Download - CAP-TB

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
Estimates of the TB burden in Myanmar, 2011 (based on 2009-2010 prevalence
survey), source: WHO TB Control Report 2012
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
TB epidemiology, Myanmar (2011)
Mortality
Prevalence
Incidence
HIV Sentinel Surveillance in Myanmar
HIV prevalence among new TB patients (2005-2012)
12
10.3
11.1
10.8
10.4
9.8
10
9.9
9.7
2011
2012
9.2
Percent
8
6
4
2
0
2005
2006
2007
2008
2009
Year
2005 – 5 tsps
2012 – 25 tsps
2010
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)
WHO-recommended Stop TB Strategy
TB case notifications
160000
147984
140000
133547
143164
134023
137403
123593
120000
107991
Cases Load
100000
97909
128739
New SS +
New SS neg
EP
All Cases Load
80000
77231
58243
60000
42455
40000
31703
20000
17008
1555
0
20196
16113
19626
14756
Years
Proportion of all form TB patients contributed by NTP and
Other reporting units (2012)
NTP, 75.8%
MSF(CH), 0.4%
MDM, 0.1%
AHRN, 0.2%
MMA, 2.1%
PPM Hospital, 2.8%
AZG(MSF-H), 2.5%
PSI, 16.1%
Treatment Success Rate of NS(+), S(-) and Relapse cases in
Country (2000-2011)cohort
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
NSP
SN
Relapse
9
MDGs for TB Control
No
6.9
Indicator
1990
2005
2007
2011
2015
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
2. Proportion of tuberculosis
cases treated successfully
78
85
85
77
85.4
At least 70%
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)
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
Cases
with DST
results
(H+R)
Previously treated cases
Multidrug-resistant
No.
%
Multidrug-resistant
Cases with
DST results
(H+R)
No.
%
20022003
3.90%
15.50%
20072008
4.2%
(3.1-5.6)
10.0%
(6.9-14.0)
2013
1,071
45
299
30
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 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
Treatment Regimens
Standardized treatment regimens
• 6 Am + Lfx + Eto + Cs + PAS + Z
• 18 Lfx + Eto + Cs + PAS +Z
OR
•
•
6 Am + Lfx + Eto + Cs + Z
18 Lfx + Eto + Cs + Z
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
2010
2011
Notified
Treated
312
690
Waiting (Lab confirmed)
312
192
120
810
162
2012
778
442
2013 (1st Q)
426
65
2013 (2nd Q)
376
218
648
1426
984
1410
1345
1721
1503
Fund
UNITAID
112 (UNITAID)
50 (GF)
GF
GF
GF
Number of MDR enrolled on
treatment 2009-2013 (2nd quarter)
1200
MDR TB Patients
Pilot YGN: 266
MDY: 43
Cumulative number
1000
1084
GF YGN: 631
MDY: 107
Other State and Region: 37
800
861
796
Total = 1,084
523
600
426
400
287
247
125
200
43
64
158
192
304
354
376
End DOTS-Plus
pilot project
92
0
2009 2009 2010 2010 2010 2010 2011 2011 2011 2011 2012 2012 2012 2012 2013 2013
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
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
Total
201
70%
52
17.7%
3
1
(1%) (0.3%)
30
10.5%
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
0.3%
3%
10.5%
Cured: 201
18%
Died: 52
70%
Failure: 3
Refuse: 1
Default: 30
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.Mingalardon
2.Mayangone
3.Hlaing
4.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 Tharzan
2.Chanaye Tharzan
3.Mahar Aungmyay
4.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 activities in
to townships
2012 -(VCCT)
TB/HIV2011
collaborative
VCCT (2011-2012)
12000
10000
9683
Registered TB patient
HIV Tested
8000
51%
6000
6394
65%
5626
4937
48%
4000
4137
61%
3530
2700
2134
2000
0
M
F
2011
M
F
2012
 Calculation based on 15 TB/HIV sites in 2011 and 18 TB/HIV sites in 2012
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)
Number of
regions or
states with
Number of TB/MDR-TB
centers
treatment
with Xpert
center
Number of
townships
with MDRTB
treatment
center
Secondline antiTB drugs
committed
from
donors
Year
Reference
diagnostic
labs with
culture/
DST
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 20132014
–
–
–
–
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 Yangon
PGK : 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 the
same.
Expansion of Activities in Monywa (MBCA)
To support package of services to MDR-TB patients by
conducting home base care activities
Progress and achievements (2011-2013)
in implementing the Stop TB Strategy
1.
2.
3.
4.
5.
6.
7.
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.
Government Budget for NTP (1995-1996 to 2011-2012) Years
800,000
Kyats in thousands
700,000
600,000
500,000
400,000
300,000
200,000
100,000
0
Budget for Programme Management
Budget for Drug Procurement
32
Funding gap (2011-2015) (USD in million)
Sr
N
Funding
sources
1
Gov.
2
2011
2012
2013
2014
2014
Total
1.23
1.93
1.93
1.93
1.93
8.98
GF
14.59
15.54
14.73
16.11
17.61
78.59
3
3DF
4.37
1.71
4
3MDG
5
JICA
6
USAID
7
TB Rearch
8
WHO
0.14
0.13
9
UNITAID
0.19
0.19
10
GDF
0.84
0.93
1.03
11
NGOs
0.24
1.87
1.34
1.34
1.3
6.1
Total
23.79
26.94
21.98
22.33
23.78
118.84
Fund needed
30.28
30.6
35.71
40.61
48,77
186.00
6.48
3.65
13.73
18.28
24.99
67.15
Gap
6.08
2.8
2.8
2.8
8.4
0.16
0.19
0.35
2.0
2.0
4.0
2.422
2.422
0.13
0.13
0.13
0.69
0.39
2.81
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
LPA
FM
MGIT
X pert