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Country Experience on the implementation of New TB Diagnostic Tools
(Myanmar)
Dr. Si Thu Aung
(Assistant Director, NTP Myanmar)
1
60 million pop.
676,577 sq km (75/sq km)
� Includes in TB HBC, 27 MDR-
TB HBC, 41 TB/HIV HBC
Regions/States - 14
Districts - 67
Townships - 330
Sub Townships- 60
Wards - 2,781
Village tracts - 13,714
Villages - 64,910
Urban - 30%
Rural - 70%
Introduction
• EXPAND TB implementation: July,
2010
• Labs covered: NTRL, Yangon &
Regional TB lab, Mandalay
• Project Agreement signed: 10th Feb.
2009
� A major public health problem
� One of the 22 TB high burden countries,
� One of the 27 high MDR TB burden countries
� One of the 41 high TB/HIV burden countries (WHO report 2009)
� Estimated incidence all forms (WHO report 2012) 377/100,000 pop.
� Estimated prevalence of TB (WHO report 2012) 489/100,000 pop.
� Estimated TB mortality (WHO report 2012) 48/100,000 pop.
� HIV sero-positive among TB patients (25 HSS) 9.7% in 20129.8%
� MDR-TB among new TB patients 5.0% (3rd DRS)
Magnitude of TB
Mandalay
Yangon
GeneXpert Machines for rapid Dx of M.tb & Rif Resistance
National Reference TB Laboratory (Yangon) Upper Myanmar TB Reference Laboratory (Mandalay)
Country achievements under Country achievements under Country achievements under Country achievements under EXPAND TBEXPAND TBEXPAND TBEXPAND TB
Tests 2010 2011 2012 2013 Total
No. of liquid culture 482 1048 1920 4108 7558
No. of liquid DST 146 370 519 611 1646
No. of LPA 155 812 1103 2735 4805
MDR cases
detected
90 482 778 1602 2952
MDR TB treated
cases
197 162 442 667 1468
8
Performance of Liquid Culture, Liquid DST & LPA in BSL-3 Labs, Myanmar (2010 to 2013)
482
1048
1920
4108
146
370519
611
155
812
1103
2735
126 90
482
778
1609
64 128 162
442
1468
0
500
1000
1500
2000
2500
3000
3500
4000
4500
2009 2010 2011 2012 2013
No. of liquid culture No. of liquid DST No. of LPA MDR cases detected MDR cases treated(NTP)
2009- MDR diagnosed (from PMDT sites) by conventional culture
Total Gene Xpert tests result done in
(Myanmar)
2012 2013
Total cases done 3136 14246
MTB not detected 2303(73%) 8895(62%)
Total MTB detected 833 (26%) 5351 (38%)
TB with Rif-resistant 259 (31%) 1689 (32%)
TB with No Rif-resistant556(67%) 3435(64%)
TB with Rif-resistant
Indeterminate18 (2%) 227 (4%)
Main challenges for project Main challenges for project Main challenges for project Main challenges for project implementationimplementationimplementationimplementationMain Challenges Action taken
1 Limited human resources in NTP• Increased workload at the 2 main laboratories to
diagnose DR-TB suspects and follow-up examinations
WHO & Myanmar Medical
Association hired 22 & 12
laboratory staff respectively to
support the need of NTP since
2011.
The Ministry of Health appointed
12 Lab. tech. for TB Centers in
2012.
Now the new sanction posts are
approved by MOH.
2 Maintenance of Machine & Equipment• Maintenance of Air pressure System
• Difficult to repair/procure spare parts for air pressure
system.
• Delayed repair of MGTT machine in Yangon laboratory.
Yearly maintenance can be made
with Natural Green Innovation
Company , Bangkok.
The performance of this machine
are replaced by solid culture &
LPA.
Main challenges for project Main challenges for project Main challenges for project Main challenges for project implementationimplementationimplementationimplementation
Main Challenges Solution
3. Technical• Technical weakness in planning, forecasting, data
management and evaluation.• In the first few year ,data verification is difficult since
manual data entry with paper based system is using.
Now NTP can use of electronic data entry, compilation and analysis; Developed laboratory strengthening and expansion plan.
4. ElectricityUnstable & insufficient voltage electrical supply
• Due to heavy thunder stroke, one generator at Yangon Lab was destroyed.
FIND/Expand TB Project supported the backup generator 85 KVA for both laboratories. NTP mobilized a back- up funding for the procurement of fuel from Global Fund since 2011.
NTP could manage to install the thunder protector by GF funding.
5. Specimen transportation•Limitation in specimen referral linkages
Set up systematic referral linkage between state/regions/districts based on Xpert sites
Challenges in Gene Xpert Challenges in Gene Xpert Challenges in Gene Xpert Challenges in Gene Xpert
Challenges concern with Gene Challenges concern with Gene Challenges concern with Gene Challenges concern with Gene XpertXpertXpertXpert
Solution
Human resources Need to fill up the vacant technicians post
where the GXP machines implemented.
Unstable & insufficient voltage electrical
supply
Need to provide generators at all places
Maintenance /Servicing for regular and
urgent matters of GXP and BSL’3’ Lab
Need two engineers
(one each for YGN & MDY)
Module errors sometimes Timely arrival of replacement module
Improper sputum transport system To establish systematic sputum transport
system
Recording & reporting system Need to have electronic recording
& reporting
Infrastructure Government support13
14
90
482
778
1602
2952
1051
2407
2010 2011 2012 2013 Cumulative/overall Target
Summary of MDR TB case detectedMyanmar
MDR cases detected Target,Expand TB
Milestones
• 2001- NTRL has been established with solid culture & DST.
• July 2010- BSL ‘3’ Laboratories was inaugurated in Yangon & Mandalay
GeneXpert
• 2012- UNION - 3
• 2012- CIDA - 2
• 2013- GF - 14
FHI - 1
UNITAID - 4
MSF - 3
• 2014 – PEPFAR - 6
GF - 8
• 2014 - Total (41)
• Launching ceremony for the roll out of Gene Xpert in September 2013 at NTRL
by UNITAID mission.
• March 2014 - National Committee for MDR-TB recommended Xpert positive with
RR positive can be directly provided with MDR-TB treatment without
conformation for high risk groups (MDR-TB contact, HIV co-infection, all
retreatment cases)
- Xpert can be repeated if RR positive in low risk group.
National MDR-TB Strategic Plan (2011-2015)
* More rapid expansion ongoing** Expansion 38 townships
Transitioning Plan
• NTP formulated plans to get uninterrupted Laboratory
supply for rapid tests and maintenance of BSL-3) labs
whenever Expand TB project support ends
• NTP requested 33 items for 2 Qr. 2014 for both
reference labs (request sent to FIND in Feb.2014)
• Projected request for 2015 was also shared with FIND
ACCELERATION PLAN
• Additional one MGIT machine each from PEPFAR & GF will increase case
detection by liquid Culture.
• Additional GeneXpert machines 14 (6+8) in 2014 will increase case
detection of rifampicin resistant cases.
• Additional Culture Laboratory in Taung Gyi , Shan State and later another
one in Mawlamyaing (Mon State) will reduce culture works at the existing 2
BSL-3 Labs for follow-up cases.
• Additional 100 iLED microscopes (existing 65) from GF will increase case
detection in 2014.
• Active TB Case Finding project with 3MDG (9 mobile teams will do active
case findings including prisons, hard-to-reach areas , poor urban areas and
mines.)
• Rapid expansion of TB/HIV collaborative activity in additional (108)
townships (Total cumulative 136 TB/HIV townships in 2014)
18
Future Plan � Introduce new tools at Regional / State level Expansion of culture & DST
laboratory Mawlamyaing (2014) and Nay Pyi Taw (2015)
� Introduce electronic lab. data entry to improve TB lab. network
� Establish culture & DST laboratories to Taunggyi : 2013
� Expand iLED FM up to Township level : (100 FM in 2015)
� Introduce GeneXpert facilities in District level laboratories
� Conduct International training for second line DST and implement 2nd
line DST at 2 Reference labs
.
Acknowledgement
• NTP, Myanmar acknowledge Expand TB Project, FIND, WHO, USAID, UNITAID, UNION, GF and GDF for their contributions in establishing the Biosafety Level-3 labs & Xpert implementation which is a great help for early detection of MDR-TB cases
• Looking forward to a continuous support.
20
THANK YOU VERY MUCH
21