.
Increase TB awareness and knowledge of treatment services among Syrian refugees and their healthcare providers by information, education and communication (IEC) material for camp and non-camp settings, and
Support the development and implementation of national guidelines for management of latent TB infection.
The strategic objectives were:
Each of the objectives had activities with indicators and responsible partner(s) for collecting those indicators. These indicators were collected by IOM and NTP and shared with UNHCR and WHO.
The strategy was implemented in July 2013 (Fig. 1). Of the five strategic objectives, objective 4: increase TB awareness and knowledge of treatment services was to ensure that the Syrian refugees with suspected TB could enter the Jordan TB control program. This objective had activities for refugees and for healthcare providers. IEC material were developed for both groups to increase awareness of TB signs and symptoms with messaging for refugees that TB is curable and where to seek care if someone had symptoms suggestive of TB. IOM conducted hour-long TB awareness sessions in the camps and community with the aid of a local medical association and collected the numbers of refugees attending by age group and sex. This strategy for the first 6 months of 2014, resulted in almost 61,000 (10 % of total) Syrian refugees attending IOM conducted TB awareness sessions, with equal proportions of males and females (Table 1). As far as anecdotal accounts, several refugees presented to IOM reporting that they had TB signs and symptoms after reading the IEC materials or attending the awareness raising sessions, while others when asked did not report having any sign and symptoms presumably because of fear of stigma within their community with a smaller fear of being deported (exact numbers not captured).
Second in importance was objective 1: increase TB screening, which offered Syrian refugees screening for TB symptoms, and if present, chest radiography and microscopic examinations, if indicated. With assistance of Jordan NTP and with UNHCR for newly arriving refugees, IOM screened almost 69,000 (11 % of total population) in first 6 months of 2014 (Table 1). Of those Syrians screened through June 2014, 45 % were 14 years of age or younger, which was comparable to the 45 % of the Syrian refugees aged 0 through 14 years derived from UNHCR regional demographic age structure. Therefore, this suggests children were captured in the TB screening efforts.
For objective 3: maximize treatment success, IOM collected, maintained, and reported TB data among Syrian refugees. Examining the 2013-2014 TB cohort data for Syrian refugees on treatment, for the first three quarters (January-March 2013, April-June 2013, July-September 2013 followed for 9 months each), 91 %, 96 %, and 85 % had completed their anti-TB treatment (or been cured) for an overall completion rate of 91 % (Table 2), with one death and no failures. For the first quarter, there was a 9 % (two persons) treatment default rate; however, zero for the following two cohort periods. These initial two persons returned to Syria and were lost to follow-up. Subsequently, IOM increased its assistance to the refugees under treatment and emphasized with them the importance of treatment completion before travelling.
For objective 2: increase TB diagnosis, for the first 6 months of 2014, of the 33 Syrian refugees with culture confirmed active TB disease, one each was diagnosed in Syria and Kuwait arriving with treatment and three were diagnosed in Syria coming without any treatment; all five once in Jordan received testing and appropriate treatment begun or was continued. Only three were found to be highly infectious with sputum smears containing Mycobacterium tuberculosis bacilli identified microscopically (smear-positive), 18 (78.3 %) were sputum smear-negative, and two (6 %) were children under 5 years of age (Table 3). The high percentage of smear-negative TB cases was because a) some patients were partially treated in Syria before coming to Jordan but were considered new cases once in Jordan, and b) with the highly dynamic movement of refugees within Jordan and the fear of losing cases, NTP increased the clinical diagnosis of TB to include smear-negative TB cases who had three additional criteria: (i) cough for more than 3 weeks, (ii) no response to an non-TB antibiotics, and (iii) a chest radiograph compatible with TB.
The public health strategy since initial development has identified TB cases among Syrian refugees at a higher rate (1.01 per 100,000 monthly or 12.17 per 100,000 for July 2013 through June 2014), than the pre-strategy period (0.73 per 100,000 monthly or 8.75 per 100,000 for 12 months), or approximately 40 % greater, using UNHCR population estimates (Table 4); more than double the Jordan TB incidence (5.8 per 100,000) for 2012.