TB IN MYANMAR

PULLING BACK THE CURTAIN

October 2013: A snapshot of the response to multi-drug resistant tuberculosis (MDR-TB) in Myanmar, a country seriously affected by this global threat. Can new diagnostic technology help make a difference? Featuring photos by renowned Asia photographer Gerhard Jörén.

Multidrug-resistant TB (MDR-TB) in Myanmar

Diagnosing drug-resistant TB: Why it matters

Until 2009, testing for the deadly strain of drug-resistant TB was done in just one laboratory in Myanmar, a country of over 50 million people. The only method available was over 100 years old and could take months to provide an accurate result. TB bacteria are spread through droplets in the air, so it is essential to get patients on treatment quickly before they can infect others. In Myanmar, around 180 000 people are thought to develop active TB each year. Just how many of these TB cases are resistant to the most important anti-TB drugs is hard to estimate, but close to 9000 people are diagnosed with multidrug-resistant TB (MDR-TB) every year. Like normal TB, MDR-TB is spread from person-to-person. But while drug-sensitive TB can be cured with a six-month course of antibiotics, MDR-TB requires 24 months of highly toxic and costly medicines and injections.

Myanmar now has access to high-tech diagnostic machinery that can revolutionize the response to drug-resistant TB. The new reality is impressive. State-of-the-art TB labs lie on the outskirts of dusty urban centres. In these carefully contained environments, lab workers use molecular approaches to detect drug-resistant TB bacteria, extracting bacterial DNA from sputum samples. Going a step further, Myanmar was recently chosen by the World Health Organization to launch a global roll-out of a new and advanced TB diagnostic machine known as GeneXpert (pictured right), which can provide a result for MDR-TB diagnosis in just 90 minutes. These compact devices are now being installed in labs and TB centres throughout the country.

Much of the impetus behind these advances has been quietly supported by the global health initiative UNITAID, which was among the first international donors to invest in treatment and improved testing for MDR-TB in Myanmar.

This site documents some of these successes. Now other donors have stepped up with major investments in MDR-TB control in the country. Yet enormous challenges remain. Access to treatment for MDR-TB is still limited, leaving over 1500 people with an MDR-TB diagnosis on waiting lists for effective medicines. Better diagnostic testing means more people will continue to be identified as suffering from drug-resistant TB by health care workers and so more effort needs to be made to get patients on appropriate treatment... and keep them on it for two years. In a country where power outages are common and the oppressive heat deteriorates equipment rapidly, the question whether advanced TB diagnostic technology is sustainable in the long term is a valid one.

The photos and stories on this mini-site help 'pull back the curtain' on TB in Myanmar and demonstrate the impact that rapid diagnostic testing can potentially have in the battle against drug-resistant TB. Myanmar still has a long journey of change ahead, but some of its successes can point the way forward for other countries struggling with this public health crisis. The recently released WHO Global TB Report found that globally, less than 25% of the people estimated to have MDR-TB were diagnosed in 2012. Moving forward, expanding access to effective MDR-TB diagnostic tests should be a priority for the international community.

TB in Myanmar - A photo essay

  • Myanmar is one of the 22 high-burden TB countries.
    Photo of Mandalay General Hospital TB Clinic.
  • The Government has an ambitious plan to tackle TB – strengthened by the recent influx in donor funding.
    Photo of Mandalay General Hospital TB Clinic.
  • Advanced diagnostic tests are a major part of this drive.
    Photo shows the National TB Reference Laboratory in Yangon.
  • UNITAID has financed two state-of-the-art labs in Yangon and Mandalay, shrinking testing time from months to hours.
    Photo shows the National TB Reference Lab in Yangon.
  • Over 19 GeneXpert® machines are already installed in the country, providing a result in 90 minutes. Older methods could take months.
  • Challenges do exist for advanced GeneXpert®: High temperatures, malfunctions, power cuts and the huge workload facing laboratory workers
  • Moreover, access to MDR-TB medicines is low. In 2012, only 800 people were on treatment.
    Photo of MDR-TB patients at Aung San TB Hospital in Yangon.
  • Up to 1500 people are on waiting lists for MDR-TB treatment.
    Photo of Mandalay General Hospital TB Clinic.
  • There are bright spots. In Mandalay, this clinic provides care for TB and HIV. Since 2009, over 1000 patients have received free HIV treatment and counselling.
  • TB and HIV community health workers receive training in Mandalay. Many are committed to raising awareness about testing and the importance of staying on treatment.
  • In 2012, 1.3 million people around the world died of TB. More efforts are needed globally to stop these preventable deaths.

Ko Min Min

A new life: before and after MDR-TB treatment

Ko Min Min, 38, was a successful auto shop owner in Mandalay, but when he was diagnosed with MDR-TB he was forced to sell his business. He had already lost his younger brother and sister to drug-resistant TB.

Luckily, Ko Min Min enrolled in a pilot MDR-TB treatment programme that was available in Mandalay and Yangon at the time. Launched in 2009, this UNITAID-financed programme was the first initiative of its kind in Myanmar. Ko Min Min was admitted to the Patheingyi TB Hospital on the outskirts of Mandalay city to begin his two-year treatment regimen. After his discharge two months later, a trained health worker (photo, right, above) visited him every day at home help him take an arduous cocktail of pills. It was not easy. During the two years of intense treatment Ko Min Min suffered from dizziness, anorexia and joint pains. Yet he held out and was declared cured of TB in July 2011.

When UNITAID was recently in Mandalay, we had the opportunity to meet Ko Min Min, who came out to meet us (photo, left). Healthy and now a shopkeeper again, Ko Min Min told us about his two-year old baby daughter.

Note: Photo at right from Stop TB Partnership/WHO

Audio Interviews

Dr Thandar Lwin, Programme Manager of Myanmar National TB Programme

"When we first started providing MDR-TB treatment in 2008-2009, we found that MDR in new cases was about 4% - very high. Now with increased diagnostic capacity, I'm worried about the availability of drugs. We need to take careful steps before we further expand GeneXpert."

Dr Mario C. Raviglione, Director of the WHO Global TB Programme

WHO is the main implementer of UNITAID's TBXpert Project. Here the Director of the WHO Global TB Programme talks about why this project was started, why the 21 countries were chosen and the plans for sustainability once UNITAID funding ends.

Dr Aye Thida, Deputy Head of Office at The Union in Mandalay

"In the beginning, there were problems in introducing GeneXpert. The technology requires appropriate temperature and skills. Moreover, many in Myanmar chew betel nut, which destroyed sputum samples."

Lucica Ditiu, Executive Secretary of the Stop TB Partnership

The Executive Secretary of the Stop TB Partnership discusses new diagnostic technology that could be available soon. "We still need a steep increase in funding for TB diagnostic R&D," she says. "We still need a diagnostic machine that is available at the point-of-care - this is not GeneXpert."

Thiha Kyaing, Head of Phoenix HIV/TB Civil Society Organization, Yangon

"HIV/AIDS and TB civil society organization in Myanmar began to emerge after 2005 but they are not sustainable, as all community activists work on a volunteer basis."

U San Lin

Advocating for others to stay on MDR-TB treatment

MDR-TB survivors can play an important role in showing those on treatment that there is a light at the end of the tunnel. U San Lin has embraced this role with energy and commitment. At a widely publicized launch event held by UNITAID in September 2013 (photo, right, above), U San Lin proudly stood in front of the assembled national media to tell his story. 58 years old, U San Lin contracted TB multiple times and learned of his MDR-TB diagnosis after completing a six months of treatment for non-resistant TB. He was admitted to hospital and received treatment under the UNITAID-financed pilot programme. He has now has returned to work as a security guard.

U San Li related a recent story: "A medical officer from my township contacted me because one of his patients refused to continue MDR-TB treatment. I went to the patient's house and explained to him the benefits and importance of a completed course and shared my own experiences. After a long discussion, he agreed to continue. I would like to share my knowledge and help other patients finish."

Facts

Q: What is multidrug-resistant TB (MDR-TB)?

MDR-TB can develop when patients are unable to complete their treatment course; are prescribed the wrong treatment or dose(s); or if the supply of drugs is not available. MDR-TB can also be spread from person-to-person. Globally in 2012, 3.6% of newly diagnosed TB cases and 20% of those previously treated for TB had MDR-TB. The highest levels are in Eastern Europe and central Asia where in several countries, more than 20% of new cases and more than 50% of previously treated TB cases have MDR-TB.
Source: WHO Global TB Report 2013

Q: Why is early diagnosis important for MDR-TB?

Early, rapid and accurate detection of TB and drug resistance are critical to ensure that people with TB signs and symptoms are correctly diagnosed and have access to the appropriate treatment as soon as possible. Detection of TB without investigating for drug resistance can lead to poor treatment outcomes, additional and unnecessary suffering and costs for patients, and further spread of drug-resistant strains of TB.

Q: What is the general TB situation in Myanmar?

Among the 22 countries that WHO classifies as 'high TB burden', Myanmar has the fourth-highest TB prevalence rate, with 525 cases per 100 000 population. TB prevalence is higher in the densely populated urban areas of the country and in the outlying minority states. There were an estimated 180 000 new TB cases in Myanmar in 2010, more than 40 000 of them among children.
Source: WHO

Q: What is the MDR-TB situation in Myanmar?

The country has set a target of enrolling half of the estimated TB patients with MDR-TB on treatment by 2016. According to WHO, this would require contributions of multiple partners to ensure deployment of rapid diagnostic tests and increased capacity to provide treatment for MDR-TB.
For more info visit WHO's fact sheet on MDR-TB in Myanmar.

Neine Naing Min

On the tenth month of his MDR-TB
treatment - provided by the community

North Okkalapa is a densely populated suburb on the outskirts of Myanmar's capital city Yangon. In this sprawling working class neighbourhood of small wooden houses, TB is the number one cause of illness. Dr Aye Aye Mu (pictured above, right) has run a small health clinic in the middle of this township for many years, and has become a lifeline for those in her community - especially for providing TB and MDR-TB medicines.

Neine Naing Min is one such patient. He's lucky: he lives just across the street from Dr Aye Aye Mu's clinic, and regularly visits her to take his treatment. Before he became sick with MDR-TB, Neine Naing Min, 29 years old, worked at a bookstore. He has now stopped working and lives at home with his wife and one child.

He took us across the street to visit his house. Although he is only on the tenth month of his two-year MDR-TB treatment course, his mask could not hide a smile - with treatment accessible and care literally across the street, Neine Naing Min had hope.

About this site

This site was developed by Inis Communication for UNITAID, following a visit to the country in September 2013. We intend to raise awareness about our catalytic investments in MDR-TB treatment and testing. We also would like to shine some more light on the many committed health workers and their patients that we met in Myanmar, offering a space to tell their story.

All photographs by Gerhard Jörén, unless otherwise noted.