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Year 4 Highlights | February 2015CARE ITB
Welcome to the 4th edition of the TB CARE I summary report which brings you an overview of TB CARE I achievements,
results and successes in the fourth and final year of the program.
Above - Cured TB patient travelling to hospital for check-up - Indonesia (Photo: TB CARE I)Below - MDR-TB patient - Zimbabwe (Photo: Jeroen van Gorkom, KNCV)
DRUG SUPPLY & MANAGEMENTTOOLS
TB CARE
Medium Investment
Large Investment
Medium/Large Investment
Small Investment
GhanaThe proven TB CARE I intensified hospital-based TB case detection approach has been included in both the new national strategic plan and the Global Fund concept note.
60% more TB patients were diagnosed by private providers in TB CARE I areas in 2013 compared to 2012.
NigeriaEQA performance has been maintained (86%) in TB CARE I areas despite major instability.
South Sudan
TB CARE I supported the development of an epi analysis, the national strategic plan and the single TB/HIV concept note.
Botswana
92% of TB patients in 2013 had an HIV test results recorded in the TB register (76% in 2010).
Namibia
Cotrimoxazole preventive therapy coverage in TB CARE I-supported integrated TB/HIV sites (96%) was well above the national average (77%).
Zimbabwe
External Quality Assessment coverage increased from 39% (Year 3) to 60% (Year 4) in TB CARE I-supported areas.
Mozambique
Treatment success rate improved from 62% in 2009 to 86% in 2012.
Kazakhstan
Case dectection rate increased from 73% (2010) to 91% (2013).
Kyrgyzstan
TB CARE I supported the development of a national strategic plan on pyscho-social support for TB patients.
Uzbekistan
A study showed that migration out of country, moving within country, treatment side effects and being a retreatment patient were significantly associated with loss to follow-up.
Tajikistan
From 2009-2013 case notification increased by 84% in TB CARE I-supported Kabul City
Afghanistan
Seven times as many RR-TB cases were diagnosed with TB CARE I support in 2013 (1,472) than in 2010 (209).
Vietnam
85% of MDR-TB patients (2011) were successfully treated.
Cambodia
Three times as many MDR-TB patients were started on treatment in 2013 (587) than in 2010 (142).
Indonesia
Three times as many MDR-TB cases were diagnosed in 2013 (558) than in 2010 (140).
Ethiopia
TB CARE I-supported Xpert implementation began in Year 4 with 10,951 tests conducted.Zambia
In the fourth and final year of the cooperative agreement with USAID (2010-2015), TB CARE I continued to achieve important results at global, regional, national and local levels. The program implemented 34 new core projects, four regional projects, and 17 country projects. Through these many projects, TB CARE I contributed to three USAID target areas:
r� Sustain or exceed 84% case detection rate and 87% treatment success rate
r� Treat successfully 2.55 million new sputum-positive TB cases
r� Diagnose and treat 57,200 new cases of multi-drug resistant TB (MDR-TB)
CONTRIBUTION TO USAID TARGETS
Since the start of the program, nearly 3.3 million TB V>ÃiÃ�>���v�À�î��>Ûi�Lii����Ì�wi`�>VÀ�ÃÃ�/�Ƃ, ���countries. In 2013, 1,105,653 TB cases (new and Ài�>«Ãi®�ÜiÀi���Ì�wi`��v�Ü��V��x£Î]ÓÓx�ÜiÀi��iÜ�L>VÌiÀ����}�V>��Þ�V��wÀ�i`�«Õ����>ÀÞ�/�V>Ãið�Case detection rates have improved in 13 TB CARE I countries since the program began, eight of which showed improvement in the last year alone. This year Ghana, Kyrgyzstan and Uzbekistan have surpassed the USAID target of 84%.
TREATMENT SUCCESS:
Treatment success rates remain strong in most TB CARE I countries, with ten countries exceeding the nx¯�-Ì�«�/�Ì>À}iÌ�>�`�wÛi��v�Ì��Ãi�>�Ã��ÃÕÀ«>ÃÃ��}�the 87% USAID target. Improvements between 2011 and 2012 were noted in seven countries. The successful treatment of 861,406 sputum smear positive (SS+) patients from 2010-2011 and 805,266 new and relapse patients in 2012 translates to 65% of the 2014 USAID target of 2.55 million SS+ patients ÃÕVViÃÃvÕ��Þ�ÌÀi>Ìi`��ÛiÀ�wÛi�Þi>Àð
���Óä£Î]�£Î]xÎÎ�V��wÀ�i`���,�/�«>Ì�i�ÌÃ�ÜiÀi�diagnosed across 19 TB CARE I countries a 29% increase from 2010, treatment initiation for MDR-TB >�Ã����«À�Ûi`�V��Ã�`iÀ>L�Þ�Ü�Ì��£Î]ä{£�V��wÀ�i`�MDR-TB patients started on second-line treatment (an 81% jump).
7�i��Ì�Ì>���}�L�Ì��V��wÀ�i`���,�/�V>ÃiÃ�and rifampicin-resistant TB (RR-TB) cases, 20,508 RR-/MDR-TB patients have been diagnosed, which is >�nä¯���VÀi>Ãi�V��«>Ài`�Ì��Óä£ä°�n�¯��v�V��wÀ�i`�>�`�Õ�V��wÀ�i`���,�/�«>Ì�i�ÌÃ�ÜiÀi�ÃÌ>ÀÌi`�on treatment in 2013 compared to 21% in 2010. Between 2011-2013, TB CARE I countries contributed a total of 32,392 patients (57%) to the USAID target �v�xÇ]Óää�Èx¯��v�Õ�V��wÀ�i`É,,�/�V>ÃiÃ�>Ài�>�Ã��included in the total).
Number of Cases Notified (All Forms and New Confirmed) in
TB CARE I Countries 2010-2013
Number of New MDR-TB Cases Diagnosed and Put on
Treatment in TB CARE I Countries 2010-2013
TB CARE I Indonesia Director Jan Voskens with woman cured of MDR-TB (Photo: KNCV)
USAID TARGETS
2010
2011
2012
2013*
1,104,344
1,122,687
1,123,638
1,105,653
Number of Cases Notifed (all forms)
New Confirmed (2013*: New Pulmonary Bacteriologically Confirmed)
490,898
511,708
517,783
513,225
Confirmed MDR Diagnosed
2010
2011
2012
2013
RR-/MDR-TB Diagnosed
Confirmed MDR-TB Started on Treatment
Confirmed & Unconfirmed MDR-TB Started on Treatment
20,508
15,405
13,041
13,533
16,788
12,721
10,952
13,281
13,270
8,804
8,152
12,458
11,380
8,141
7,206
10,514
CASE NOTIFICATION & CASE DETECTION:
NUMBER OF NEW MDR-TB CASES DIAGNOSED AND PUT ON TREATMENT:
32
Medium Investment
Large Investment
Medium/Large Investment
Small Investment
GhanaThe proven TB CARE I intensified hospital-based TB case detection approach has been included in both the new national strategic plan and the Global Fund concept note.
60% more TB patients were diagnosed by private providers in TB CARE I areas in 2013 compared to 2012.
NigeriaEQA performance has been maintained (86%) in TB CARE I areas despite major instability.
South Sudan
TB CARE I supported the development of an epi analysis, the national strategic plan and the single TB/HIV concept note.
Botswana
92% of TB patients in 2013 had an HIV test results recorded in the TB register (76% in 2010).
Namibia
Cotrimoxazole preventive therapy coverage in TB CARE I-supported integrated TB/HIV sites (96%) was well above the national average (77%).
Zimbabwe
External Quality Assessment coverage increased from 39% (Year 3) to 60% (Year 4) in TB CARE I-supported areas.
Mozambique
Treatment success rate improved from 62% in 2009 to 86% in 2012.
Kazakhstan
Case dectection rate increased from 73% (2010) to 91% (2013).
Kyrgyzstan
TB CARE I supported the development of a national strategic plan on pyscho-social support for TB patients.
Uzbekistan
A study showed that migration out of country, moving within country, treatment side effects and being a retreatment patient were significantly associated with loss to follow-up.
Tajikistan
From 2009-2013 case notification increased by 84% in TB CARE I-supported Kabul City
Afghanistan
Seven times as many RR-TB cases were diagnosed with TB CARE I support in 2013 (1,472) than in 2010 (209).
Vietnam
85% of MDR-TB patients (2011) were successfully treated.
Cambodia
Three times as many MDR-TB patients were started on treatment in 2013 (587) than in 2010 (142).
Indonesia
Three times as many MDR-TB cases were diagnosed in 2013 (558) than in 2010 (140).
Ethiopia
TB CARE I-supported Xpert implementation began in Year 4 with 10,951 tests conducted.Zambia
TB CARE I COUNTRY HIGHLIGHTS
3
Medium Investment
Large Investment
Medium/Large Investment
Small Investment
GhanaThe proven TB CARE I intensified hospital-based TB case detection approach has been included in both the new national strategic plan and the Global Fund concept note.
60% more TB patients were diagnosed by private providers in TB CARE I areas in 2013 compared to 2012.
NigeriaEQA performance has been maintained (86%) in TB CARE I areas despite major instability.
South Sudan
TB CARE I supported the development of an epi analysis, the national strategic plan and the single TB/HIV concept note.
Botswana
92% of TB patients in 2013 had an HIV test results recorded in the TB register (76% in 2010).
Namibia
Cotrimoxazole preventive therapy coverage in TB CARE I-supported integrated TB/HIV sites (96%) was well above the national average (77%).
Zimbabwe
External Quality Assessment coverage increased from 39% (Year 3) to 60% (Year 4) in TB CARE I-supported areas.
Mozambique
Treatment success rate improved from 62% in 2009 to 86% in 2012.
Kazakhstan
Case dectection rate increased from 73% (2010) to 91% (2013).
Kyrgyzstan
TB CARE I supported the development of a national strategic plan on pyscho-social support for TB patients.
Uzbekistan
A study showed that migration out of country, moving within country, treatment side effects and being a retreatment patient were significantly associated with loss to follow-up.
Tajikistan
From 2009-2013 case notification increased by 84% in TB CARE I-supported Kabul City
Afghanistan
Seven times as many RR-TB cases were diagnosed with TB CARE I support in 2013 (1,472) than in 2010 (209).
Vietnam
85% of MDR-TB patients (2011) were successfully treated.
Cambodia
Three times as many MDR-TB patients were started on treatment in 2013 (587) than in 2010 (142).
Indonesia
Three times as many MDR-TB cases were diagnosed in 2013 (558) than in 2010 (140).
Ethiopia
TB CARE I-supported Xpert implementation began in Year 4 with 10,951 tests conducted.Zambia
TB CARE I COUNTRY HIGHLIGHTS
4
Medium Investment
Large Investment
Medium/Large Investment
Small Investment
GhanaThe proven TB CARE I intensified hospital-based TB case detection approach has been included in both the new national strategic plan and the Global Fund concept note.
60% more TB patients were diagnosed by private providers in TB CARE I areas in 2013 compared to 2012.
NigeriaEQA performance has been maintained (86%) in TB CARE I areas despite major instability.
South Sudan
TB CARE I supported the development of an epi analysis, the national strategic plan and the single TB/HIV concept note.
Botswana
92% of TB patients in 2013 had an HIV test results recorded in the TB register (76% in 2010).
Namibia
Cotrimoxazole preventive therapy coverage in TB CARE I-supported integrated TB/HIV sites (96%) was well above the national average (77%).
Zimbabwe
External Quality Assessment coverage increased from 39% (Year 3) to 60% (Year 4) in TB CARE I-supported areas.
Mozambique
Treatment success rate improved from 62% in 2009 to 86% in 2012.
Kazakhstan
Case dectection rate increased from 73% (2010) to 91% (2013).
Kyrgyzstan
TB CARE I supported the development of a national strategic plan on pyscho-social support for TB patients.
Uzbekistan
A study showed that migration out of country, moving within country, treatment side effects and being a retreatment patient were significantly associated with loss to follow-up.
Tajikistan
From 2009-2013 case notification increased by 84% in TB CARE I-supported Kabul City
Afghanistan
Seven times as many RR-TB cases were diagnosed with TB CARE I support in 2013 (1,472) than in 2010 (209).
Vietnam
85% of MDR-TB patients (2011) were successfully treated.
Cambodia
Three times as many MDR-TB patients were started on treatment in 2013 (587) than in 2010 (142).
Indonesia
Three times as many MDR-TB cases were diagnosed in 2013 (558) than in 2010 (140).
Ethiopia
TB CARE I-supported Xpert implementation began in Year 4 with 10,951 tests conducted.Zambia
International Standards for Tuberculosis Care 3rd Edition
TB CARE I funded the development of the third edition of the ‘International Standards for Tuberculosis Care’ (ISTC) which describes a widely accepted level of care that all practitioners, public and private, should seek to achieve in managing patients who have or are suspected of having TB. This edition brings updated standards that are in line with recent WHO guidelines, and is accompanied by a free mobile phone app that features clinical decision algorithms with step by step guidance for diagnosing and managing TB, along with the full text of the ISTC. The app is designed for use by TB practitioners, and provides all the essential information for diagnosing and managing TB.
Summary of TB CARE I supported Xpert testing activity over four years of implementation, including TB positivity rate and
RIF-resistance rates (RR)
UNIVERSAL & EARLY ACCESS:
Universal and Early Access is a priority for TB CARE I given the range of technical issues that it covers, from a patient-centered approach to service quality, whether in the public or private sector, in the community or in prisons.
Among the 11 countries where TB CARE I has made moderate to substantial investments in addressing TB in children, ÇÎ]xx��«i`�>ÌÀ�V�/�V>ÃiÃ�ÜiÀi���Ì�wi`�in 2013 to NTPs in TB CARE I countries, making up 8% of all new and relapse cases with age information known, which is within the target range of 5-15% of all TB cases.
LABORATORIES:
One of TB CARE I’s greatest undertakings has been the rollout, strategic implementation and expansion of GeneXpert MTB/RIF (Xpert) across all TB CARE I countries. Although the level of investment and TB CARE I project role varied from country to country, these efforts began with training and procurements, and then expanded to providing extensive mentoring, supervision, and monitoring activities. In Year 4 training, technical assistance and mentoring were provided to 14 out of 17 countries, and at the end of the year 101 Xpert instruments were operational due to TB CARE I support.
Since the start of TB CARE I, 114,699 TB CARE I -supported tests have been conducted with a TB positivity rate of 34% and RR-TB detection rate of 26%. Testing jumped by 153% from Year 3 to Year 4 alone, 88% more samples in Year 4 detected TB (MTB+) than in Year 3 and 50% more RR-TB was diagnosed.
All but two supported countries have laboratory strategic plans that will enable national TB programs Ì��ivwV�i�Ì�Þ�>�`�ivviVÌ�Ûi�Þ�V��À`��>Ìi]���«�i�i�Ì�and budget laboratory activities over the next round of Global Fund grants.
Year 1/Year 2 Year 3 Year 4
Num
ber
of S
ucce
ssfu
l Tes
ts
8,133
3,6051,005
30,188
12,431
3,623
76,378
23,362
31%
5,432
23%
41%
29%44%28%
Total Tests MTB+ RR
In addition to strategic planning for laboratories, new linkages have also been established between national reference laboratories in TB CARE I countries and supranational reference laboratories (SNRLs). At present, all countries have developed SNRL linkages and have had at least one on-site visit.
Child with MDR-TB - Zimbabwe (Photo - Jeroen van Gorkom, KNCV)
UNIVERSAL AND EARLY ACCESSLABORATORIES
5
INFECTION CONTROL (TB-IC):
All TB CARE I countries have developed national TB-IC guidelines, compared to only 50% at 2010 baseline, and TB-IC is now incorporated in the overall national Infection Prevention and Control Policy of all TB CARE I countries.
Ethiopia, Nigeria, Zambia and Viet Nam piloted the FAST strategy (Finding cases Actively, Separating them safely and Treating them effectively). The FAST strategy assumes that getting TB patients on effective (Xpert or DST-based) treatment faster will reduce the transmission of TB, long before the conversion of sputum smear or culture to negative. Preliminary data from the pilots in Zambia and Nigeria show a reduction in the average time to diagnosis and time to treatment and an increased level of case detection.
PROGRAMMATIC MANAGEMENT OF DRUG RESISTANT TB (PMDT):
As the diagnosis and treatment initiation for MDR-TB are scaled up, it is also essential to ensure the quality and completion of appropriate treatment. As PMDT programs expand, many countries have seen treatment success rates decrease (or remain low) as the complexities of managing more patients À�Ãi°�ƂÃ�Ãii�����Ì�i�w}ÕÀi��ivÌ®]���Ài�«>Ì�i�ÌÃ�ÜiÀi�successfully treated from the 2011 cohort (5,994) than the 2010 cohort (5,596), however the overall number of MDR-TB patients on treatment also grew, resulting in only 69% treatment success (compared to 68% in 2010). Although an improvement over 2009 levels (only 3,811 treated and 66% successfully treated), there is still major work to be done.
TB/HIV:
The program implements TB/HIV-related activities in 11 country projects, 10 of which have U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)-supported activities or workplans. The average percentage of co-infected patients on Antiretroviral Treatment (ART) rose from 39% to 71% between 2010 and 2013. In general, the use of cotrimoxazole preventive therapy (CPT) did not expand over this period (85% coverage), although improvements were seen in some countries.In Zimbabwe where TB CARE I has been implementing a TB/HIV integrated care approach in 23 sites, CPT coverage is at 96% which is well above the national average of 77%.
Percentage of reported HIV-Positive TB patients started or
continued on ART (2010-2013)
MDR-TB patients registered on treatment and number (percent) that
successfully completed treatment (2009-2011)
% of HIV-positive patients started or continued on ART
Number of HIV-positive patients started or continued on ART
Thou
sand
s of
TB
Pat
ient
s
2010 2011 20132012
30
60
90
120
150
39%
49%
65%
71%
75
91
121127
MDR-TB patient receiving treatment - Kyrgyzstan (Photo: Nurgulya Kulbekova, KNCV)
Number Confirmed Started on Treatment Number Treated Successfully
2000
4000
6000
8000
10000
Num
ber o
f MD
R-TB
Pat
ient
s
5,805
3,811
8,172
5,596
8,739
5,994
2009 2010 2011
66%
68%69%
INFECTION CONTROLPMDTTB/HIV
6
8
HEALTH SYSTEM STRENGTHENING:
Health system strengthening is a component of nearly every country workplan with activities ranging from supportive supervision of and technical assistance with Global Fund planning, to the implementation and development of sustainable funding mechanisms. In the most recent scoring of Global Fund grants, 50% of all grants in TB CARE I countries are rated as A1/A2, whereas only 39% of grants in non-TB CARE I countries ha the same rating.
In Year 4, TB CARE I trained 15,772 individuals (health care workers, community volunteers, consultants, NTP staff, laboratory technicians, etc.), across all technical areas (see above), compared to Year 1 when 4,354 people were trained.
MONITORING & EVALUATION, OPERATIONS RESEARCH AND SURVEILLANCE:
Electronic recording and reporting (ERR) is established in ten TB CARE I countries (Botswana, Cambodia, Indonesia, Kazakhstan, Kyrgyzstan (not fully functional), Namibia, Nigeria, Tajikistan, Uzbekistan and Viet Nam) and TB CARE I provided moderate to substantial support for ERR in Botswana, Cambodia, Indonesia, Nigeria and Viet Nam.
TB CARE I has worked in 14 (82%) project countries to improve the quality of data at various levels of the system. The measurement of data quality has consistently gained greater traction with 88% of active TB CARE I countries now measuring data quality on a regular basis, compared to 50% of countries at the start.
Over the course of TB CARE I, operations research studies have been conducted in 18 countries. In total, 114 studies have been initiated, with TB CARE I’s level of involvement varying from major or minor w�>�V�>�ÉÌiV���V>��ÃÕ««�ÀÌ�Ì��vÕ�����«�i�i�Ì>Ì�����v�the studies.
Percentage of TB CARE I-Trained
Individuals by Technical Area, Year 4
(15,772 Trained)
Overview of Topic Areas for Completed or Ongoing Operations Research Studies, Years 1-4
Comparison of Grant Performance in TB CARE I
and Non-TB CARE I Countries
Trainees conducting a health facility risk assessment - Ethiopia (Photo: Max Meis, KNCV)
Patient interview on the quality of care Indonesia (Photo: KNCV)
Universal Access 56%
Laboratories4%
Epidemiology/M&E 11%
PMDT15%
TB/HIV6%
HSS4%
Morbidity/Mortality 2%
Drugs2%
Universal Access 31%
Laboratories 16%
TB IC 12%
PMDT9%
TB/HIV 7%
HSS6%
M&E 7%
Drug Supply & Management 3%
Other 7%
Region-funded 1%
Core-funded 1%
INFECTION CONTROLPMDTTB/HIV
M&E, OPERATIONS RESEARCH & SURVEILLANCEHEALTH SYSTEMS STRENGTHENING
7
8
The Global Health Bureau, Office of Health, Infectious Disease and Nutrition (HIDN), US Agency for International Development, financially supports this publication through TB CARE I under
the terms of Agreement No. AID-OAA-A-10-00020. This publication is made possible by the generous support of the American people through the United States Agency for International
Development (USAID). The contents are the responsibility of TB CARE I and do not necessarily reflect the views of USAID or the United States Government.
TB CARE contributed to three USAID
target areas:
p� Sustain or exceed 84% case detection rate
and 87% treatment success rate
p� Treat successfully 2.55 million new sputum-
positive TB cases
p� Diagnose and treat 57,200 new cases
of multi-drug resistant TB (MDR-TB)
By focusing on eight priority technical
areas:
r� Universal and Early Access
r� Laboratories
r� Infection Control (IC)
r� Programmatic Management of Drug
Resistant TB (PMDT)
r� TB/HIV
r� Health Systems Strengthening
r� Monitoring & Evaluation (M&E), Operations
Research (OR) and Surveillance
r� Drug Supply and Management
And four over-arching elements:
r� Collaboration and Coordination
r� Access to TB services for all people
r� Responsible and Responsive Management
Practices
r� Evidence based M&E
WHAT IS TB CARE I?
E-mail pmu@tbcare1.orgPhone +31-70-7508447Website www.tbcare1.orgTwitter @TBCARE1
CONTACT DETAILS:
TB CARE I is a USAID five year cooperative
agreement (2010-2015) that was awarded
to the Tuberculosis Coalition for Technical
Assistance (TBCTA) with KNCV Tuberculosis
Foundation as the lead partner.
TB CARE I is a unique coalition of the major
international organizations in TB control:
American Thoracic Society (ATS), FHI 360,
International Union Against Tuberculosis
and Lung Disease (The Union), Japan Anti-
Tuberculosis Association (JATA), KNCV
Tuberculosis Foundation, Management
Sciences for Health (MSH), World Health
Organization (WHO).
WANT TO FIND OUT MORE?
The full TB CARE I Year 4 Annual Report is available on the TB CARE I website, along with all the tools that have been published.
CARE ITBDRUG SUPPLY AND MANAGEMENT:
In six countries, TB CARE I helps to ensure there are nationwide systems for a sustainable supply of drugs, by providing technical assistance to NTPs. Compared to baseline and Year 1 (8 countries), drug management Standard Operating Procedures (SOPs) are now available in 76% of TB CARE I countries.
TOOLS:
TB CARE I strives to make its documents and tools available to as wide an audience as possible. In the final year, the project produced over 30 publications covering a wide range of technical areas, all of which can be found on the TB CARE I website (www.tbcare1.org/publications)
A fundamental aspect of introducing new TB drugs in countries is to ensure that national authorities establish the necessary conditions for optimal and responsible use of new TB drugs/regimens. These conditions include: development/update of national guidelines, inventory of minimal infrastructure and resources required (clinical, laboratory, recording & reporting, monitoring and evaluation, drug supply etc.) for proper case-management, efficient pharmacovigilance, and surveillance of drug resistance. In Year 4, TB CARE I developed a protocol for the rational and safe introduction of Bedaquiline, a new TB drug for MDR-TB treatment, and supported Indonesia and Kazakhstan to develop country-specific versions of the protocol.
Design + Layout - Tristan Bayly
DOT for MDR-TB - Viet Nam (Photo - Matthieu Zellweger, WHO)
Universal Access 31%
Laboratories 16%
TB IC 12%
PMDT9%
TB/HIV 7%
HSS6%
M&E 7%
Drug Supply & Management 3%
Other 7%
Region-funded 1%
Core-funded 1%
M&E, OPERATIONS RESEARCH & SURVEILLANCEHEALTH SYSTEMS STRENGTHENING
DRUG SUPPLY & MANAGEMENTTOOLS
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