Report on National TB Prevalence Survey 2009-2010 Acknowledgements The National Tuberculosis Prevalence Survey 2009-2010 for Myanmar was conducted by the National Tuberculosis Programme (NTP), Department of Health (DOH), Ministry of Health (MOH), the Union of Myanmar with the technical support from the World Health Organization (WHO) and the Research Institute of Tuberculosis/Japan Anti-Tuberculosis Association (RIT/JATA). Financial, human resources and technical support for the survey were provided by the MOH, WHO, Three Diseases Fund, Japan International Cooperation Agency, RIT/JATA, Population Services International and the United States Agency for International Development (see Annex 1). For data collection, NTP coordinated with state, regional, district and township health authorities. Local laboratory technicians and Basic Health Staff worked closely with the survey teams. The contribution of the Myanmar Health Assistant Association was also of great value in completing data collection, data cleaning and data entry. In addition, volunteers, local authorities and local communities participated and made great contributions to the survey. The NTP is most grateful to MOH for its guidance and approval of this survey and for the continual encouragement which enabled NTP to complete the survey during a challenging period. We express our deep thanks and appreciation to all organizations and individuals for their contribution in making this survey successful. We record our special thanks to Dr Hans H. Kluge from WHO for his strong support for this survey, and to Dr Ikushi Onozaki of WHO and Dr Norio Yamada of RIT/JATA for their tremendous contributions. It is our hope both that the survey’s findings reflect our country’s actual disease burden, and also that it will lead to constructive changes in future plans to control tuberculosis in Myanmar. i Report on National TB Prevalence Survey 2009-2010 Table of contents List of Tables and Figures iv List of Abbreviations vi EXECUTIVE SUMMARY vii 1. INTRODUCTION 1 1.1 History of the National TB Programme 1 1.2 Historical and current status of TB control in Myanmar 3 1.3 Goals of the National TB Programme 4 2. OBJECTIVES AND METHODOLOGY OF THE SURVEY 5 2.1 Primary objectives 5 2.2 Secondary objectives 5 2.3 Methodology 5 2.4 Survey organization 5 2.5 Survey design 7 2.6 Survey preparations 9 2.7 Field survey procedures 10 2.8 Laboratory procedures 13 2.9 Management 15 3. RESULTS 18 3.1 Census: Survey-eligible population 18 3.2 Participants 22 3.3 Screening 28 3.4 Laboratory examinations 31 3.5 Central Medical Panel 33 3.6 Prevalence 39 4. DISCUSSION 42 4.1 Eligibility criteria 42 4.2 Survey participation 42 4.3 Participants 43 4.4 Smear examination results 43 4.5 Prevalence of TB 43 4.6 Comparison of screening tools 44 4.7 Prevalence of smear-positive TB with chronic cough 45 4.8 Health-seeking behaviour towards chronic cough 48 4.9 Risk analysis 48 4.10 High prevalence of smear-negative, culture-positive TB and limitation of CXR diagnosis 50 4.11 Comparison with the 1994 national TB prevalence survey 55 4.12 Comparison with surveillance data 57 4.13 Comparison with other surveys in ASEAN countries 59 4.14 Strengths and limitations of the survey and analysis 60 5. PROGRAMME IMPLICATIONS 62 5.1 TB prevalence 62 5.2 Programme impact 62 5.3 DOTS 63 5.4 Case detection 63 5.5 Stop TB Strategy 64 5.6 Conclusion 66 ii Report on National TB Prevalence Survey 2009-2010 Annex 1. Survey funding sources and cost breakdown 70 Annex 2. Steering Committee 71 Annex 3. Technical Committee 72 Annex 4. Central Panel for Diagnosis 72 Annex 5. Central Coordinating Unit 73 Annex 6. Prevalence survey report writing committee 75 Annex 7. Equipment and consumables 75 Annex 8. Survey clusters 77 Annex 9. Individual survey card 80 Annex 10. Laboratory procedures 83 Annex 11. Methods of estimating overall prevalence of bacteriologically positive TB 87 Annex 12. Photographs from the survey 96 Annex 13. Photographs from the dissemination workshop in Nay Pyi Taw, 15 December 2010 100 Annex 14. Photographs from the dissemination workshop in Yangon, 16 December 2010 101 Annex 15. Forms used in the survey 102 iii Report on National TB Prevalence Survey 2009-2010 List of Tables and Figures Table 1. Survey clusters re-assigned for logistical or other reasons 9 Table 2. Survey census results: Eligible and ineligible subjects 20 Table 3. Survey participation rates 22 Table 4. Backgrounds of survey participants 23 Table 5. Smoking and drinking habits of survey participants 25 Table 6. Body Mass Index (BMI) of survey participants 26 Table 7. TB contact history of survey participants 26 Table 8. Current and previous TB treatment and providers of survey participants 27 Table 9. Results of screening interview: TB-related symptoms 28 Table 10. Detailed results of screening interview 29 Table 11. Chest X-ray field screening results 30 Table 12. Relationship between field screening readings and central expert readings 31 Table 13. Summary screening results: reasons for eligibility for sputum examinations 31 Table 14. Screening and CXR results and sputum examinations 32 Table 15. Smear examination results 34 Table 16. Relationship between spot and morning specimen results by smear examination (grading by ZN staining) 35 Table 17. Culture examination results 36 Table 18. Relationship between smear and culture results 37 Table 19. Relationship between spot and morning specimen results by culture examination 37 Table 20. TB cases (survey cases) by interview and CXR results 38 Table 21. TB prevalence among survey participants aged 15 years or above 41 Table 22. Screening results of definite TB cases 46 Table 23. Prevalence of smear-positive symptomatic cases 47 Table 24. Risk Analysis: Prevalence, crude odds ratio and adjusted odds ratio (random effect model) 51 Table 25. Analysis of predictive factors of being a bacteriologically positive prevalent case: Prevalence, crude odds ratio and adjusted odds ratio (random effect model) 53 Table 26. Association of not taking CXR with bacteriologically positive TB among females aged 15-44 yrs 54 Table 27. Notification/Prevalence ratios by different groups 58 Table 28. Results of recent TB prevalence surveys in Asia 59 Table 29. Cluster summary 67 Table 30. Prevalence of smear-positive TB by different analytical methods 87 Table 31. Prevalence of bacteriologically positive TB by different analytical methods 89 iv Report on National TB Prevalence Survey 2009-2010 Table 32. Analysis methods described in the manual and applied in this report 91 Table 33. Imputation methods used in this report 92 Table 34. Categorization of survey population and TB screening implementation (based on variables of sputum request) 94 Table 35. Categorization of survey population and TB screening implementation (including persons with field reading recorded as active/suspect but who did not have sputum request recorded) 94 Figure 1. Case notification rate of TB patients (1999-2010) 3 Figure 2. Basic schedule for field survey 10 Figure 3. Summary of National TB Prevalence Survey, 2009-2010 19 Figure 4. Population pyramids: Survey-eligible population, UN estimation and NTP/MOH statistics 21 Figure 5. Number of cases detected by sex and age group 40 Figure 6. Cluster variation: Number of bacteriologically positive TB cases 45 Figure 7. Comparison of prevalence of smear-positive TB and TB with chronic cough 47 Figure 8. Behaviour patterns of TB cases towards symptoms 49 Figure 9. Gap between smear-positive and bacteriologically positive TB cases 50 Figure 10. Comparison between National TB Prevalence Survey results, 1994 and 2000-2010 55 Figure 11. Notification/Prevalence ratios for smear-positive TB by different groups 58 Unless otherwise stated, data for all Tables and Figures are derived from the National TB Prevalence Survey, Myanmar, 2009-2010 v Report on National TB Prevalence Survey 2009-2010 List of Abbreviations AFB Acid-fast bacillus ASEAN Association of Southeast Asian Nations BHS Basic Health Staff BMI Body mass index CCU Central Coordinating Unit CXR Chest X-ray DOH Department of Health DOTS the basic package that underpins the Stop TB Strategy GDF Global Drug Facility GP General practitioner IPW Inverse probability weighting JICA Japan International Cooperation Agency MDR-TB Multidrug-resistant TB MIDCP Major Infectious Disease Control Project MMA Myanmar Medical Association MOH Ministry of Health MOTT Mycobacterium other than TB NGO Non-governmental organization N/P Notification/Prevalence NTP National Tuberculosis Programme NTRL National TB Reference Laboratory OR Odds ratio PAL Practical Approach to Lung Health PNB Para-nitrobenzoic acid PPM Public-private mix PPS Probability proportionate to size PSI Population Services International PSU Primary sampling unit RHC Rural Health Centre RIT/JATA Research Institute of Tuberculosis/Japan Anti-Tuberculosis Association SOP Standard operating procedures TB Tuberculosis 3DF Three Diseases Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development UTI Union Tuberculosis Institute WHO World Health Organization ZN Ziehl-Neelsen vi Report on National TB Prevalence Survey 2009-2010 Executive summary The National TB Prevalence Survey for Myanmar was concluded by the National Tuberculosis Programme in April 2010. In this survey, 57 607 eligible adults aged 15 or older were recruited, of whom 51 367 (89.2%) participated, in 70 clusters. The average number of participants per cluster was 728 (ranging from 621 to 850). Females showed higher a participation rate (91.8%) than males (86%), and rural clusters had a slightly higher participation rate (90%) than urban clusters (86.3%). Among the 70 clusters, only four had a participation rate of less than 80%. There was no significant difference in participation rate among age groups. The methodology was to first conduct symptom screening by face-to-face interview, followed by chest X-ray screening for all participants except pregnant women and those who refused.