CESVI. Myanmar Red Cross Society. Family Health International. International Organization for Migration. Bilateral agenc
Dr. Tin Mi Mi Khaing Sr. NTO, WHO (TB Unit)
1
Estimated incidence, 2016
Estimated number of deaths, 2016
All forms of TB
10.4 million
1.3 million
HIV-associated TB
1.4 million
374,000
600,000
240,000
MDR/RR- TB
Source: WHO Global Tuberculosis Report 2017
Source: Global TB Report 2017
3
4
5
10th Position
6
TB is a major public health problem One of the world’s 30 high TB burden countries 30 high MDR-TB burden countries
Population
53 million
Estimated incidence all forms
361
Estimated TB Mortality
47
Gap in overall case detection (53 Millions Pop.)
27%
MDR-TB among new TB patients (3rd DRS, 2012-2013)
5.0%
30 high TB/HIV burden countries Estimates of the TB burden , 2016 ( source: Global TB Report 2017 )
7
TB Epidemiology, Myanmar (2016) Incidence & Notification trend
Mortality trend
Data source: Global TB Report (2017)
8
NTP Activities TB Team and BHS region/state/district/ township level
INGO/NGO • •
WHO & UN Local NGO & INGO
Activities 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Advocacy Awareness raising (Health Education) DOTS implementation Capacity building (training) at all levels Contact screening Programmatic Management of DR-TB Collaborative TB/HIV activities Public- public mix and public-private mix DOTS Coordination between INGOs and NGO Intra and inter Departmental coordination Coordination between other Ministries Accelerated TB Case finding activities Community based TB Care Supervision, monitoring ,evaluation and research
9
- First-line anti-TB drugs, laboratory reagents and supplies are available all over the time to 330 townships.
1000 900
22
22
800
21
20 20 20 20
700 600
434 431 445 436
400 300
292
338
20 16
514
500
825
19
25
873 889 878
15
604
374
652
15 14
15 13
12 10
Positivity Rate(%)
- Basic TB care and prevention services cover all 330 townships.
Presumptive TB examination rate / 100,000 pop;
- TB services are standardized nationwide, except for a few targeted interventions in selected townships or population groups
Trend of Presumptive TB examination rate & sputum positivity rate (2003-2016)
5
200 100 0
0 Years
Presumptive TB examination rate
Positivity rate
10
0 18444
Bacteriologically Confirmed Cases
Year Clinically Diagnosed Cases Total TB Cases
11
51416
48825
50188
42595
42910
88209
91875
91824
87406
93544
89815
84816
82893
78481
81828
139625
140700
142012
142162
148149
143164
137403
134023
128739
133547
123593
160000
42332
42318
41389
41248
42588
77219
140000
40244
107991
97909
120000
36541
65853
56891
77231
100000
30164
43802
58243
80000
27448
29186
42455
60000
24162
21161
40000 31703
19626
14756
16113
20196
17008
20000
17410
1555
No. of TB Patients
Trend of Total TB Case Notification (1994-2016)
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Trend of Childhood TB (2007-2016) No. of TB patients
160000 140000
133547
128739
134023 137403
143164
148149
142162
142012
139625
140700
120000
105711
100000 105314 80000
100779
101483
27960
32540
104932 105431 105715 106349
105770
107992
60000 40000
28233
32471 37733
42434
35813
36301 34930
20000
(25%)
0 2007
2008
2009
2010
Childhood TB cases
2011
2012
All TB cases
Year
2013
2014
2015
31633
(23%) 2016
Adult TB Cases 12
• Coordination through TB-TSG including nonGF supports such as 3MDG and USAID • Public Private Partnership (with GP and hospitals) is very essential part of TB service
13
Local NGO
International NGO
Myanmar Women’s Affairs Federation
Asia Harm Reduction Network
Myanmar Maternal & Child Welfare Asso
Burnet Institute
Myanmar Medical Association
Clinton Health Access Initiative
Myanmar Health Assistants Association
CESVI
Myanmar Red Cross Society
Family Health International International Organization for Migration
Bilateral agency
International Union Against Tuberculosis and Lung Disease
Japan International Cooperation Agency
Medecins du Monde Malteser International
United Nations
Medecins sans Frontieres (Holland)
World Health Organization
Medecins sans Frontieres(Switzerland)
UN Office for Project Services
Medical Action Myanmar
WFP World Food Programme
PACT Myanmar Population Services International World Vision International SMRU Health Poverty Action Progetto
2015 TB Annual Evaluation Meeting Presentation, NTP
14
Case Notification Rate (CNR) (All TB Cases) per 100,000 pop. according to Region & State (2016)
NTP Only
NTP + Partners
Country CNR (All form) =272/100000 pop
15
Proportion of Total TB cases contributed by NTP & Other units (Annual 2016) (N=139,625)
16
Treatment Outcomes of All form TB Cases (2015 Cohort) (N=138423) (TSR 87%)
17
18
2012: 12 points policy package: What's new? A. Establish the mechanisms for integrated TB & HIV services 1. Set up or strengthen a TB/HIV coordinating body effective at all levels 2. Conduct HIV and TB surveillance among TB and HIV patients respectively 3. Carry out joint TB/HIV planning 4. B. Conduct Decreasemonitoring the burden and of TBevaluation in PLHIV (Three Is for HIV/TB and earlier initiation of ART) 5. Intensify TB case finding and ensure quality TB treatment 6. Introduce TB prevention with IPT and ART 6.TBIntroduce with IPT 7. Infection control for in health careTB andprevention congregate settings ensured
and ART
C. Decrease the burden of HIV in patients with presumptive and diagnosed TB 8. Provide HIV testing & counselling to patients with presumptive and diagnosed TB 9. Introduce HIV preventive methods patients with presumptive and diagnosed TB 10. Provide CPT for TB patients living with HIV 11. Ensure HIV prevention, treatment & care for TB patients living with HIV 19 12. Provide Antiretroviral therapy to TB patients living with HIV
initiated in 7 townships since
12000
2005
gradually up to 2013 scale up 108 townships in
10000 Number of TB/HIV patients
expand to 28 townships
10952
80% CPT coverage
8774
58% ART coverage
6351
8000 6000 4000 2000
2014; total--- 136 townships 0
scale up 100 townships in
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Years
Diagnosis TB/HIV patients
2015; total--- 236 townships
12 years
CPT
ART 20
Trends of HIV prevalence among new TB patients, HSS 2005-2016
Source: HSS 2006-2016
21
Strengthen early TB diagnosis among PLH HCWs need to think of TB!
Policy guidance on LF-LAM, WHO/HTM/TB/2015.25, 2015
Point-of-care urine TB-LAM in severely immunosuppressed PLH 22
2 Reference Lab for second line LPA
3 Culture and DST Lab 71 Gene X pert Sites 516 sputum smear microscopy centers under EQA system ( including 158 iLED Fluorescent microscope)
Nati onal leve Disl tric t lev el
Regio nal/ State level Tow nshi p level
23
8 years
Year
townships
2009
10
2011
22
2012
38
2013
53
2014
68
2015
108
2016
330
Entire Yangon Region is covered by MDRTB management in 2015 All 330 townships became MDR-TB townships since Q1, 2016. 24
Total cases done Total MTB detected
2012 (5) machines
2013 (11) machines
2014 (22) machines
2015 (48) machines
2016 (66) Machines
3136
14246
26240
41957
69558
833
5351
10210
17692
29169
TB with Rif-resistant
259
1689
2631
2719
3095
Proportion “Rifampicin resistant TB cases”
9%
12%
10%
6%
5%
25
Activities DR-TB case finding
MDR-TB Notify Cases and Treatment enrollment (2009 - 2016)
20 month standardized treatment regimen
3500
3213
3000
2701
2500
2207
2000
1721
690 312
500 0
64 2009
128 2010
167 2011
778
2537
Counseling and Health education
1537
1500 1000
Model of care ( Ambulatory, clinic based and hospital based care)
2793
MDR-TB Enrollment
667
MDR-TB Notifiy
442 2012
2013
2014
2015
2016
Treatment coverage 79%
Provision of Directly Observed Treatment Patient support (FOC baseline investigations, ATM card and nutrition support) DOT provider support
26
MDR-TB Treatment outcomes of 2013
MDR-TB Treatment outcomes of 2014
cohort
cohort
(N= 666 evaluated)
(N= 1495 evaluated)
Treatment Success Rate = 83%
Treatment Success Rate = 81%
27
Update on Shorter Regimen • Approved from National Expert DR-TB Committee • Pilot programme started in June 2017 (200 patients) • Second line LPA and first line DST for Ethambutol and Pyrazinamide • Regimen
28
Accelerated Case Finding Contribution of ACF to total Case Notification (2012-2016)
Year 29
Contribution of ACF (2016) Activities CBTBC
Number of TB Patients 19769
Initial home visit & contact tracing
890
Sputum Collection Centre
180
Mobile Team
5004
TB screening in PPM hospital (OPD)
756
TB screening in Pregnant and lactating mother
985
TB screening in under 5 children Total
4585 32169
National contribution --- 23% (32169/139625)
30
TB mobile team activity at hard-to-reach area 31
Launching Ceremony on “End TB strategy & National TB Strategic Plan (2016-2020)” 32 th 13 October 2016
Vision, Goal and Objectives on Ending TB in Myanmar Vision: Myanmar free of TB Zero deaths, disease and suffering due to TB by 2050 Goal: End TB epidemic in Myanmar Fewer than1:10 cases per 100,000 population by 2035 Objective 3: Objective accelerate the decline in the prevalence of drug-sensitive and drug-resistant TB
Objective 2: fully integrate TB prevention and care in Universal Health Coverage
enhance the prevention of TB, particularly for high-risk populations 33
Strategic Directions and Key Interventions of National Strategic Plan (2016-2020) Strategic Direction I: Integrated, Patient-centred Care and Prevention
Strategic Direction II: Bold Policies and Supportive Systems
1.1. Accelerate the appropriate diagnosis of TB
2.1. Secure human and financial resources for implementation of the NSP
1.2. Identify and treat all forms of TB, among all ages and including drugresistant and drug-sensitive
2.2. Promote a coordinated and multi-sectoral response and policy development
1.3. Prevent transmission and the emergence of active TB
2.3. Ensure inclusion of TB in UHC and wider economic development plans and activities (social protection)
1.4. Intensify targeted action(s) to reach marginalized and at-risk populations 1.5. Implement a robust communication strategy, extending from policy makers to patient education 1.6. Engage all care providers, including NGOs and the private sector, in appropriate TB diagnosis and care 1.7. Promote and strengthen community engagement 1.8. Joint TB and HIV programming to enable decentralized and integrated services for TB and HIV
2.4. Ensure a stable and quality-assured supply of drugs, diagnostic tests and commodities 2.5. Human resources for health
Strategic Direction III: Intensified Research and Innovation 3.1. Implement the prioritized research agenda 3.2. Enhance evidence-based programme monitoring and implementation
34
National Response: Government Budget for NTP (2008-2009 to 2016-2017)
35
Funding Gap (2017-2020)
Year
36
Challenges Funding sustainability beyond 2020 HR necessity and staff motivation Gap in overall case detection for Drug Sensitive TB (26%) Gap between notified and enrollment of MDR-TB (21%) Lab Capacity & additional infrastructure/maintenance Infection control measures Reaching to the un-reached – Accessibility (UHC)
37
Future Plan Strengthening existing activities including ACF, TB/HIV & PMDT Strengthening TB laboratory capacity & Infection control measures Implementation of e-based R & R system for both DSTB & DRTB Epidemiological surveys (National TB Prevalence Survey & 4th Nationwide DRS) Implementation research after identifying prioritized research areas
38
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