National TB Prevalence survey in Myanmar By Dr. Thandar Lwin Programme Manager National TB Programme Department of Health
58 million pop. 676,577 sq km (75/sq km) S+ notification rate/100,000 population in Myanmar (1997-2008) per 100,000 population 100 90 80 70 60 50 40 30 20 10 0 1996 1998 2000 2002 2004 2006 2008 2010 Year Includes in 22 TB HBC Est. ARTI - 1.66% (1972), 1.5% (1994) Est. TB prev.- 162/100,000 pop. (All TB cases) Est. TB death rate 13/100,000 (2006)
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: 20792 S(+) TB 58 279 193 364 New 47 226 148 304 S(-), Culture (+) TB 53 258 170 347 New 47 230 148 312 S(-), Culture (-), X-ray(+) TB suggestive 272 1318 1070 1567 New 219 1066 849 1282 Bacteriologically positive TB 111 537 421 653 New 94 456 344 568 For all population Size of population: 25182 S(+) TB (*) 58 229 161 297 * Assuming there was no smear + cases in children under 10 years
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.
Sample size Sample size of 49,690 eligible subjects are required Cluster Capacity of the cluster work: ~ 200/day Capacity / week: 650-750 Therefore 70 clusters, 710 eligible subjects aged 15 or more Stratification States (28%) and Divisions (72%) Cluster distribution (70 clusters): States 20, Divisions 50 32 townships excluded from a sampling frame due to logistical difficulties to carry out field operations (2.4% of total populations)
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)
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.)
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
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
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 2008 2009 Oct Nov Dec Jan Feb March Apr May June July Aug Sept
Time Frame Item Survey operation Lab results Data manageme nt and analysis Post survey Preliminary Results Final Results TA (WHO) TA (JICA/JATA) 2009 2010 Oct Nov Dec Jan Feb March Apr May June July Aug Sept Oct Nov Dec
Budget Items USD % 1 Technical assistant (WHO) 8,000 0.9 2 3 Capital cost (Procurement) 4 X-ray units with portable generator (7.5KVA) Incubators and generator (45KVA) for lab. 429170 48.9 Field operation cost in 70 clusters Car hiring cost and fuel Fuel cost for generators 261657 29.8 4 Supervision only to 25 clusters 2,909 0.3 5 Pre visits 2 times of pre visits to each cluster 18,992 2.2 6 Training 9,174 1.0 7 Expenses for X-ray machine maintenance 6,000 0.7 Expenses for lab maintenance 5,000 0.6 8 Expenses for sputum microscopy and culture 20451 2.3 9 Central Data Management 9080 1.0 10 Stationery & printing forms 23,491 2.7 11 Contingency 2,036 0.2 13 WHO administrative cost 81,040 9.2 Total 877,001 100
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 877,000 270,000 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
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
Trainings
Training
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
Pre Visit: Collaboration of local community is essential
Briefing, Preparation for census and census
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)
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.
X-ray Cars & Portable X-ray machine
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
Age 15years Taking X ray RIT/JATA provided X-ray cars and JICA provided portable X- ray units
Developing Film and reading on the Spot using Auto processor
Field X-ray reading
Quality Sputum collection and Quality Bacteriology Examinations are Keys for the Survey
Data entry and analysis EPI Info version 6.4d and STATA version 9 are used Data entry and validation will be done with partners
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
Thank you
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
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
Field practice: Flow of participants and placing of survey team
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 10,946 8 73 (34-150) Rural 26,478 31 117 (81-168) Total 37,424 39 104 (75-144)