National TB Prevalence survey in Myanmar

ByDr. Thandar Lwin

Programme ManagerNational TB ProgrammeDepartment of Health

58 million pop. 676,577 sq km (75/sq km)

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)

S+ notification rate/100,000 population in Myanmar (1997-2008)

0102030405060708090

100

1996 1998 2000 2002 2004 2006 2008 2010

Year

per 1

00,0

00 p

opul

atio

n

Detected

Point Estimate of TB

prevalenceper 100,000 95% CI

For population aged 10 or moreEligible samples: 20792S(+) 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 populationSize of population: 25182S(+) TB (*) 58 229 161 297 * Assuming there was no smear + cases in children under 10 years

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

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 sizeSample size of 49,690 eligible subjects are required

• Capacity of the cluster work: ~ 200/day • Capacity / week: 650-750Therefore• 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)

Cluster

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)

OrganizationCentral Steering CommitteeTechnical Advisory GroupCentral 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.)

Survey MethodScreening:

Interview and Chest X-rayBacteriology• 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

2008 2009ItemOct Nov Dec Jan Feb March Apr May June July Aug Sept

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

Time Frame

Time Frame2009 2010Item

Oct Nov Dec Jan Feb March Apr May June July Aug Sept Oct Nov Dec

Survey operationLab resultsData management and analysis

Post survey Preliminary ResultsFinal ResultsTA (WHO)TA (JICA/JATA)

BudgetItems USD %

1 Technical assistant (WHO) 8,000 0.9

2

Capital cost (Procurement)4 X-ray units with portable generator (7.5KVA)Incubators and generator (45KVA) for lab. 429170 48.9

3

Field operation cost in 70 clustersCar hiring cost and fuelFuel 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 sourcesSources of funding Contribution

in USD Remarks

MOH/DOH/NTP Human resourceWHO 15,000 Technical Assistance

3DF 270,000 Equipment & field operational costJICA 114,000 Technical Assistance, Training and

one X-ray unit, generator for lab.JATA Technical Assistance

Bill & Melinda Gates foundation

/PSI/WHO

358,000 Equipment & field operational cost

USAID/PSI/WHO 120,000

Available budget 877,000Including 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 provedwere 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

SubjectsReception

(1+2)

Chest X ray(1+3)

Abnormal

Lab.: Sputum Exam. Registration & collection

(1)

X ray normal

X-Ray reading

Check out &

incentive (1)

Interview (3)

Explanation if necessary

Flow Not Eligible

Team Leader

Age ≥15years  Taking X‐ray

RIT/JATA provided X-ray cars

and JICA provided portable X-ray units

Developing Film and reading on the Spotusing 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 presentations1.Background – map, pop2.Epidemiology – estimated incidence, notification rate3.Yangon survey result4.Outline of national survey (sample size, clusters, screening methodology)5.A photo of portable CXR6.Timeline of preparation7.Organogram, staffing8.Training – field testing9.Role of partners10.Lessons learnt11.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)