NATIONAL TUBERCULOSIS PROGRAMME ANNUAL REPORT (2012) 1. Introduction Tuberculosis is an ancient illness. By all rights as a bacterial disease that is curable with antimicrobial drugs, it should belong to the past. However, according to the Global Tuberculosis (TB) Report (2013), approximately 8.6 million developed TB and 1.3 million people died of TB in 2012. These figures acknowledge that TB is a unique pandemic. A third of the world's population harbours latent TB infection, which can emerge at any time as an airborne and transmittable disease. Reducing this human reservoir of infection will require many years of steady and untiring effort, plus more effective tools than we have today. The goal of National Tuberculosis Programmes (NTP) is to dramatically reduce the global burden of tuberculosis by 2015 by ensuring all TB patients, including those co‐ infected with HIV and those with drug‐resistant TB, benefit from universal access to high‐ quality diagnosis and patient‐centered treatment. Despite the efforts of NTP with the support of government and partners, tuberculosis (TB) is still a major health problem in Myanmar. Of the 198 countries reported to World Health Organization concerning Tuberculosis Control, Myanmar is still included in 22 TB high burden countries, in 27 MDR‐TB high burden countries as well as in 41 TB/HIV high burden countries. For 2012, WHO estimated that TB prevalence in Myanmar was 489 per 100,000 population, incidence 377 per 100,000 population and mortality 48 per 100,000 population. NTP, Myanmar was established in 1966. NTP has been running with 14 Regional and State TB Centres with 101 TB teams at district and township levels since 2009. TB control activities have been assimilated with Primary Health Care since 1978. NTP introduced Short Course Chemotherapy (SCC) in 18 townships in 1994 and then rapidly expanded up to 144 townships in 1995, another 9 townships in 1996 (altogether 153 townships), and no further expansion in 1997 and 1998. In 1997, NTP adopted WHO recommended Directly Observed Treatment, Short Course (DOTS) Strategy. NTP implemented DOTS strategy through primary health care approach, in co‐ordination with the other governmental sectors, private sectors and non‐ governmental organizations. DOTS coverage became increased year by year, and NTP 1 gained 100% DOTS coverage in 2003. Then, NTP adopted the Stop TB Strategy in Myanmar context in 2007. TB patients have been treated with WHO recommended regimens using Fixed Dose Combination of first line anti‐TB drugs (FDC) since 2004. TB control activities were carried out in line with 5‐year National TB Strategic Plan and 'Stop TB Strategy' in order to achieve the global targets and Millennium Development Goals (MDGs). In 2012, Myanmar NTP achieved 78.2% Case Detection Rate and 85.7% Treatment Success Rate. This annual report purposes to record the Myanmar TB situation, progress of TB control activities year by year and to evaluate strength, weaknesses, opportunities, threats and challenges which were detected in 2012. 2. Objectives of NTP General objectives To reduce the mortality, morbidity and transmission of TB, until it is no longer a public health problem To prevent the development of drug resistant TB To have halted by 2015 and begun to reverse incidence of TB Specific Objectives The objectives are set towards achieving the MDGs, 2015. To reach the interim targets of halving TB deaths and prevalence by 2015 from the 1990 situation. (MDGs, Goal 6, Target 6.c, Indicator 6.9) To reach and thereafter sustain the targets ‐ achieving at least 70% case detection and successfully treat at least 85% of detected TB cases under DOTS (MDGs, Goal 6, Target 6.c, Indicator 6.10) 3. Progress of the Stop TB Strategy In order to achieve the MDGs by 2015, Myanmar NTP initiated WHO recommended Stop TB Strategy in 2007. 2 All the planned activities in 5‐Year National Strategic Plan for TB Control (2006‐2010) were reviewed and revised to be in accordance with the National Health Plan, global and regional plans. The Ministry of Health (MoH) approved the 5‐year National Strategic Plan (2011‐2015) in 2011. Operational plan for 2 years, Monitoring & Evaluation plan and technical assistance plan were also developed. MDR‐TB scale up plan, TB/HIV scale up plan and accelerated case finding plan were appended in the National Strategic Plan (NSP) in 2012. NTP is implementing the 5‐year Strategic Plan (2011‐2015) with the support of the government as well as the funding from WHO, Global Fund (GF), Global Drug Facility (GDF), International facility for the purchase of drugs and laboratory commodities for HIV/AIDS, Malaria and Tuberculosis (UNITAID), Japan International Cooperation Agency (JICA), Three Diseases Fund (3DF), United States Agency for International Development (USAID) and the UNION. There are 6 components in the Stop TB strategy: 1. Pursuing high quality DOTS expansion and enhancement 2. Addressing TB/HIV, MDR‐TB and the needs of poor and vulnerable populations 3. Contributing to health system strengthening based on primary health care 4. Engaging all care providers 5. Empowering people with TB and communities through partnership 6. Enabling and promoting research As a result of implementing those components, NTP Myanmar has achieved the Global TB Control targets since 2006. In 2011, the case detection target was revised according to the finding of National TB Prevalence Survey conducted in 2009‐2010. Even though, the target for case detection rate was achieved. i. Pursue high‐quality DOTS expansion and enhancement To enable known constraints to be addressed and new challenges met, further strengthening of the basic components of the DOTS strategy is required on the following lines: 3 a. Secure political commitment with increased and sustained financing b. Ensure case detection through quality‐assured bacteriology c. Provide standardized treatment with supervision and patient support d. Ensure effective drug supply and management e. Monitor and evaluate performance and impact a. Political commitment with increased and sustained financing Myanmar government is increasing the budget for TB control gradually, especially for anti‐TB drugs procurement. The government’s commitment is to increase its contribution to 3% of the annual anti‐TB drug cost, with annual 1% incremental increase thereafter, starting from 2009. b. Case detection through quality‐assured bacteriology Diagnosis for TB depends mainly on sputum smear microscopy. Sputum Culture is available only at National TB Reference Laboratory (NTRL) in Yangon and at Upper Myanmar TB Laboratory in Mandalay. Drug Susceptibility Testing (DST) has been available at NTRL since 2001. Upper Myanmar TB Laboratory, Mandalay was upgraded to do culture and DST in 2008‐2009. Then, rapid TB, MDR‐TB diagnostic methods of line probe assay (LPA), liquid culture and DST using MGIT machine were introduced to Myanmar at both TB laboratories in 2010. External Quality by Lot Quality Assurance Sampling system (LQAS) on sputum microscopy was introduced in 2006, and expanded in phase wise manner. Private laboratories doing sputum microscopy for AFB could also be covered by EQA and 464 laboratories have been under EQAS in 2012. Binocular microscopes were replaced with Flourescent microscopes at 65 district TB centres. NTP is taking a step to decentralize DOTS units or microscopy centres up to strategic Station Hospitals with quality assurance system. As an innovative approach, new diagnostic tools were installed in TB control facilities. In 2012, altogether 8 GeneXpert machines were received, 6 by GF and 2 by Canadian International Development Agency (CIDA). Two Xpert machines (CIDA) were set up at Latha TB Diagnostic Centre and NTRL (Aung San) .Six machines (GF) were set up at Latha, Union Tuberculosis Institute (Aung San), Bago, Mawlamyaing, Pathein and Monywa TB centres. For upper Myanmar, 2 GeneXpert machines were installed at Upper Myanmar TB 4 laboratory (Mandalay) and MGH (Mandalay General Hospital) in late 2011 for accelerating case finding with the support of PICT project (UNION). Laboratory performance Routinely three sputum specimens are collected for diagnosis and two specimens are collected for follow‐up at all laboratories performing sputum AFB microscopy using Ziehl‐ Neelsen (ZN) stain. The Union supported 7 Fluorescent microscopes (FM) for Mandalay district and the GF provided 25 FM especially for high case load areas. Township laboratory performances are closely monitored by township medical officer and TB Team Leader. AFB microscopy work performed at Regional and State level is monitored by Regional/State TB officers, Microbiologists and Senior TB Laboratory Supervisors (STLS). Maintaining the quality of AFB Microscopy In 1997, NTP developed the framework for the implementation of External Quality Assessment activities using conventional method in which all positive slides and 10% of the negative slides examined were checked. This method increased the workload of NTRL and Regional and State TB Laboratories. After a pilot study of External Quality Assessment based on Lot Quality Assurance Sampling (EQA‐LQAS) method at Yangon and Mandalay Regions, workshops and trainings were given to 20 STLSs assigned by Ministry of Health to reinforce this work. The National Guidelines on EQA‐LQAS for AFB Microcopy were developed in October 2007 and the orientation training was given in February, 2008 to Regional/State TB Officers, Pathologists/Laboratory Officers from Regional and State Hospitals and STLSs. The training focused on random selection of slides per month to be sent to Regional and State TB centres for blinded re‐checking. Timely feedback to peripheral laboratories and supervisory visits for corrective actions were also important components of this EQA system. Supervisory visits to Regional and State TB laboratories were done by Microbiologists once a year. The quarterly supervisory visits were conducted by STLSs. For places showing major errors, either Microbiologists or responsible STLSs visited those sites. Laboratory of Mandalay Regional TB Centre took responsibility for EQA for Kachin State, Sagaing, Magway and Mandalay Regions.