National TB Prevalence survey in Myanmar. By Dr. Thandar Lwin Programme Manager National TB Programme Department of Health

Transcription

1 National TB Prevalence survey in Myanmar By Dr. Thandar Lwin Programme Manager National TB Programme Department of Health

2 58 million pop. 676,577 sq km (75/sq km) S+ notification rate/100,000 population in Myanmar ( ) per 100,000 population Year Includes in 22 TB HBC Est. ARTI % (1972), 1.5% (1994) Est. TB prev.- 162/100,000 pop. (All TB cases) Est. TB death rate 13/100,000 (2006)

3 Yangon Divisional Survey (2006) (GF, WHO, JICA, JATA) - Screened for TB symptoms by interview - CXR screening - Sputum examination for those with TB symptoms and CXR abnormalities f/b culture Point Estimate Detected of TB prevalence per 100,000 95% CI For population aged 10 or more Eligible samples: S(+) TB New S(-), Culture (+) TB New S(-), Culture (-), X-ray(+) TB suggestive New Bacteriologically positive TB New For all population Size of population: S(+) TB (*) * Assuming there was no smear + cases in children under 10 years

4 National TB prevalence survey (2009) Primary objective: To determine the prevalence of pulmonary TB at a defined point in time (2009) in Myanmar: - smear positive pulmonary TB - culture positive pulmonary TB - symptoms suggestive of TB - radiological abnormalities suggestive of pul. TB Secondary objective: To identify Health seeking behaviour of TB patients and individuals reporting chest symptoms Utility of private sector TB Risk factors such as nutrition, smoking, housing conditions (SE factors), etc.

5 Sample size Sample size of 49,690 eligible subjects are required Cluster Capacity of the cluster work: ~ 200/day Capacity / week: Therefore 70 clusters, 710 eligible subjects aged 15 or more Stratification States (28%) and Divisions (72%) Cluster distribution (70 clusters): States 20, Divisions townships excluded from a sampling frame due to logistical difficulties to carry out field operations (2.4% of total populations)

6 Preparation for survey Protocol development and put up for the permission of MOH and ethical committee Secure funding Procurement takes 3-6 months Develop survey field manual Field testing of questionnaire Provide trainings Organize survey teams (3 based in Yangon, 2 based in Mandalay) (2 teams operation at the same time, 8 months may be necessary to complete 70 clusters)

7 Organization Central Steering Committee Technical Advisory Group Central coordinating unit Administration: Finance/Logistic management Lab. unit X ray unit Statistics (Data management) unit Field Teams Team leader (Dr.), 4 Interviewers, 2 X-ray Technicians and 1 Assistant, 1 Dr. for X ray screening, 3 Drivers (12 No.) Local: TB coordinator, Lab technician, Health workers and community volunteers (11 No.)

8 Screening: Survey Method Interview and Chest X-ray Bacteriology 2 Sputum samples (spot & early morning home collection) will be collected from those with TB suspected symptom and/or those with defined abnormality on Chest X-ray

9 Microscopy/Culture 2 sputum specimens from TB suspects Screen by Fluorescence microscope Confirming only positive slides by ZN Culture with Egg-based Solid Mediums Identification : PNB, Niacin test, capillia test

10 Time Frame Item Preparation for protocol Selection of cluster Approval from MOH, Ethical committee (DOH), Advocacy and resource mobilization Procurement Training / filed testing Pre visits Survey operation Technical assistance (WHO) JICA/JATA Oct Nov Dec Jan Feb March Apr May June July Aug Sept

11 Time Frame Item Survey operation Lab results Data manageme nt and analysis Post survey Preliminary Results Final Results TA (WHO) TA (JICA/JATA) Oct Nov Dec Jan Feb March Apr May June July Aug Sept Oct Nov Dec

12 Budget Items USD % 1 Technical assistant (WHO) 8, Capital cost (Procurement) 4 X-ray units with portable generator (7.5KVA) Incubators and generator (45KVA) for lab Field operation cost in 70 clusters Car hiring cost and fuel Fuel cost for generators Supervision only to 25 clusters 2, Pre visits 2 times of pre visits to each cluster 18, Training 9, Expenses for X-ray machine maintenance 6, Expenses for lab maintenance 5, Expenses for sputum microscopy and culture Central Data Management Stationery & printing forms 23, Contingency 2, WHO administrative cost 81, Total 877,

13 Funding sources Sources of funding MOH/DOH/NTP WHO Contribution in USD Human resource Remarks 15,000 Technical Assistance 3DF JICA JATA Bill & Melinda Gates foundation /PSI/WHO USAID/PSI/WHO 120,000 Available budget 877, ,000 Equipment & field operational cost 114,000 Technical Assistance, Training and one X-ray unit, generator for lab. Technical Assistance 358,000 Equipment & field operational cost Including WHO administrative cost (7%) for 3DF, (13%) for BMGF/USAID/PSI

14 Major Challenges Timely procurement Different funding mechanism Human Resource Capacity of TB Lab Culture and quality control Mobilization of clinical staff especially for field works for 8 months Staff motivation Monsoon, rainy season

15 Trainings

16 Training

17 Pre testing 519 Young ladies working in a garment factory were screened and treated 3. 2 S +, C+ 1 S neg., C neg. CXR proved were treated DOT at work place

18 Pre Visit: Collaboration of local community is essential

19 Briefing, Preparation for census and census

20 Census: Confirming eligible population and asking for participation People who basically stay in a defined area more than two weeks are eligible population regardless the possession of their house or having Form 10 (household register)

21 Structured Interview by a trained interviewers Basic socioeconomic data TB related symptoms Duration of sickness TB history Previous treatment Consultation Places Current Treatment Utilization of Public and Private Service Home visits are carried out to those who can t afford to come due to illness, age etc.

22 X-ray Cars & Portable X-ray machine

23 Flow Not Eligible Subjects Reception (1+2) Interview (3) Team Leader Chest X ray(1+3) Lab.: Sputum Exam. Registration & collection (1) X-Ray reading X ray normal Abnormal Check out & incentive (1) Explanation if necessary

24 Age 15years Taking X ray RIT/JATA provided X-ray cars and JICA provided portable X- ray units

25 Developing Film and reading on the Spot using Auto processor

26 Field X-ray reading

27 Quality Sputum collection and Quality Bacteriology Examinations are Keys for the Survey

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29 Data entry and analysis EPI Info version 6.4d and STATA version 9 are used Data entry and validation will be done with partners

30 Role of partners - PSI, 3DF, WHO, JICA, JATA - Synchronized contribution of fund - Involve in Central Steering Committee - PSI Post survey case control study - Involvement in data analysis and documentation Lessons learnt - Quality of laboratory and laboratory capacity - Maintenance of equipment - Strong leadership - Staff motivation - Not to do survey in raining season Recommendations to other countries - To have high political commitment - To secure fund and make sure to have simple funding mechanism - Need a full time survey coordinitor

31 Thank you

32 Outline of the presentations 1.Background map, pop 2.Epidemiology estimated incidence, notification rate 3.Yangon survey result 4.Outline of national survey (sample size, clusters, screening methodology) 5.A photo of portable CXR 6.Timeline of preparation 7.Organogram, staffing 8.Training field testing 9.Role of partners 10.Lessons learnt 11.Recommendations to other countries

33 Sample size Expected prevalence of S(+) in aged 15 or more: 278.4/100,000 Precision (d)= 20%(0.0005) 95% Confidence Level Participation rate 90% Cluster effect = 1.3 from Yangon Survey experience more precise study than that of previously planned for future comparison to show a decline, impact of the efforts Sample size of 49,690 eligible subjects are required

34 Field practice: Flow of participants and placing of survey team

35 Nation wide Sputum positive point prevalence Survey in 1994 Screened for chest symptoms Sputum examination for TB suspects Age 10 years and above Examined S + Per 100,000 (95% CI) Urban 10, (34-150) Rural 26, (81-168) Total 37, (75-144)