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

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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)

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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.

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THANK YOU VERY MUCH

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