Scale up of shorter all oral DR-TB treatment in Myanmar; a game changer

Myanmar, a country rich in culture and history, faces a significant challenge in the form of Drug-Resistant Tuberculosis (DR-TB). This not only takes a toll on patients but also strains the healthcare system leading to further spread of the disease. Myanmar is a high DR-TB burden country in the WHO South-east Asia Region. The country has been struggling against drug-resistant tuberculosis (DR-TB) from early 2000. In the era of diagnosis of resistance by phenotypic test (Culture and Drug Susceptibility testing), limited DR-TB cases were notified, and the cases that were missed detection served as the source of new infections, consequently, resulting in soaring up of DR-TB cases. Most notified DR-TB cases did not get treatment as they lived away from treatment sites. In recent years, the landscape of DR-TB treatment has undergone, significant transformation with improvement of access to PMDT services. However, both health care providers and patients faced challenges to tackle treatment adherence problems because of injection related pain and significant toxicities of the multiple drugs used for DR-TB treatment.

International laboratory training on “Phenotypic Drug susceptibility Testing of New and Repurposed anti-TB drugs (Oct 2023) for the support/preparation of BPaLM/BPaL treatment regimens. Photo Credit: WHO Myanmar

WHO supported the planning, implementation and scaling up of PMDT services by providing technical assistance on the DOTS-PLUS PILOT (2009) and developing of the first ever “Guideline for the management of MDR-TB in Myanmar (2013)”, second guideline (2017) and a new version in 2023 accommodating new WHO recommendations of 2022 with several trainings to implement the guideline. The infrastructure requirements were inbuilt in donor proposals and all states and regions now have facilities for molecular tests and tools to measure treatment effectiveness and active drug side effect monitoring and management. Myanmar was one of the 7 countries holding a prospective observational single group cohort study to generate evidence on effectiveness and safety of BPaL regimen and WHO was part of the inception and technical support team. WHO also supported development of BPaLM/BPaL operational handbook and its implementation plan to support  programmatic management of the effective, shorter and safer regimen in the country. Required drugs have been ordered and logistics have been included in the forecasting, procurement plan.

Prior to 2013, DR-TB cases had no access to quality DR-TB care. When PMDT started in 2013 and was decentralised to all townships by 2016, health equity for DR-TB improved. Before 2013, DR-TB were diagnosed by culture and DST (phenotypic test) only. After molecular test of Xpert MTB/RIF were endorsed and introduced in Myanmar, the notified number of TB and RR-TB cases doubled. Now GXP MTB/XDR has been set up in all regions/states for early case finding including for pre-XDR cases. To solve the adherence problem and improve patient’s quality of life, standardised shorter DR-TB treatment Regimen (SSTR) was initiated in 2018 and phasing out of injection-based treatment started from 2020.

There has been substantial progress in transition to shorter all oral regimen for DR-TB treatment in Myanmar. In the year 2022, 68% of DR-TB cases were treated with all oral regimen, of which 40% were treated with BPaL (6 months) and OSTR (9-11 months), treatment which lasted for less than one year. Starting from 2023, all new DR-TB  cases are being treated with all oral regimen. BPaLM/BPaL treatment will be introduced as the preferred treatment in Yangon from the last quarter of 2023. More than 90% of DR-TB cases treated with BPaLM/ will be successfully treated and treatment will be completed in about 6 months. This is a paradigm shift in DR-TB treatment with significant reduction in treatment duration, without any painful injections and with chances of treatment success of more than 95% compared to 75% of the early regimens.

Training on Adverse Event Management of DR-TB patients for DR-TB Medical Officers (Sep 2023) to facilitate aDSM as a preparation for BPaLM/BPaL programmatic implementation. Photo Credit: WHO Myanmar

These regimens offer renewed hope for both patients and healthcare providers. Shorter regimens and higher cure rate reduce significant out of pocket expenditures for TB cases, 60% of whom face catastrophic cost.  However, to accelerate the scale-up of these treatments and combat DR-TB effectively, it is crucial to establish diagnostic and treatment centre closer to community, provide nutrition support, fight stigma, and quickly improve the coverage of TB Preventive Treatment. Through a concerted effort by national health authorities, healthcare professionals, and partners, Myanmar can bring relief to its DR-TB patients and work towards a TB – free future. 

Footnote/Acronyms:

PMDT: Programmatic Management of Drug Resistant Tuberculosis

MDR-TB: Multidrug-resistant TB 

Xpert MTB/RIF: a cartridge-based automated nucleic acid amplification test (NAATs) for detection of Mycobacterium tuberculosis complex bacteria (MTBC) and rifampicin (RIF) resistance

Xpert MTB/XDR: a cartridge-based automated nucleic acid amplification test (NAATs) for detection of Mycobacterium tuberculosis complex bacteria (MTBC) and resistance to isoniazid and second-line anti-TB agents

SSTR: Standardized Shorter Treatment Regimen

OSTR: Oral Standardized Shorter Treatment Regimen

BPaLM: a regimen of bedaquiline, pretomanid, linezolid and moxifloxacin

BPaL: a regimen of bedaquiline, pretomanid and linezolid