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TB, MDR – TB control updates, Myanmar. CAP-TB Strategic Planning Meeting, Bangkok, Thailand, 1-2 August, 2013. TB burden . TB is a major public health problem One of the world’s 22 high TB burden countries, 27 high MDR-TB burden countries and 41 high TB/HIV burden countries. - PowerPoint PPT Presentation
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TB, MDR – TB control updates, Myanmar
CAP-TB Strategic Planning Meeting,Bangkok, Thailand, 1-2 August, 2013
TB burden
TB is a major public health problemOne of the world’s 22 high TB burden
countries, 27 high MDR-TB burden countries and 41 high TB/HIV burden countries
Population 60 million -
Number Rate (per 100,000 population)
Prevalence 240,000 506 (390-637)
Incidence 180,000 381 (326-439)
Incidence (HIV positive) 18,000 38 (31-45)
Mortality (excluding TB/HIV) 23,000 48 (22-84)
Notifications (new and relapse) 136,737 283
Estimates of the TB burden in Myanmar, 2011 (based on 2009-2010 prevalence survey), source: WHO TB Control Report 2012
TB epidemiology, Myanmar (2011)
Mortality
Prevalence
Incidence
HIV prevalence among new TB patients (2005-2012)
10.310.8
9.8
11.1
9.2
10.49.9 9.7
0
2
4
6
8
10
12
2005 2006 2007 2008 2009 2010 2011 2012
Year
Perc
ent
HIV Sentinel Surveillance in Myanmar
2005 – 5 tsps2012 – 25 tsps
Goal, Objectives & targetsGoal
To reduce morbidity, mortality and transmission of TB until it is no longer a public health problem and to prevent the development of drug resistant TB.
Specific Objectives are set towards achieving the Millennium Development Goals (MDGs) for 2015.
To reach and thereafter sustain the targets • achieving at least 70% case detection and
successfully treat at least 85% of detected TB cases under DOTS
(MDGs: Goal 6, Target 6.c, Indicator 6.10)
To reach the interim targets of halving TB deaths and prevalence by 2015 from the 1990 situation.
(MDGs: Goal 6, Target 6.c, Indicator 6.9)
WHO-recommended Stop TB Strategy
TB case notifications
1555
17008 2019616113
14756
19626
31703
42455
58243
77231
97909
107991
123593
133547
128739
134023
137403
143164
147984
0
20000
40000
60000
80000
100000
120000
140000
160000
New SS +
New SS neg
EP
All Cases Load
Years
Cases Loa
d
Proportion of all form TB patients contributed by NTP and Other reporting units (2012)
NTP, 75.8%
PSI, 16.1%AZG(MSF-H), 2.5%
PPM Hospital, 2.8%
MMA, 2.1%
AHRN, 0.2%
MSF(CH), 0.4% MDM, 0.1%
99
0%10%20%30%40%50%60%70%80%90%100%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Treatment Success Rate of NS(+), S(-) and Relapse cases in Country (2000-2011)cohort
NSP SN Relapse
No Indicator 1990 2005 2007 2011 20156.9 Incidence, prevalence and death rates associated with tuberculosis
1 . Incidence 404 404 404 381 To halt and reverse
2. Tuberculosis Prevalence all cases / 100,000 pop.
922 628 596 506 (45%)
461
3. Tuberculosis Death rate / 100,000
133 67 58 48 (64%)
66
6.10 #
Proportion of tuberculosis cases detected and cured under directly observed treatment, short course
1. Proportion of tuberculosis cases detected 38 95 90 77 At least 70%
2. Proportion of tuberculosis cases treated successfully 78 85 85 85.4 At least 85%
6.9 Global Tuberculosis Control 2010, WHO, Geneva # 6.10 National Tuberculosis Programme, Department of Health, Ministry of Health, Annual Reports (2000-2009)
MDGs for TB Control
Estimates of MDR-TB burden (2012)
• WHO estimates that there were 5,500 MDR-TB cases among notified pulmonary TB cases in 2011
• Among the total annual TB cases 9,000 are estimated to have MDR-TB
• A total of 6 XDR-TB cases have been confirmed
New cases Previously treated casesCases
with DST results (H+R)
Multidrug-resistantCases with DST results
(H+R)
Multidrug-resistant
No. % No. %
2002-2003 3.90% 15.50%
2007-2008 1,071 45
4.2% (3.1-5.6) 299 30
10.0% (6.9-14.0)
2013 Third survey to be completed in 2013
MDR-TB suspects definition and diagnostic algorithms
Patient to be tested for drug sensitivity • Retreatment cases including Category II
failure, Category I failure, relapse and return after default and other cases
• Close contacts of MDR-TB patients who develop active TB
• All TB patients living with HIV/AIDS
Three diagnostic algorithms developedbased on Xpert MTB/RIF:• Diagnosis of TB in HIV-negative patients
with no significant risk for MDR-TB• Diagnosis of TB/MDR-TB in HIV-positive
TB patients• Diagnosis of MDR-TB in patients with risk
factors for resistance
Treatment Regimens
• 6 Am + Lfx + Eto + Cs + PAS + Z• 18 Lfx + Eto + Cs + PAS +Z
• 6 Am + Lfx + Eto + Cs + Z• 18 Lfx + Eto + Cs + Z
Standardized treatment regimens
OR
Key activities to date to combat drug resistant TB
• DOTS-Plus pilot project started in July 2009• The Global Fund supported MDR-TB management
started in December 2011• SOP of pilot phase was reviewed and revised in 2012.• Model of MDR-TB care –community-based • Patients enrolment category – expanded beyond Cat II
failure • Treatment regimen revised – PAS to be included only for
Cat II failure MDR-TB patients
• MDR-TB township expansion started in 2012 according to scale up plan (2011-2015)
• MDR townships expanded from 22 to 38/ 330 townships in 6 States/Regions
(Yangon 18, Mandalay 11, Sagaing 3, Magway 2, Mon 2, Shan 2)
Case notification of MDR-TB (2008-2013)Year Cases (Solid/Liquid
Culture/LPA)Cases put on SLD
2010 312 192
2011 690 162
2012 778 442
2013 (Q1) 426 65
2013 (Q2) 376 218
Year Notified Treated Waiting (Lab confirmed) Fund2010 312 312
192 120 UNITAID2011 690 810
162 648112 (UNITAID)
50 (GF)2012 778 1426
442 984 GF2013 (1st Q) 426 1410
65 1345 GF2013 (2nd Q) 376 1721
218 1503 GF
Number of MDR enrolled on treatment 2009-2013 (2nd quarter)
4364 92
125158
192247
287304
354 376426
523
796
861
1084
0
200
400
600
800
1000
1200
2009Q3
2009Q4
2010Q1
2010Q2
2010Q3
2010Q4
2011Q1
2011Q2
2011Q3
2011Q4
2012Q1
2012Q2
2012Q3
2012Q4
2013Q1
2013Q2
Cum
ulat
ive
num
ber
End DOTS-Plus pilot project
MDR TB PatientsPilot YGN: 266 MDY: 43
GF YGN: 631 MDY: 107 Other State and Region: 37
Total = 1,084
Cohort report, Treatment Outcome(July 2009 - June 2011)
Cured Died Failure Refuse Default Total
YGN 172 45 3 1 28 249
MDY 29 7
0 0 2 38
Total20170%
5217.7%
3(1%)
1 (0.3%)
3010.5% 287
Total cohort cases (July 2009 – June 2011) ---- 309 casesDied before treatment ---- 6 casesStill on treatment ---- 16 (MDY- 5 cases & YGN- 11 cases)
Cohort report, Treatment Outcome(July 2009 - June 2011)
70%
18%
3%0%
11%
Cured: 201
Died: 52
Failure: 3
Refuse: 1
Default: 30
n = 287
MDR-TB patients at Aung San TB Hospital, Yangon, and in Meiktila
Township, Mandalay Region
Laboratories, drugs, staff and information
systems
Key activities to improve management of TB in hospitals
• MDR-TB management in hospitals (free of charge to the patient):– Vehicle is available for referring and
transfer of patients to various Specialist Hospitals if needed
– Nutritional support for MDR-TB patients hospitalized
– Side effect management– Laboratory investigations
• Infection control measures have been upgraded
• TB Control in Hospitals:– 23 hospitals are under Public-Public
Mix DOTS, however, weak commitment to treat MDR.
Family Health International 360 • FHI 360 work in close collaboration with the National
Tuberculosis Programme and implement activities in Mandalay and Yangon initially through 4 local partners:
1. Myanmar Medical Association (MMA) 2. Pyi Gyi Khin (PGK) 3. Myanmar Health Assistant Association (MHAA) 4. Myanmar Business Coalition on AID (MBCA)
Local Partners
Project Township Activity Current Status
MMA 1.South Okkalapa 2.Chan Mya Thazi.
-DOT to MDR-TB Patients-Manage minor adverse effects-Refer cases
-PMDT training-- 5 sessions(135)-Community supporter training ---- 1 session (15)
PGK 1.Mingalardon2.Mayangone3.Hlaing4.North Dagon
-Community outreach-Case finding & referral-Infection control and support package of services to MDR-TB patients
-176 MDR TB patients were provided with package of support-Total 1,483 beneficiaries were reached with TB prevention and treatment message
MHAA 1.Aungmyay Tharzan2.Chanaye Tharzan3.Mahar Aungmyay4.Pathein Gyi
Implementing the same activities as PGK
-38 MDR TB patients were provided with package of support-Total 2,294 beneficiaries were reached with TB prevention and treatment message
MBCA 1.Monywa (Industrial zone) -Community outreach-Case finding & referral
-Total number of volunteer trained --- 39-Total 1,619 factory workers and their family members were reached with TB prevention message.
TB/HIV collaborative townships - VCCT (2011-2012)
9683
56266394
3530
4937
2700
4137
2134
0
2000
4000
6000
8000
10000
12000
M F M F
2011 2012
Registered TB patient HIV Tested
Calculation based on 15 TB/HIV sites in 2011 and 18 TB/HIV sites in 2012
51%
48%
65%
61%
TB/HIV collaborative activities in 2011 to 2012 (VCCT)
Key activities to improve management of TB by private providers
• Private providers engaged at national scale:– Population Services
International (PSI): 190 tsps, 855 GPs
– Myanmar Medical Association (MMA): 116 tsps, 1443 GPs
• Contributing to about 16% of TB notifications
• ISTC adopted & disseminated since 2009
Major Challenges in combating drug resistant TB
• Strengthen human resources (number and skills), willingness of physicians
• Referral network for utilization of Xpert• Timely arrival of second-line anti-TB
drugs• Ensure ancillary drugs and support for
infection control• Geographical expansion • Expand MDR-TB follow-up sites
(decentralization)• Provide more incentive for Basic Health
Staff• Ensure/sustain nutritional support for
MDR-TB patients• Infection control measure for health
care settings
Expansion plan (with committed resources)
Year
Reference diagnostic labs with culture/
DST
Number of centers
with Xpert
Number of regions or states with TB/MDR-TB treatment
center
Number of townships with MDR-
TB treatment
center
Second-line anti-TB drugs
committed from
donors
2012 2 6 2 38 442
2013 3 24 7 53 984*
2014 4 38 13 68 500
2015 5 38 13 100 800
2016 5 38 13 100 1000
2017 5 38 13 130 • Patients to be treated also in 2014• Reference labs and Xpert MTB/RIF more ambitious that MDR-TB scale-up plan• MDR-TB patient enrollment less ambitious than MDR-TB scale-up plan
Planned activities• Case detection and diagnosis of MDR-TB by Xpert MTB/RIF,
Liquid Culture and LPA for all retreatment cases• Second-line anti-TB drug procurement:
– 2013: 508 (Global Fund and UNITAID) – 2014: 1084 (Global Fund)– 2015: 800 (Global Fund)– 2016: 1000 (Global Fund)
• MDR-TB support package for providers and patients• Procurement of infection control materials• Expansion of an additional three culture & DST laboratories• Timely procurement of lab. consumables for culture and
DST
Planned activities
• Publication and dissemination of new guidelines
• Geographical expansion 15 townships per year to 38 townships in 2014 (major training activities planned)
• Xpert MTB/RIF will be expanded in 2013-2014– 12 machines up and running– 4 machines from UNITAID (2013)– 6 machines from PEPFAR– 16 from GF (8 in 2013 and 8 in 2014)
• Increase of DOT provider allowance and patient support (nutrition and transportation)
Future Plan (FHI)
Expansion of Activities in YangonPGK : 2 new townships (Shwe Pyi Thar and NorthOkkalarpa Township)MHAA: 2 new townships (Insein and Hlaing Thar Yar) Activities will be the same as current townships
Expansion of Activities in Mandalay (MHAA)To expand 3 more townships and activities will be thesame.Expansion of Activities in Monywa (MBCA)To support package of services to MDR-TB patients byconducting home base care activities
Progress and achievements (2011-2013) in implementing the Stop TB Strategy
1. Nationwide DOTS2. EQA system on sputum smear microscopy for 425 laboratories,
introduced iLED fluorescence microscope to district.3. TB-HIV sentinel surveillance in 25 sites, TB/HIV collaborative
activities in 28 townships. 4. MDR-TB pilot successful and now expanding to programmatic
MDR-TB management.5. Successful PPM at nationwide scale, 20 partners involving in TB
control.6. Community based TB control activities with NGOs started in 154
townships (international NGOs in 23 townships).7. Operational Research are conducting in collaboration with Dept.
of Medical Research.
32
Government Budget for NTP (1995-1996 to 2011-2012) Years
32
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
Kyat
s in
thou
sand
s
Budget for Programme Management Budget for Drug Procurement
SrN
Funding sources
2011 2012 2013 2014 2014 Total
1 Gov. 1.23 1.93 1.93 1.93 1.93 8.98
2 GF 14.59 15.54 14.73 16.11 17.61 78.593 3DF 4.37 1.71 6.084 3MDG 2.8 2.8 2.8 8.45 JICA 0.16 0.19 0.356 USAID 2.0 2.0 4.0
7 TB Rearch 2.422 2.4228 WHO 0.14 0.13 0.13 0.13 0.13 0.699 UNITAID 0.19 0.19 0.3910 GDF 0.84 0.93 1.03 2.81
11 NGOs 0.24 1.87 1.34 1.34 1.3 6.1Total 23.79 26.94 21.98 22.33 23.78 118.84Fund needed 30.28 30.6 35.71 40.61 48,77 186.00Gap 6.48 3.65 13.73 18.28 24.99 67.15
Funding gap (2011-2015) (USD in million)
GF (NFM) – 82.3 Million USD, 3MDG - ~ 17 Million USD (2013-2016)
Issues and challenges
Sustainability of current achievement is limited due to following issues:
Limitation in human resource development
Limitation in capacity building
Improving case finding and treatment outcomes in selected townships (border and remote) with high treatment interruption rates and low community involvement in TB control
Limited access to HIV care for TB/HIV co-infected patients
Limited resources for MDR-TB management (Availability of diagnostic facilities and SLD, infection control measures)
Need technical assistance for new tools
Paper based R&R
New technology X pert
LPA
FM
MGIT
Thank you