Special collection of articles on neglected infectious diseases in Myanmar

TDR news item
16 June 2017

The journal Infectious Diseases of Poverty is issuing a special collection of operational research articles seeking evidence-based solutions for improving the performance of national programmes for neglected infectious diseases in Myanmar. Five papers, focused on malaria and tuberculosis (TB) control, have been published to date.

Children in Myanmar
Children in Myanmar
Credit: WHO/SEARO /Payden

All the articles were developed with support from the Structured Operational Research and Training Initiative (SORT IT), a global initiative led by TDR. SORT IT supports countries to conduct operational research around their own priorities and build operational research capacity in their public health programs.

The national SORT IT program in Myanmar is led by the Ministry of Health’s Department for Medical Research. Training workshops have been facilitated by teams of national researchers with support from experienced facilitators from the China Centre for Disease Control and Prevention, Belgium’s Institute of Tropical Medicine, the International Union Against Tuberculosis and Lung Diseases and Médecins Sans Frontières. SORT IT leads trainees through the entire operational research cycle from formulation of a research question, through protocol development and data analysis to the writing of a scientific paper for publication.

All first, second and last authors of the articles briefly summarized below are Myanmar nationals.

Tackling TB in hard-to-reach populations

Four of the studies in the special supplement focus on finding solutions to diagnosis and treatment of TB in hard-to-reach populations. One study sought to establish whether active case finding would be well accepted in hard-to-reach rural areas of Myanmar.

Over a 3-month period, a mobile team equipped with portable digital chest radiography visited 20 townships in 3 states. The team examined 9349 people with symptoms suggestive of TB, and in one-third the test was abnormal. However, only half of the people with abnormal radiography went on to have a sputum sample examined by microscopy, which required travel to a township health centre. The researchers conclude that although active case finding is well accepted in Myanmar, the lack of one-stop-service discourages patients from seeking a firm diagnosis.

In another study, the contribution of a community-based TB care programme run by local non-governmental organizations (NGOs) – through which unpaid volunteers are engaged in active case finding – was assessed in 84 townships in Myanmar. Contrary to expectations, the number of TB cases identified by community volunteers decreased during the 4 years of the study, with their contribution to total case detection decreasing from 6% to 4%. This finding points to several areas where the programme should be strengthened, such as improving supervision.

By contrast, a third study found that community-based care supported by 4 international NGOs contributed to the detection, on average, of 36% of total new TB cases, demonstrating that they were successful in achieving TB case detection in hard-to-reach and vulnerable populations. The researchers conducted a descriptive study using programme data from the international NGOs and Myanmar’s National TB Programme and extracted information on the approach and key activities of each NGO; the number of presumptive TB cases referred and undergoing TB testing; and the number of patients diagnosed with TB and their treatment outcomes. The authors conclude that the contributions of these international NGOs will be critical to achieving WHO’s End TB Strategy, provided that strategies to ensure sustainability are explored.

International NGOs use a variety of approaches to community-based care: 1) community mobilization, 2) recruitment of community volunteers, 3) training of community volunteers, 4) TB awareness-raising, 5) detection of suspected TB cases by volunteers, 6) attending directly observed treatment, 7) counseling TB patients for treatment adherence, and 8) support for TB patients (transportation, nutritional support, incentives). A fourth study found that the total cost per patient varied widely among NGOs. For example, the price of treatment of a new patient ranged from US$ 215 to US$ 1076.

Based on these findings, the authors recommend the development of standardized tools to evaluate the performance and cost-effectiveness of community-based TB care. In the interim, they write, the largest share of resources should be allocated to patient-centred care.

A comprehensive approach to malaria elimination

Malaria incidence has been decreasing steadily in Myanmar, but resistance to artemisinin-based treatment has emerged as a barrier. A research group studied 52 townships with 8.7 million residents to examine how prevention and active case detection had affected malaria incidence and was contributing to the country’s efforts towards malaria elimination – despite drug resistance.

They found that malaria incidence had decreased from 10.54 per 100 000 people to 2.53 between 2010 and 2014. Illnesses from all parasites species, including Plasmodium falciparum, had decreased. The authors conclude that prevention had played an important role, because coverage with long-lasting insecticidal or insecticide-treated bed nets and indoor residual spraying was high in areas where residents were known to be at risk for malaria.

In addition, there were improvements in detecting malaria in hard-to-reach areas and worksites where mobile migrant populations were present. The authors conclude that a combination of preventive approaches and active case detection could help Myanmar’s national malaria programme move towards its goal of elimination.

These are the articles that result from this SORT IT programme in Myanmar:

  • Ohnmar Myint, Saw Saw, Petros Isaakidis, Mohammed Khogali, Anthony Reid, Nguyen Binh Hoa, Thi Thi Kyaw, Ko Ko Zaw, Tin Mi Mi Khaing and Si Thu Aung
    Active case-finding for tuberculosis by mobile teams in Myanmar: yield and treatment outcomes
    Infectious Diseases of Poverty 2017 6:77
  • Htet Myet Win Maung, Saw Saw, Petros Isaakidis, Mohammed Khogali, Anthony Reid, Nguyen Binh Hoa, Ko Ko Zaw, Saw Thein and Si Thu Aung
    The contribution of a non-governmental organisation’s Community Based Tuberculosis Care Programme to case finding in Myanmar: trend over time
    Infectious Diseases of Poverty 2017 6:51
  • Kyaw Thu Soe, Saw Saw, Johan van Griensven, Shuisen Zhou, Le Win, Palanivel Chinnakali, Safieh Shah, Myo Myo Mon and Si Thu Aung
    International non-governmental organizations’ provision of community-based tuberculosis care for hard-to-reach populations in Myanmar, 2013–2014
    Infectious Diseases of Poverty 2017 6:69
  • Wai Wai Han, Saw Saw, Petros Isaakidis, Mohammed Khogali, Anthony Reid, Nguyen Hoa, Ko Ko Zaw and Si Thu Aung
    Different challenges, different approaches and related expenditures of community-based tuberculosis activities by international non-governmental organizations in Myanmar
    Infectious Diseases of Poverty 2017 6:59
  • Thet Wai Nwe, Tin Oo, Khin Thet Wai, Shuisen Zhou, Johan van Griensven, Palanivel Chinnakali, Safieh Shah and Aung Thi
    Malaria profiles and challenges in artemisinin resistance containment in Myanmar
    Infectious Diseases of Poverty 2017 6:76

For more information, contact Dr Andy Ramsay