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TB, MDR – TB control updates, Myanmar

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.

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TB, MDR – TB control updates, Myanmar

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  1. TB, MDR – TB control updates, Myanmar CAP-TB Strategic Planning Meeting, Bangkok, Thailand, 1-2 August, 2013

  2. TB burden • TB is a major public health problem • One of the world’s 22 high TB burdencountries, 27 high MDR-TB burden countries and 41 high TB/HIV burden countries Estimates of the TB burden in Myanmar, 2011 (based on 2009-2010 prevalence survey), source: WHO TB Control Report 2012

  3. TB epidemiology, Myanmar (2011) Mortality Prevalence Incidence

  4. HIV Sentinel Surveillance in Myanmar 2005 – 5 tsps 2012 – 25 tsps

  5. 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 Objectivesare 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)

  6. WHO-recommended Stop TB Strategy

  7. TB case notifications

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

  9. 9

  10. MDGs for TB Control  6.9 Global Tuberculosis Control 2010, WHO, Geneva # 6.10 National Tuberculosis Programme, Department of Health, Ministry of Health, Annual Reports (2000-2009)

  11. 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 Estimates of MDR-TB burden (2012)

  12. 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

  13. Treatment Regimens Standardized treatment regimens • 6 Am + Lfx + Eto + Cs + Z • 18 Lfx + Eto + Cs + Z OR 6 Am + Lfx + Eto + Cs + PAS + Z 18 Lfx + Eto + Cs + PAS +Z

  14. 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) Key activities to date to combat drug resistant TB

  15. Case notification of MDR-TB (2008-2013)

  16. Number of MDR enrolled on treatment 2009-2013 (2nd quarter) MDR TB Patients Pilot YGN: 266 MDY: 43 GF YGN: 631 MDY: 107 Other State and Region: 37 Total = 1,084 End DOTS-Plus pilot project

  17. Cohort report, Treatment Outcome(July 2009 - June 2011) Total cohort cases (July 2009 – June 2011) ---- 309 cases Died before treatment ---- 6 cases Still on treatment ---- 16 (MDY- 5 cases & YGN- 11 cases)

  18. Cohort report, Treatment Outcome(July 2009 - June 2011) n = 287

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

  20. Laboratories, drugs, staff and information systems

  21. 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. Key activities to improve management of TB in hospitals

  22. 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)

  23. TB/HIV collaborative activities in 2011 to 2012 (VCCT) 51% 65% 48% 61% • Calculation based on 15 TB/HIV sites in 2011 and 18 TB/HIV sites in 2012

  24. 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 Key activities to improve management of TB by private providers

  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) • 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

  27. 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

  28. 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) Planned activities

  29. Future Plan (FHI) Expansion of Activities in Yangon PGK : 2 new townships (ShwePyiThar and NorthOkkalarpa Township) MHAA: 2 new townships (Insein and HlaingTharYar) Activities will be the same as current townships Expansion of Activities in Mandalay (MHAA) To expand 3 more townships and activities will be the same. Expansion of Activities in Monywa (MBCA) To support package of services to MDR-TB patients by conducting home base care activities

  30. Progress and achievements (2011-2013) in implementing the Stop TB Strategy • Nationwide DOTS • EQA system on sputum smear microscopy for 425 laboratories, introduced iLED fluorescence microscope to district. • TB-HIV sentinel surveillance in 25 sites, TB/HIV collaborative activities in 28 townships. • MDR-TB pilot successful and now expanding to programmatic MDR-TB management. • Successful PPM at nationwide scale, 20 partners involving in TB control. • Community based TB control activities with NGOs started in 154 townships (international NGOs in 23 townships). • Operational Research are conducting in collaboration with Dept. of Medical Research.

  31. Government Budget for NTP (1995-1996 to 2011-2012) Years 32 32

  32. Funding gap (2011-2015) (USD in million) GF (NFM) – 82.3 Million USD, 3MDG - ~ 17 Million USD (2013-2016)

  33. 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

  34. X pert New technology LPA FM Thank you MGIT

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