TB, MDR – TB control updates, Myanmar

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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

Transcript of TB, MDR – TB control updates, Myanmar

Country Response to the M/XDR-TB challenge Poster Presentation

TB, MDR TB control updates, Myanmar

CAP-TB Strategic Planning Meeting,

Bangkok, Thailand, 1-2 August, 2013

1

TB burden

TB is a major public health problem

One of the worlds 22 high TB burdencountries, 27 high MDR-TB burden countries and 41 high TB/HIV burden countries

Population 60 million-NumberRate (per 100,000 population)Prevalence240,000506 (390-637)Incidence180,000381 (326-439)Incidence (HIV positive)18,00038 (31-45)Mortality (excluding TB/HIV)23,00048 (22-84)Notifications (new and relapse)136,737283

Estimates of the TB burden in Myanmar, 2011 (based on 2009-2010 prevalence survey), source: WHO TB Control Report 2012

2

TB epidemiology, Myanmar (2011)

Mortality

Prevalence

Incidence

3

HIV Sentinel Surveillance in Myanmar

2005 5 tsps

2012 25 tsps

Goal, Objectives & targets

Goal

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)

5

WHO-recommended Stop TB Strategy

TB case notifications

7

Proportion of all form TB patients contributed by NTP and Other reporting units (2012)

9

9

NoIndicator199020052007201120156.9Incidence, prevalence and death rates associated with tuberculosis 1 . Incidence404404404381To halt and reverse2. Tuberculosis Prevalence all cases / 100,000 pop. 922628596506 (45%)4613. Tuberculosis Death rate / 100,000 133675848 (64%)666.10 # Proportion of tuberculosis cases detected and cured under directly observed treatment, short course1. Proportion of tuberculosis cases detected38959077At least 70%2. Proportion of tuberculosis cases treated successfully78858585.4At 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 casesPreviously treated casesCases with DST results (H+R)Multidrug-resistantCases with DST results (H+R)Multidrug-resistantNo.% No.% 2002-20033.90%15.50%2007-20081,071454.2% (3.1-5.6)2993010.0% (6.9-14.0)2013Third survey to be completed in 2013

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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 developed

based 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

12

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)

14

Case notification of MDR-TB (2008-2013)

YearCases (Solid/Liquid Culture/LPA)Cases put on SLD2010312 1922011690 1622012778 4422013 (Q1)426 652013 (Q2)376 218

15

Number of MDR enrolled on treatment 2009-2013 (2nd quarter)

End DOTS-Plus pilot project

MDR TB Patients

Pilot YGN: 266

MDY: 43

GF YGN: 631

MDY: 107

Other State and Region: 37

Total = 1,084

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Cohort report, Treatment Outcome(July 2009 - June 2011)

CuredDiedFailureRefuseDefaultTotalYGN172453128249MDY2970 0238Total20170%5217.7%3(1%)1 (0.3%)3010.5%287

Total cohort cases (July 2009 June 2011) ---- 309 cases

Died before treatment ---- 6 cases

Still on treatment ---- 16 (MDY- 5 cases & YGN- 11 cases)

Cohort report, Treatment Outcome(July 2009 - June 2011)

n = 287

Column1Cured: 201Died: 52Failure: 3Refuse: 1Default: 300.70000000000000040.17700000000000013.0000000000000006E-23.0000000000000022E-30.10500000000000002

MDR-TB patients at Aung San TB Hospital, Yangon, and in Meiktila Township, Mandalay Region

19

Laboratories, drugs, staff and information systems

20

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.

21

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 PartnersProject TownshipActivityCurrent StatusMMA1.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)PGK1.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 messageMHAA1.Aungmyay Tharzan2.Chanaye Tharzan3.Mahar Aungmyay4.Pathein GyiImplementing 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 messageMBCA1.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.

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)

24

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

25

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

26

Expansion plan (with committed resources)

YearReference diagnostic labs with culture/DSTNumber of centers with XpertNumber of regions or states with TB/MDR-TB treatment centerNumber of townships with MDR-TB treatment center Second-line anti-TB drugs committed from donors2012262384422013324753984*201443813685002015538131008002016538131001000201753813130

Patients to be treated also in 2014

Reference labs and Xpert MTB/RIF more ambiti