Outline. Milestone of survey in Myanmar Objectives Method Results Discussion Limitation Programme implications

Transcription

1 MHAA

2 Outline Milestone of survey in Myanmar Objectives Method Results Discussion Limitation Programme implications

3 1972 National TT survey 1994 National Sputum smear positive TB prevalence survey Protocol drafted in 2005, however, due to funding limitation, Yangon Divisional TB prevalence survey was conducted in 2006 as a pilot phase, capacity building was done and some equipment for survey were procured. Preparation for Protocol - October, November, 2008 Approval of MOH - December, 2008 Ethical Approval - 16 th February, 2009 Procurement started - December, 2008 Selection of Clusters - November, 2008 Meetings for NPS - February, 2009 Training to , to Pre testing/ Field testing at Singu Ward, Insein Township, 1 st Steering Committee Meeting nd Steering Committee Meeting

4 National TB Prevalence survey (MYANMAR) - smear positive pulmonary TB - Culture positive pulmonary TB - symptoms suggestive of TB - radiological abnormalities suggestive of pulmonary TB Health seeking behaviour of TB patients and individuals reporting chest symptoms Utility of private sector such as proportion of TB patients under treatment in private sector TB Risk factors

5 Survey sites: Eligible pop: Country wide 15 years age group Study period: January, 2009 to December, 2010 : Cluster sampling method stratified by state and division. : A cluster

6 Myanmar 17 States & Divisions 70 clusters 7 Divisions (72% of pop) 50 clusters PPS 7 States (28% of pop) 20 clusters Remark: For Division - Urban 11 clusters, Rural 39 clusters For State - Urban 5 clusters, Rural 15 clusters 32 townships excluded from a sampling frame due to logistical difficulties to carry out field operations (2.5% of total populations excluded)

7 Distribution of survey clusters Documented Video Supported by JICA

8 TB Prevalent Case : 2 sputum smear positive results or 1 positive smear result with an X-ray result consistent with active TB or 1 positive smear result with a culture confirmation. Even scanty positive (<10/100HPF) was considered as smear positive. : 2 sputum smear results were negative with at least 1 culture confirmation of M.tb. negative/culture positive. : a case of smear positive or smear : No evidence of bacteriologically positive TB but with strongly suggested active TB disease in the X-ray examination were judged by the central panel consisted of at least 2 chest physicians.

9 to the participants on TB symptoms and history Compulsory with informed consent For pregnant women, sputum specimens were took compulsory, No CXR If CXR shows abnormal lesion or any chest symptomatics or those who gave any history of current / previous anti-tb treatment 2 sputum specimens were taken - Sputum for AFB examination at Reference Laboratories, Yangon and Mandalay using fluorescence microscopy, confirmed by ZN stain - Culture egg based solid mediums were used - Identification Niacin test, PNB and Capilia test were used

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12 Results

13 Summary of National TB Prevalence Survey Individuals enumerated in Census 93,806 Ineligible individuals: 27,399 Children 8,800 adults due to residential criteria Eligible study population 57,607 (61.4%) Participants 51,367 (89.2%) -Interview only 1,126 (2.2%) - Interview and CXR 50,241(97.8%) Eligible for Sputum Examinations 12,235 (23.8%) Submitted at least one specimen 12,144(99.3%) Symptom+CXR+ 1,259 Symptom+CXR- 402 Symptom-CXR+ 9,378 Symptom+CXR NA 30 Symptom-CXR NA 1,096 By corrective action 70

14 Summary of National TB Prevalence Survey, Myanmar, Lab Results available 12,087(98.8% of eligible) (2 Smear 2 Culture results 11,587) Any Smear Positive 132 (2S+:89,1S+:43) Smear Negative 11,955 (2S - =11,875,1S - = 80) Culture Result MTB MOTT - 2 Contaminated - 0 Negative 14 N.A 0 Culture Result MTB MOTT - 22 Contaminated 51 Negative 11,672 N.A 9

15 Summary of National TB Prevalence Survey, Myanmar, Central Panel S+C+TB cases 116 S+C-TB cases 7 Excluded cases 7 MOTT 2 C+TB Cases 188 Excluded cases 13 MOTT 22

16 TB Prevalence among Survey Participants (aged 15 years) Smear-positive cases Smear-negative, culture-positive cases Bacteriologically confirmed cases All participants n % n / % CI n / % CI n / % CI % Strata Division % State % Urban/Rural Urban % Rural % Sex Male % Female %

17 Variations by clusters Red: S+; Blue S C+ No. Cases in 5 clusters 25 S-C+ S urban cases 10 Rural 5 0

18 No. of S+ and C+ case detected cases by sex M S+ M C+ F S+ F C+ 40 cases

19 Urban and Rural Differences Smear Positive TB Prevalence U Male R Male U Female R Female S+/100K age

20 Urban and Rural Differences Bacteriological Positive Cases 4000 Bac+ TB/100, Urban Male Rural Male Urban Female Rural Female

21 TB Cases (Survey cases) by Interview and CXR results S+ C+ TB case S+ C- TB case S- C+ TB case Smearpositive study case % Bac confirmed study cases % Total % % Symptom Eligible Ineligible Field CXR Eligible Ineligible No CXR Central reading Normal Active TB suggestive TB suspect Healed TB Other lung disease Cardiovascular abn Other findings in lung Findings other than lung Not interpretable Not available for reading

22 TB Cases (Survey cases) by Interview and CXR results S+ C+ TB case S+ C- TB case S- C+ TB case Smearpositive study case % Bac confirmed study cases % Total % % Sex and Age Male % % % 8 2.6% % % % % % % % % % % Female % % % 3 1.0% % % % % % % % % % % Geography State Rural Clusters % % State Urban Clusters % % Division Rural Clusters % % Division Urban Clusters % % Treatment On TB treatment % % Previously treated (not on Tx) % %

23 Symptom screening and TB diagnosis 42/123 (34.1%) S+ cases reported cough > 21 days (66/311 (21.2%) Bact + reported cough > 21 days ) 21/123 (17.1%) smear positive cases did not report any symptom 24/188 (12.8%) S- C+ cases reported "cough > 21 days 96/188 (51.1%) S- C+ cases did not report any symptom

24 Past History of TB On Treatment (79) S % Bact % With TB History (1,523) S % Bact %

25 Place of TB Treatment Current Treatment Previously Treated Place % % HP/HC 27 34% % public hosp 36 46% % GP 12 15% % private hosp 2 3% 29 2% pharmacy 1 1% 11 1% others 1 1% 21 1% unknown 3 0% Total Access to DOTS through HP/HC have improved, while private sector notified more cases

26 State/Division Bac+ TB Crude OR Adjusted OR (random effect model)* Participants Cases / OR 95% CI P>z OR 95% CI P>z Division Reference Reference State Urban/Rural Rural Reference Reference Urban Sex Risk analysis: Prevalence, Crude & adjusted OR Male Reference Reference Female Age group Reference

27 Risk analysis: Prevalence, Crude & adjusted OR Religion Bacteriologically + TB Prevalence Crude OR Adjusted OR (Random effect model) Cases Participants per 100,000 OR 95% CI P>z OR 95% CI P>z Non-Buddhist Reference Reference Buddhist Education Literate Reference Reference Illiterate Occupation Non-farmer Reference Reference Farmer Previous Tx Not answered Yes Reference Reference Answered Yes Contact Not answered Yes Reference Reference Answered Yes Smoking Never smoked Reference Reference Ex-smoker Current smoker Alcohol Never Reference Reference Ex-drinker Current drinker Predictors such as CXR suggestive of having TB, Chest symptoms, and BMI are associated with bacteriologically positive TB and significant in the random effects model.

28 Health seeking practice

29 First Action when having chronic cough With Chronic Cough Traditional Medicine, Pharmacy Visit Medical facility Visit Public Facilities Total 10,856 8,038 4,251 (41,374) 26% 19% 10% TB CASES (265) 22% 25% 14% Symtomatic (1663) 31% 22% 12%

30 First Action when having chronic cough among TB cases S+C+ % S C+ % CXR+ % Go to traditional healer + pharmacy Go to private sector Go to public sector Self medication Neglect and others Total

31 Discussion

32 Survey in 1994 Sputum collection from TB suspects by symptoms/all age (10y or more) Examined S+ Per 100,000 cases Urban 10, Rural 26, Total 37, (132)

33 Has TB Situation become worse as we observed higher prevalence? National TB Prevalence Surveys, Myanmar 400 Smear Positive TB/ 100K aged 15 or more / Age Group Do we have younger patients than previous surveys?

34 Comparison between Myanmar National TB Prevalence Survey results, 1994 and (Direct comparison of survey findings)

35 Survey findings adjusted with screening and diagnostic algorithm 35% reduction in prevalence was observed over 15 years, when the same screening and Dx algorithm was applied for 2 surveys

36 Comparison with the past surveys and Case notification data 2009 smear positive case Y Yangon / /10symp 2009Notifi National Symptomatic

37 High Prevalence and Gap between prevalence and Notification /2010 Survey 2009 Notification 2009/ Notifi

38 Notification and Prevalence S+ in Notification S+/100, S+ with cough >3w Prevalence

39 National TB Prevalence Survey in ASEAN countries (Surveys with CXR and Culture) Smear Positive Bac Confirmed Cambodia y- 362 ( ) 1208 ( ) Philippines y- 260 ( ) 660 ( ) Viet Nam y- 197 ( ) 307 ( )* Myanmar y- 242 ( ) 613 ( ) *Viet Nam: one culture only

40 Limitations Design of the study TB in children and EP could not be assessed HIV, MDR-TB data are not available Operational aspects Delay in logistic procurement: quality of CXR Sputum cups used in survey were not appropriate In few urban clusters and remote clusters with ethnic minorities had a relatively low participation rate Fewer participation in male Some positive subjects may be missed by screening especially those with milder symptoms without detectable CXR abnormality A few positive subjects might not submit sputum samples

41 Limitations Operational aspects Cross contamination in the laboratory in Mandalay Language barrieer Analysis Removing possible TB cases : one S+ or one culture positive without other evidence of disease from the survey case list without imputation of missing value may lead to an underestimation of the prevalence by around 10-15%.

42 Summary of the 3 rd National TB Prevalence Survey Myanmar Field Operation From June April 2010 No of clusters 70 No of Eligible (>15y) 57,607 No of participated 51, % No detected /100K 95% C.I. Smear positive TB (all age*) S-C+ TB Bac+ TB *Assuming that 73% of population are aged 15y or more and that there is no smear positive case in Children

43 Summary Quality survey confirmed the high prevalence of TB Only 1/3 of S+ reported cough >3 weeks 35% decline of S+TB with Chronic cough compared with 1994 survey It seems that DOTS has worked in the target group (S+ with chronic cough) However, no-decline was observed in younger age groups: Migration and HIV?

44 Summary cont Urban-Rural discrepancies (R>U in 1994 ) Urban areas are having high prevalence cases than rural in current survey Male-Female differences State had higher prevalence than Division Visiting medical facilities as first action for chronic cough is not common. Difference between urban and rural is large. Lower proportion of people visit medical facilities in rural areas: Mainly access problem?

45 Implication for the programme Higher prevalence in States with fewer notification suggests challenge in access High prevalence in urban with high notification rate suggests higher burden of TB in urban, congestive areas "Gap between prevalence and notification" and "recent decline of notification rate" suggest a slow decline of TB incidence and limitations of current case finding strategy Removing serious cases from community, impact on TB mortality might be significant. However, the impact of control efforts on TB incidence might not be sufficient

46 Most TB symptomatics have not received appropriate TB screening and diagnosis Limitation of access even in urban areas Limitation of the screening criteria by symptoms Limitation of smear microscopy diagnosis Limitation of CXR diagnosis in routine practice (Are smear negative cases really TB? Under-diagnosis as healed TB?) Speculations Probable 2 nd wave of TB epidemic in two decades Possible spread of 2 nd epidemic wave from Urban to Rural Low prevalent clusters: the 2 nd wave not reached yet

47 Population 59,000,000 Estimated incidence all forms 384/100,000 (Global TB control: a short update to the 2010 report, WHO, Geneva. 2011) Estimated TB prevalence 525/100,000 Estimated TB mortality 49/100,000 HIV sero-positive among TB patients 4.5% (1997) (For 20 sentinel sites) 10.4% (2010) MDR-TB ( country wide 2 nd DRS) 4.2 % (new cases) 10% (treated cases) TB control achievement for 2010 CDR = 76% & TSR = 85% Case Notification Rate for /100,000 pop. Smear + TB Notification Rate for /100,000 pop.

48 Acknowledgement NTP Myanmar appreciates to multiple partners (MOH/DOH, WHO, JICA/RIT, PSI, USAID, 3DF, MHAA) involved in this survey contributing either technical or financial support for the making the survey successful. The support of local health authorities and basic health staff, local volunteers, local communities was also a great value in data collection phase. Special thanks to Dr. Hans, H. Kluge, WHO, Dr. Ikushi Onozaki, WHO and Dr. Norio Yamada, RIT were recorded for their tremendous contributions.

49 Thank you

50 To improve access to diagnostic service Remote States: Distance, Engaging Pharmacies and Traditional Healers Congestive urban areas: Private, Service Hours Aggressive service in collaboration with private sector and partners seems to be essential Active case detection, mobile services TB screening in HIV service and Anti-natal care To improve TB screening Appropriate use of CXR Widening CXR screening criteria Widening symptom screening criteria Improving quality of CXR

51 To improve TB diagnosis Give up the expansion plan of culture service Introduce new molecular technology to detect S- TB Pilot the direct administration of new technology among high risk/predictive TB suspects Develop and pilot the transportation system of sputum specimens and feedback mechanism Review diagnostic algorism of smear negative subjects in settings where only smear MS and CXR are available

52 Pilot and Study the impact of One time clean up operation on TB incidence in community in high burden areas of both urban and rural Discuss to plan next survey to measure changes after 2015

53 With strong leadership and partnership, Myanmar will be able to show the impact of new interventions and strategy. A quality survey was carried out to provide the base line data and scientific evidences Quality of routine surveillance is essential to follow the future change Quality of diagnosis Coverage of surveillance Data of Children HIV Data MDR Surveillance data

54 Prevalence of TB among aged 15 or more Smear Positive case Bacteriologically confirmed case n /100,000 95% CI n /100,000 95% CI All participants ( ) ( ) Strata Urban/Rural Division ( ) ( ) State ( ) ( ) Urban ( ) ( ) Rural ( ) ( ) All age 172/100, /100,000 (NTP Notification: 0.7% of S+ are Children) (No data)

55 Smear Positive Subjects 132 Smear Positive Subjects 118 Definite Cases: Culture+ for Mycobacterium TB 5 Probable Cases without culture confirmation Two slides positive CXR TB consistent findings 7 Possible Case: One slide positive without any other evidence suggesting TB disease : exclude from the study case 2 Mycobacterium Other Than TB by Culture

56 Culture Positive Subjects 223 Smear Negative Culture Positive Subjects 188 Definite Case with Mycobacterium TB Isolates Positive with >5colonies or other evidence of TB 0 Probable Case: No confirmation of M TB 13 lab contamination susp: possible cases (non-study cases) 12: <5 (1-2) colonies without other evidence of disease 1 : 10 colonies with a possible lab accident 22 with MOTT isolates without M TB

57 TB history of Prevalent Cases 118 S+C+ 110 Not on treatment (91.5%) 89 New Cases (75.4%) 21 Previously Treated 7 First Treatment 1 Retreatment 188 S C+ 167 New (88.8%) 18 Previously treated 3 On treatment 2 on 1 st treatment 1 on retreatment 5 S+C 2 New 1 Previously treated 2 On Tx 1 On 1 st treatment 1 On Retreatment

58 Categorization of survey population and TB screening implementation (based on variables of sputum request) Survey Population and Status Abbrevi -ation Number Proportion Population under census N % of population under Eligible population N census Identified TB cases S+TB S-C+TB B+TB Participants N % of eligible population Received symptom screening N Received CXR N Not received CXR Received both N Eligible for sputum exam based on symptoms and CXR N At least two smears examined At least one culture done N % of those eligible for sputum exam 98.3% of those eligible for sputum exam N Ineligible for sputum examination N6b At least two smears examined N7b 80 At least one culture done N8b 80 [1] Judged as TB symptomatic and/or as having CXR shadow eligible for sputum examination or having no CXR examination. [2] All participants except those meeting the criteria of note 3 above.

59 Categorization of survey population and TB screening implementation (including persons with field reading recorded as active/suspect but who did not have sputum request recorded) Survey Population and Status Abbrevi -ation Number Proportion Population under census N % of population under Eligible population N census Identified TB cases S+TB S-C+TB B+TB Participants N % of eligible population Received symptom screening N Received CXR N Not received CXR Received both N Eligible for sputum examination based on symptoms and CXR N At least two smears examined N At least one culture done N % of those eligible for sputum exam 98.2% of those eligible for sputum exam Ineligible for sputum examination N6b At least two smears examined N7b 56 At least one culture done N8b 56

60 Prevalence Estimates were done with deferent methodologies Most have similar results Considering the participations by age and sex, estimate changes 1-2% Some scenarios with counting those with missing value may increase the prevalence around 10% However Central Review and CXR QA reading suggest that those who missed examinations are less likely to be positive than those who submitted, few major error in screening reading was observed by audit. ex. No symptomatic subject with TB suggestive CXR was missed

61 Use of Medical facility among symptomatic With Chronic Cough Visit Traditional Healer, Visit Medical facility Visit Public Facilities Pharmacy TB CASES (265) 18% 25% 14% Symtomatic (1663) 25% 22% 12%

62 Comparison with the past surveys and Case notification for smear positive case in 2009 Yangon 2006 National 2009 Symptomatic 2009

63 Notification/ Prevalence ratios by different groups Prevalence * 95% CI Notification 2009 N/P 95% CI Total Sex Male Female Age Strata State Division Upper Lower

64 Notification/Prevalence ratios for smear-positive TB by different groups, Myanmar National TB Prevalence Survey,

65 Further studies and analysis Further bacteriological exams in RIT/Japan Follow up in depth interview to detected cases Socio Economic, Risk, and Predictive factors Pilot and Operational Researches from survey findings

66 TB Prevalence Among Survey Participants (age 15 years) by Sex and Age Groups Smear-positive cases Smear-negative, culture-positive cases Bacteriologically confirmed cases Sex and Age n % n / % CI n / % CI n / % CI Male % % % % % % % Female % % % % % % %

67 Smear Positive: M/F = 88/35=2.5 Smear Postive Cases Male Female Age Group

68 B confirmed Cases M/F=1.96 Bacteriologically Confirmed Cases Male Female Age Group

69 Impact of control efforts Decline of S+ with Chronic Cough S+/100, National Survey 1972 National Survey S+ with cough >3w Prevalence % decline of S+ Prevalence if we don't have CXR in 2009/10 survey

70 First Action when having chronic cough Age Group Sex Area Fem ale Male Rural Urban 0% 5% 10% 15% 20% 25% 30%

71 First Action when having chronic cough Education G raduate University Higher M iddle Primary lite ra te Illite ra te 0% 5% 10% 15% 20% 25% 30% 35%