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