Gaps in Implementing Bidirectional Screening for Tuberculosis and Diabetes Mellitus in Myanmar: An Operational Research Study

In Myanmar from July 2018, as a pilot project in 32 townships, all tuberculosis (TB) patients aged ≥40 years were eligible for diabetes mellitus (DM) screening by random blood sugar (RBS) and all DM patients attending hospitals were eligible for TB screening. We assessed the bidirectional screening coverage of target groups through a cross sectional study involving secondary analysis of routine program data. From January to March 2019, of the 5202 TB patients enrolled, 48% were aged ≥40 years. Of those aged ≥40 years, 159 (6%) were known to have DM, and the remaining 2343 with unknown DM status were eligible for DM screening. Of these, 1280 (55%) were screened and 139 (11%) had high RBS values (≥200 mg/dL, as defined by the national program). There was no information on whether patients with high RBS values were linked to DM care. Of the total 8198 DM patients attending hospitals, 302 (3.7%) patients were tested for sputum smear and 147 (1.7%) were diagnosed with TB. In conclusion, only half of the eligible TB patients were screened for DM and the yield of TB cases among screened DM patients was high. There is an urgent need for improving and scaling up bidirectional screening in the country.

IPT in people living with HIV in Myanmar: a five-fold decrease in incidence of TB disease and all-cause mortality

SETTING

Myanmar, a country with a high human immunodeficiency virus-tuberculosis (HIV-TB) burden, where the tuberculin skin test or interferon-gamma release assays are not routinely available for the diagnosis of latent tuberculous infection.

OBJECTIVE

To assess the effect of isoniazid (INH) preventive therapy (IPT) on the risk of TB disease and mortality among people living with HIV (PLHIV).

DESIGN

A retrospective cohort study of routinely collected data on PLHIV enrolled into care between 2009 and 2014.

RESULTS

Of 7177 patients (median age 36 years, interquartile range 31-42; 53% male) included in the study, 1278 (18%) patients received IPT. Among patients receiving IPT, 855 (67%) completed 6 or 9 months of INH. Patients who completed IPT had a significantly lower risk of incident TB than those who never received IPT (adjusted hazard ratio [aHR] 0.21, 95%CI 0.12-0.34) after controlling for potential confounders. PLHIV who received IPT had a significantly lower risk of death than those who never received IPT (PLHIV who completed IPT, aHR 0.25, 95%CI 0.16-0.37; those who received but did not complete IPT, aHR 0.55, 95%CI 0.37-0.82).

CONCLUSION

Among PLHIV in Myanmar, completing a course of IPT significantly reduced the risk of TB disease, and receiving IPT significantly reduced the risk of death.

Contact Investigation of Multidrug-Resistant Tuberculosis Patients: A Mixed-Methods Study from Myanmar

There is no published evidence on contact investigation among multidrug-resistant tuberculosis (MDR-TB) patients from Myanmar. We describe the cascade of contact investigation conducted in 27 townships of Myanmar from January 2018 to June 2019 and its implementation challenges. This was a mixed-methods study involving quantitative (cohort analysis of programme data) and qualitative components (thematic analysis of interviews of 8 contacts and 13 health care providers). There were 556 MDR-TB patients and 1908 contacts, of whom 1134 (59%) reached the health centres for screening (chest radiography and symptoms). Of the latter, 344 (30%) had presumptive TB and of them, 186 (54%) were investigated (sputum microscopy or Xpert MTB/RIF®). A total of 27 TB patients were diagnosed (six bacteriologically-confirmed including five with rifampicin resistance). The key reasons for not reaching township TB centres included lack of knowledge and lack of risk perception owing to wrong beliefs among contacts, financial constraints related to loss of wages and transportation charges, and inconvenient clinic hours. The reasons for not being investigated included inability to produce sputum, health care providers being unaware of or not agreeing to the investigation protocol, fixed clinic days and times, and charges for investigation. The National Tuberculosis Programme needs to note these findings and take necessary action.

Treatment outcome of tuberculosis patients detected using accelerated vs. passive case finding in Myanmar

SETTING

Several projects involving accelerated or active case finding (ACF) of tuberculosis (TB) cases are being implemented in Myanmar. However, there is a concern that patients detected using ACF have poorer TB treatment outcomes than those detected using passive case finding (PCF).

OBJECTIVE

To assess differences in the demographics, clinical profile and treatment outcomes of patients detected using ACF and PCF.

DESIGN

Retrospective cohort study of TB patients diagnosed and enrolled for treatment during 2014-2016.

RESULTS

Of 16 048 patients enrolled, 2226 (16%) were detected using ACF; the treatment success rate (cured and completed) was 88%. A higher proportion of cases detected using ACF were aged 55 years, human immunodeficiency virus (HIV) negative and sputum smear-positive pulmonary TB. After adjusting for differences in demographic and clinical characteristics, we found that treatment outcomes in patients detected using ACF and PCF were not significantly different (adjusted relative risk [aRR] 0.89, 95%CI 0.78-1.00). Male sex, age  55 years, patients with a previous history of TB and HIV positivity were independently associated with unsuccessful outcomes.

CONCLUSION

ACF detected a significant proportion of TB cases in study townships; treatment outcomes in cases detected using ACF and those detected using PCF were similar. More tailored interventions are needed to improve treatment outcomes in patients at a higher risk of unsuccessful treatment outcomes.

Family planning awareness and service accessibility among women living with HIV in Myanmar

Background: Accessibility and availability of family planning services is critical for improvement in maternal health. There is limited information on awareness and accessibility to family planning services among women living with HIV in Myanmar. Methods: A mixed-methods cross-sectional descriptive study was conducted from Feb-March, 2018 at two antiretroviral therapy (ART) centers in Myanmar. Results: This study included 184 women living with HIV. The mean (SD) age was 38 (9) years. In total, 90 women (49%) were married, 10 (5%) were single. Among the respondents, 124 (67%) have never received health education on family planning, and 64 (35%) didn’t know any source of information for family planning services. In the last six months, 55 (30%) of them have used any type of contraception. Among married women, 16 (29%) intended to have a child. One-fourth of women with HIV responded that transmission of HIV from mother to child cannot be preventable. Perceived geographical accessibility to any type of family planning services was measured, and only 7% had high accessibility. The main barriers to accessing family planning information and services among women living with HIV were also explored. Most participants responded that they had poor knowledge and received insufficient information on the family planning services. Some of them mentioned they had financial constraints to access modern contraceptive methods. Key informant interviews with public service providers revealed that there was the lack of referral system, and poor linkage between ART teams and maternal and reproductive health teams for women living with HIV to provide the quality family planning services. Conclusions: This study highlighted the need for awareness raising among women living with HIV about family planning, and effective referral system between maternal and reproductive health unit, and HIV/AIDS care unit in Myanmar.

Rifampicin-resistant tuberculosis patients in Myanmar in 2016: how many are lost on the path to treatment?

SETTING

Regional tuberculosis (TB) centres of the Yangon and Mandalay Regions of Myanmar, which account for 65% of all notified rifampicin-resistant tuberculosis (RR-TB) cases countrywide.

OBJECTIVE

To determine 1) initial loss to follow-up (LTFU), 2) treatment delay, and 3) factors associated with initial LTFU and treatment delay among RR-TB patients residing in the Yangon and Mandalay regions diagnosed using Xpert® during January-August 2016.

DESIGN

This was a retrospective cohort study. Each diagnosed patient was tracked in the drug-resistant TB treatment registers of the Yangon and Mandalay regional treatment centres for January-December 2016 using patient name, age, sex, township and date of diagnosis. If the diagnosed patient was not found in the treatment register by 31 December 2016, he/she was considered 'initial LTFU'.

RESULTS

Of the 1037 RR-TB patients diagnosed, 310 (30%) experienced initial LTFU, which was significantly higher among patients aged 55 years and among those diagnosed in the Mandalay Region. A treatment delay of >1 month was observed in 440 (70%) patients (median delay 41 days). Delay was uniformly high across patient subgroups, and was not associated with any factor.

CONCLUSION

Initial LTFU and treatment delays among RR-TB patients were high. Future studies using qualitative research methods are needed to ascertain the reasons for this observation.

Early Success With Retention in Care Among People Living With HIV at Decentralized ART Satellite Sites in Yangon, Myanmar, 2015-2016

Introduction: Myanmar is one of the countries in the Asia-Pacific region hit hardest by the HIV epidemic that is concentrated among urban areas and key populations. In 2014, the National AIDS Programme (NAP) launched a new model of decentralized service delivery with the establishment ART satellite sites with care delivered by HIV peer workers.

Methods: ART satellite sites are implemented by non-government organizations to service high burden HIV areas and populations that suffer stigma or find access to public sector services difficult. They provide continuity of HIV care from outreach testing, counseling, linkage to care, and retention in care. Anti-retroviral (ART) initiation occurs at health facilities by specialist physicians. We conducted a retrospective cohort study of people living with HIV (PLHIV) who were initiated on ART from 2015 to 2016 at five ART satellite sites in Yangon, Myanmar to assess outcomes and time from enrolment to ART initiation.

Results: Of 1,339 PLHIV on ART treatment in 2015–16, 1,157 (89%) were retained, and 5% were lost from care and 5% reported dead, at the end of March 2018. Attrition rates (death and lost-to-follow-up) were found to be significantly associated with a CD4 count ≤ 50 cells/mm³ and having baseline weight ≤ 50 kg. Median time taken from enrolment to ART initiation was 1.9 months (interquartile range: 1.4–2.5).

Conclusion: We report high rates of retention in care of PLHIV in a new model of ART satellite sties in Yangon, Myanmar after 3 years of follow-up. The delays identified in time taken from enrolment to ART initiation need to be explored further and addressed. This initial study supports continuation of plans to scale-up ART satellite sites in Myanmar. To optimize outcomes for patients and the program and accelerate progress to reduce HIV transmission and end the HIV epidemic, operational research needs to be embedded within the response.

Reliable mortality statistics in Myanmar: a qualitative assessment of challenges in two townships

Background

The vital registration system is universally recognized as the main source of mortality data which is essential for policy formulation, proper interventions and resource allocation to address priority health challenges. To improve availability and quality of mortality statistics by strengthening the vital registration system, understanding the current vital registration system is essential. This study identified challenges in generating reliable mortality statistics in the vital registration system of Myanmar.

Methods

Qualitative methods were used to collect data in two selected townships of Mandalay Region. Grey literature related to the management of mortality registration was reviewed; in-depth interviews of sixteen key informants and fourteen focus group discussions were conducted with those involved in death registration at the local level, such as healthcare providers, local administrators and knowledgeable adults in households where deaths occurred during the past three years. Thematic analysis was performed to identify system barriers in the death registration process.

Results

Weaknesses in the death registration system are classified in three areas: a) administrative which includes the lack of enforcement of mandatory death registration, limited issuance of death certificates and no formal mandatory notification of death events by households and; b) technical which includes absence of proper and regular on-the-job trainings, ineffective cause-of-death certification practice for deaths in the communities and the absence of routine data plausibility checks at the local level; and c) societal which includes poor community awareness and inadequate participation in death registration.

Conclusion

The study highlighted challenges in the death registration system at the operational level, which undermines the achievement of a satisfactory level of completeness and accuracy of mortality data. We recommend establishing a strong legal framework, improving technical capacities and raising public awareness and cooperation to strengthen the system that can generate reliable mortality statistics.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6671-y) contains supplementary material, which is available to authorized users.

Under-reporting of diagnosed tuberculosis to the national surveillance system in China: an inventory study in nine counties in 2015

OBJECTIVE

The WHO estimates that almost 40% of patients diagnosed with tuberculosis (TB) are not reported. We implemented this study to assess TB under-reporting and delayed treatment registration in nine counties in China.

DESIGN

A retrospective inventory study (record review).

SETTING

Counties were selected using purposive sampling from nine provinces distributed across eastern, central and western regions of China in 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Under-reporting was calculated as the percentage of patients with TB not reported to TB Information Management System (TBIMS) within 6 months of diagnosis. Delayed registration was estimated as the percentage of reported cases initiating treatment 7 or more days after diagnosis. Multivariable logistic regression and an alpha level of 0.05 were used to examine factors associated with these outcomes.

RESULTS

Of the 5606 patients with TB identified from project health facilities and social insurance systems, 1082 (19.3%) were not reported to TBIMS. Of the 4524 patients successfully reported, 1416 (31.3%) were not registered for treatment within 7 days of diagnosis. Children, TB pleurisy, patients diagnosed in the eastern and central regions and patients with a TB diagnosis recorded in either health facilities or social insurance system-but not both-were statistically more likely to be unreported. Delayed treatment registration was more likely for previously treated patients with TB, patients with negative or unknown sputum results and for patients diagnosed in the eastern region.

CONCLUSION

Almost one in every five patients diagnosed with TB in this study was unknown to local or national TB control programmes. We recommend strengthening TB data management practices, particularly in the eastern and central regions, and developing specific guidelines for reporting paediatric TB and TB pleurisy. Patient education and follow-up by diagnosing facilities could improve timely treatment registration. Additional studies are needed to assess under-reporting elsewhere in China.

What happens to migrant tuberculosis patients who are transferred out using a web-based system in China?

Background

In China, internal migrants constitute one-fifth of tuberculosis (TB) patients registered for treatment in web-based TB information management system (TBIMS). Though China added a specific module in the web-based TBIMS in 2009, web-based transfer-out is not specifically recommended in the national guidelines.

Objective

In this country wide study among all registered migrant TB patients (2014–2015) that were transferred out using web-based TBIMS in China, to determine the i) timing of transfer-out in relation to period of treatment; ii) delay and attrition during transfer interval (between transfer-out and transfer-in); and iii) extent and risk factors for ‘not evaluated’ as the treatment outcome.

Methods

This was a cohort study involving review of web-based TBIMS data. Modified Poisson regression was used to build a predictive model for risk factors of ‘not evaluated’ as the treatment outcome.

Results

Among 7 284 patients, 5 900 (81.0%) were transferred out during the first two months after initiation of treatment or before treatment initiation and 7 088 (97.3%) patients had arrived at transfer-in unit. The median transfer interval was three (interquartile range: 0–14) days. Sixteen percent (1 176/7 284) patients had ‘not evaluated’ as their treatment outcome. ‘Not evaluated’ contributed to 66% of the unfavourable outcomes. Patients transferred from referral hospitals, migrated from out of prefecture, transferred out of prefecture, with sputum smear negative pulmonary TB, with TB pleurisy and with long delay between symptom onset and treatment initiation had significantly higher risk of ‘not evaluated’ as the outcome.

Conclusion

Web-based transfer helped as the delay and attrition during the transfer interval was quite short and treatment outcomes of more than four-fifths of transferred out migrant TB patients were available with transfer-out BMU. Once strategies to address the independent predictors of ‘not evaluated’ treatment outcome are devised, China may consider mandatory use of web-based TBIMS for transferring out migrant TB patients.

Patient and health system delays before registration among migrant patients with tuberculosis who were transferred out in China

Background

Early diagnosis and treatment is vital for effective tuberculosis (TB) management especially among migrant populations who are a vulnerable group. We aimed to study factors associated with delay before registration at country level among registered migrant TB patients in China (2014–15) who were transferred out (during treatment) through web-based TB information management system (TBIMS).

Methods

This was a cross sectional study involving review of TBIMS data. Delays (in days) were classified as follows: patient delay (from symptom onset to first doctor visit), health system delay (from first doctor visit to treatment initiation, divided into health system diagnosis and treatment delay before and after date of diagnosis respectively), diagnosis delay (from symptom onset to diagnosis) and total delay (from symptom onset to treatment initiation). Linear regression was used to build a predictive model (forward stepwise) for the socio-demographic, clinical and health system related factors associated with delay: one model for each type of delay. Delays were log transformed and included in the model.

Results

The median (IQR) patient delay, health system delay and total delay was 16 (6, 34), two (0, 6) and 22 (11, 41) days respectively. Factors associated with long patient, diagnosis and total delay were: female gender, age ≥ 65 years, sputum smear positive pulmonary TB and registration at referral hospital. Treatment initiation delay was significantly higher among those registered in referral hospitals, unemployed and previously treated. Among migrant patients having permanent residence out of province, health system diagnosis delay was significantly higher while treatment initiation delay after diagnosis was significantly lower when compared to patients having permanent residence within the prefecture.

Conclusion

Among migrant population with TB, patient delay contributed to the total delay. The factors identified including the need for improved coordination between referral hospitals and national programme have to be addressed if China has to end TB.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3583-y) contains supplementary material, which is available to authorized users.

Community-based MDR-TB care project improves treatment initiation in patients diagnosed with MDR-TB in Myanmar

Background

The Union in collaboration with national TB programme (NTP) started the community-based MDR-TB care (CBMDR-TBC) project in 33 townships of upper Myanmar to improve treatment initiation and treatment adherence. Patients with MDR-TB diagnosed/registered under NTP received support through the project staff, in addition to the routine domiciliary care provided by NTP staff. Each township had a project nurse exclusively for MDR-TB and 30 USD per month (max. for 4 months) were provided to the patient as a pre-treatment support.

Objectives

To assess whether CBMDR-TBC project’s support improved treatment initiation.

Methods

In this cohort study (involving record review) of all diagnosed MDR-TB between January 2015 and June 2016 in project townships, CBMDR-TBC status was categorized as “receiving support” if date of project initiation in patient’s township was before the date of diagnosis and “not receiving support”, if otherwise. Cox proportional hazards regression (censored on 31 Dec 2016) was done to identify predictors of treatment initiation.

Results

Of 456 patients, 57% initiated treatment: 64% and 56% among patients “receiving support (n = 208)” and “not receiving support (n = 228)” respectively (CBMDR-TBC status was not known in 20 (4%) patients due to missing diagnosis dates). Among those initiated on treatment (n = 261), median (IQR) time to initiate treatment was 38 (20, 76) days: 31 (18, 50) among patients “receiving support” and 50 (26,101) among patients “not receiving support”. After adjusting other potential confounders (age, sex, region, HIV, past history of TB treatment), patients “receiving support” had 80% higher chance of initiating treatment [aHR (0.95 CI): 1.8 (1.3, 2.3)] when compared to patients “not receiving support”. In addition, age 15–54 years, previous history of TB and being HIV negative were independent predictors of treatment initiation.

Conclusion

Receiving support under CBMDR-TBC project improved treatment initiation: it not only improved the proportion initiated but also reduced time to treatment initiation. We also recommend improved tracking of all diagnosed patients as early as possible.

Evaluation of a tuberculosis active case finding project in peri-urban areas, Myanmar: 2014-2016

OBJECTIVES

We assessed the effect of an active case finding (ACF) project on tuberculosis (TB) case notification and the yields from a household and neigbourhood intervention (screening contacts of historical index TB patients diagnosed >24months ago) and a community intervention (screening attendants of health education sessions/mobile clinics).

DESIGN

Cross-sectional analysis of project records, township TB registers and annual TB reports.

RESULTS

In the household and neigbourhood intervention, of 56,709 people screened, 1,076 were presumptive TB and 74 patients were treated for active TB with a screening yield of 0.1% and a yield from presumptive cases of 6.9%. In the community intervention, of 162,881 people screened, 4,497 were presumptive TB and 984 were treated for active TB with a screening yield of 0.6% and yield from presumptive cases of 21.9%. Of active TB cases, 94% were new, 89% were pulmonary, 44% were bacteriologically-confirmed and 5% had HIV. Case notification rates per 100,000 in project townships increased from 142 during baseline (2011-2013) to 148 during intervention (2014-2016) periods.

CONCLUSIONS

The yield from household and neigbourhood intervention was lower than community intervention. This finding highlights reconsidering the strategy of screening of contacts from historical index cases. Strategies to reach high-risk groups should be explored for future ACF interventions to increase yield of TB.

Patients with MDR-TB on domiciliary care in programmatic settings in Myanmar: Effect of a support package on preventing early deaths

BACKGROUND

The community-based MDR-TB care (CBMDR-TBC) project was implemented in 2015 by The Union in collaboration with national TB programme (NTP) in 33 townships of upper Myanmar to improve treatment outcomes among patients with MDR-TB registered under NTP. They received community-based support through the project staff, in addition to the routine domiciliary care provided by NTP staff. Each project township had a project nurse exclusively for MDR-TB and a community volunteer who provided evening directly observed therapy (in addition to morning directly observed therapy by NTP).

OBJECTIVES

To determine the effect of CBMDR-TBC project on death and unfavourable outcomes during the intensive phase of MDR-TB treatment.

METHODS

In this cohort study involving record review, all patients diagnosed with MDR-TB between January 2015 and June 2016 in project townships and initiated on treatment till 31 Dec 2016 were included. CBMDR-TBC status was categorized as "receiving support" if project initiation in patient's township was before treatment initiation, "receiving partial support" if project initiation was after treatment initiation, and "not receiving support" if project initiation was after intensive phase treatment outcome declaration. Time to event analysis (censored on 10 April 2017) and cox regression was done.

RESULTS

Of 261 patients initiated on treatment, death and unfavourable outcomes were accounted for 13% and 21% among "receiving support (n = 163)", 3% and 24% among "receiving partial support (n = 75)" and 13% and 26% among "not receiving support (n = 23)" respectively. After adjusting for other potential confounders, the association between CBMDR-TBC and unfavourable outcomes was not statistically significant. However, when compared to "not receiving support", those "receiving support" and "receiving partial support" had 20% [aHR (0.95 CI: 0.8 (0.2-3.1)] and 90% lower hazard [aHR (0.95 CI: 0.1 (0.02-0.9)] of death, respectively. This was intriguing. Implementation of CBMDR-TBC coincided with implementation of decentralized MDR-TB centers at district level. Hence, patients that would have generally not accessed MDR-TB treatment before decentralization also started receiving treatment and were also included under CBMDR-TBC "received support" group. These patients could possibly be expected to sicker at treatment initiation than patients in other CBMDR-TBC groups. This could be the possible reason for nullifying the effect of CBMDR-TBC in "receiving support" group and therefore similar survival was found when compared to "not receiving support".

CONCLUSION

CBMDR-TBC may prevent early deaths and has a scope for expansion to other townships of Myanmar and implications for NTPs globally. However, future studies should consider including data on extent of sickness at treatment initiation and patient level support received under CBMDR-TBC.

Prevalence and risk factors of musculoskeletal disorders among Myanmar migrant workers in Thai seafood industries

A cross-sectional descriptive study was conducted with self-administered questionnaires among 368 Myanmar migrant workers to investigate the prevalence of and to determine the risk factors for musculoskeletal disorders (MSDs) in the Thai seafood industry. The results showed the prevalence of MSDs was 45.1% occurring in the last 7 days. Marital status, number of dependents, other health problems, working hours, repetitive hand movements, awkward posture of wrists, prolonged standing, and manual handling of heavy loads were found to be associated with MSDs. Multiple logistic regression indicated that the workers who were married, had more than two dependents, and had more exposure to awkward wrist postures were at significantly increased risk of MSDs. The study findings suggest the need for adequate knowledge of ergonomics and for awareness campaign programs focusing on prevention of MSDs, especially low back pain, to be initiated in industries for earlier detection of symptoms among seafood processing workers.