MHAA

OutlineMilestone of survey in MyanmarObjectivesMethodResultsDiscussionLimitationProgramme implications

1972 – National TT survey

1994 – National Sputum smear positive TB prevalence survey

Protocol drafted in 2005, however, due to funding limitation, Yangon Divisional TB prevalence survey was conducted in 2006 as a pilot phase, capacity building was done and some equipment for survey were procured.

Preparation for Protocol - October, November, 2008

Approval of MOH - December, 2008

Ethical Approval - 16th February, 2009

Procurement started - December, 2008

Selection of Clusters - November, 2008

Meetings for NPS - February, 2009

Training - 23-2-2009 to 24-2-2009, 14-3-09 to 17-3-09

Pre testing/ Field testing - 17-3-2009 at Singu Ward, Insein Township,

1st Steering Committee Meeting - 26-11-2009

2nd Steering Committee Meeting - 9-5- 2010

National TB Prevalence survey (MYANMAR)

- smear positive pulmonary TB- Culture positive pulmonary TB- symptoms suggestive of TB - radiological abnormalities suggestive of pulmonary TB

Health seeking behaviour of TB patients and individuals reporting chest symptomsUtility of private sector such as proportion of TB patients under treatment in

private sector TB Risk factors

Survey sites: Country wide

Eligible pop: ≥ 15 years age group

Study period: January, 2009 to December, 2010

: Cluster sampling method stratified by

state and division.

: A cluster

Myanmar17 States & Divisions

70 clusters

7 States (28% of pop)20 clusters

7 Divisions (72% of pop)50 clusters

Remark:

For Division - Urban – 11 clusters, Rural – 39 clustersFor State - Urban – 5 clusters, Rural – 15 clusters

32 townships excluded from a sampling frame due to logistical difficulties to carry out field operations (2.5% of total populations excluded)

PPS

Distribution of

survey clusters

Documented Video

Supported by JICA

: 2 sputum smear positive results or 1 positivesmear result with an X-ray result consistent with active TB or 1 positive smearresult with a culture confirmation. Even scanty positive (<10/100HPF) wasconsidered as smear positive.

: 2 sputum smear results werenegative with at least 1 culture confirmation of M.tb.

: a case of smear positive or smearnegative/culture positive.

: No evidence ofbacteriologically positive TB but with strongly suggested active TB disease inthe X-ray examination were judged by the central panel consisted of at least 2chest physicians.

TB Prevalent Case

to the participants on TB symptoms and history

Compulsory with informed consent

For pregnant women, sputum specimens were took compulsory, No CXR

If CXR shows abnormal lesion or any chest symptomatics or those who gaveany history of current / previous anti-TB treatment – 2 sputum specimens weretaken

- Sputum for AFB examination at Reference Laboratories, Yangon andMandalay using fluorescence microscopy, confirmed by ZN stain

- Culture – egg based solid mediums were used

- Identification – Niacin test, PNB and Capilia test were used

Results

Individuals enumerated in Census93,806

Participants 51,367 (89.2%)-Interview only 1,126 (2.2%)

- Interview and CXR 50,241(97.8%)

Eligible study population57,607 (61.4%)

Ineligible individuals: 27,399 Children 8,800 adults due to residential criteria

Eligible for Sputum Examinations 12,235 (23.8%)

Submitted at least one specimen 12,144(99.3%)

Symptom+CXR+ 1,259Symptom+CXR- 402Symptom-CXR+ 9,378Symptom+CXR NA 30Symptom-CXR NA 1,096By corrective action 70

Summary of National TB Prevalence Survey

Summary of National TB Prevalence Survey, Myanmar, 2009-2010

Lab Results available 12,087(98.8% of eligible)(2 Smear 2 Culture results 11,587)

Any Smear Positive132 (2S+:89,1S+:43)

Smear Negative 11,955 (2S - =11,875,1S - = 80)

Culture ResultMTB - 116MOTT - 2Contaminated - 0Negative 14N.A 0

Culture ResultMTB - 201MOTT - 22Contaminated 51Negative 11,672N.A 9

Summary of National TB Prevalence Survey, Myanmar, 2009-2010

Central Panel

S+C+TB cases 116S+C-TB cases 7Excluded cases 7MOTT 2

C+TB Cases 188Excluded cases 13MOTT 22

Smear-positive casesSmear-negative,

culture-positive casesBacteriologically confirmed cases

n % n/100 000 95% CI n

/100 000 95% CI n

/100 000 95% CI

All participants 51 367 100% 123 242.3 186.1 315.3 188 370.5 293.3 468.0 311 612.8 502.2 747.6

Strata

Division 37 163 72% 70 191.6 137.4 267.3 122 331.1 256.1 428.1 192 522.8 420.9 649.1

State 14 204 28% 53 369.0 235.6 577.5 66 469.0 288.4 761.8 119 838.0 560.3 1 251.5

Urban/Rural

Urban 11 254 22% 38 330.7 216.2 505.7 65 572.4 415.0 789.2 103 903.2 661.8 1 231.5

Rural 40 113 78% 85 216.1 153.6 304.0 123 310.7 228.7 422.0 208 526.8 410.1 676.5

Sex

Male 22394 44% 88 397.8 301.3 524.9 118 532.8 407.2 696.9 206 930.6 742.6 1165.5

Female 28973 56% 35 122.2 76.9 194.2 70 245.2 181.7 330.8 105 367.4 287.7 469.1

TB Prevalence among Survey Participants (aged ≥ 15 years)

Variations by clustersRed: S+; Blue S‐C+No. Cases in 5 clusters

0

5

10

15

20

25

case

s

S-C+ S+

Rural

urban

No. of S+ and C+ case detected cases by sex

0

10

20

30

40

50

60

15- 25- 35- 45- 55- 65-

case

s

M S+ M C+ F S+ F C+

Urban and Rural DifferencesSmear Positive TB Prevalence 

0

200

400

600

800

1000

1200

1400

1600

15- 25- 35- 45- 55- 65-

S+/1

00K

age

U Male R Male U Female R Female

Urban and Rural DifferencesBacteriological Positive Cases

0

500

1000

1500

2000

2500

3000

3500

4000

15- 25- 35- 45- 55- 65-

Bac

+ TB

/100

,000

Urban Male

Rural Male

Urban Female

Rural Female

S+ C+TB case

S+ C-TB case

S- C+TB case

Smear-positive

study case %Bac confirmed

study cases %

Total 116 7 188 123 100% 311 100.0%SymptomEligible 40 2 24 42 34.1 66 21.2Ineligible 76 5 164 81 65.9 245 78.8Field CXREligible 115 6 175 121 98.4 296 95.2Ineligible 0 0 2 0 0 2 0.6No CXR 1 1 11 2 1.6 13 4.2Central readingNormal 6 0 12 6 4.9 18 5.8Active TB suggestive 77 5 82 82 66.7 164 52.7TB suspect 12 0 41 12 9.8 53 17Healed TB 19 0 29 19 15.4 48 15.4Other lung disease 1 0 7 1 0.8 8 2.6Cardiovascular abn. 0 0 3 0 0 3 1Other findings in lung 0 1 2 1 0.8 3 1Findings other than lung 0 0 1 0 0 1 0.3Not interpretable 0 0 0 0 0 0 0Not available for reading 1 1 11 2 1.6 13 4.2

TB Cases (Survey cases) by Interview and CXR results

S+ C+TB case

S+ C-TB case

S- C+TB case

Smear-positive

study case %Bac confirmed

study cases %

Total 116 7 188 123 100% 311 100.0%Sex and Age

Male 83 5 118 88 71.5% 206 66.2%15-24 3 0 5 3 2.4% 8 2.6%25-34 14 1 17 15 12.2% 32 10.3%35-44 23 1 26 24 19.5% 50 16.1%45-54 16 2 30 18 14.6% 48 15.4%55-64 14 1 14 15 12.2% 29 9.3%65+ 13 0 26 13 10.6% 39 12.5%

Female 33 2 70 35 28.5% 105 33.8%15-24 1 1 1 2 1.6% 3 1.0%25-34 5 1 14 6 4.9% 20 6.4%35-44 12 0 14 12 9.8% 26 8.4%45-54 7 0 11 7 5.7% 18 5.8%55-64 4 0 11 4 3.3% 15 4.8%65+ 4 0 19 4 3.3% 23 7.4%

GeographyState Rural Clusters 37 1 48 38 30.9% 86 27.7%State Urban Clusters 13 2 18 15 12.2% 33 10.6%Division Rural Clusters 43 4 75 47 38.2% 122 39.2%Division Urban Clusters 23 0 47 23 18.7% 70 22.5%

TreatmentOn TB treatment 8 0 3 8 6.5% 11 3.5%Previously treated (not on Tx) 22 1 19 23 18.7% 42 13.5%

TB Cases (Survey cases) by Interview and CXR results

Symptom screening and TB diagnosis

42/123 (34.1%) S+ cases reported “cough > 21 days”(66/311 (21.2%) Bact + reported “cough > 21 days”)

21/123 (17.1%) smear positive cases did not report any symptom

24/188 (12.8%) S- C+ cases reported "cough > 21 days“

96/188 (51.1%) S- C+ cases did not report any symptom

Past History of TBOn Treatment (79)S+ 8 10.1%Bact + 11 13.9%

With TB History (1,523)S+ 23 1.5%Bact+ 42 2.8%

Place of TB Treatment

Access to DOTS through HP/HC have improved, while private sector notified more cases

Current Treatment Previously TreatedPlace % %HP/HC 27 34% 250 17%public hosp 36 46% 716 49%GP 12 15% 433 30%private hosp 2 3% 29 2%pharmacy 1 1% 11 1%others 1 1% 21 1%unknown 3 0%Total 79 1463

Bac+ TB

/100 000

Crude ORAdjusted OR

(random effect model)*

CasesPartici-pants OR 95% CI P>z OR 95% CI P>z

State/Division

Division 192 37 163 516.6 Reference Reference

State 119 14 204 837.8 1.63 1.29 2.05 0.00 1.43 0.98 2.09 0.065

Urban/RuralRural 208 40 113 518.5 Reference ReferenceUrban 103 11 254 915.2 1.77 1.40 2.25 0.00 1.50 1.02 2.22 0.041

SexMale 206 22 394 919.9 Reference ReferenceFemale 105 28 973 362.4 0.39 0.31 0.50 0.00 0.41 0.30 0.56 0.000

Age group15-24 11 11 899 92.4 0.20 0.10 0.38 0.00 0.36 0.18 0.72 0.00425-34 52 11 224 463.3 Reference35-44 76 10 462 726.4 1.57 1.10 2.24 0.01 1.47 0.97 2.22 0.06745-54 66 8 280 797.1 1.73 1.20 2.49 0.00 1.08 0.70 1.65 0.73655-64 44 5 167 851.6 1.85 1.23 2.76 0.00 0.84 0.53 1.34 0.46365+ 62 4 335 1 430.2 3.12 2.15 4.51 0.00 0.83 0.52 1.32 0.434

Risk analysis: Prevalence, Crude & adjusted OR

Risk analysis: Prevalence, Crude & adjusted ORBacteriologically + TB Prevalence Crude OR Adjusted OR (Random effect model)

Cases Participants per 100,000 OR 95% CI P>z OR 95% CI P>zReligion

Non-Buddhist 48 4 265 1 125.4 Reference Reference Buddhist 263 47 102 558.4 0.49 0.36 0.67 0.00 0.71 0.46 1.1 0.127EducationLiterate 256 45 743 559.6Reference Reference Illiterate 55 5 624 978 1.75 1.31 2.35 0.00 1.36 0.95 1.95 0.091OccupationNon-farmer 198 28 470 695.5Reference Reference Farmer 113 22 897 493.5 0.71 0.56 0.89 0.00 0.7 0.53 0.93 0.012Previous Tx

Not answered Yes 269 49 904 539Reference Reference

Answered Yes 42 1 463 2 870.8 5.45 3.92 7.58 0.00 3.28 2.31 4.64 0.000Contact

Not answered Yes 267 47 934 557Reference Reference

Answered Yes 44 3 433 1 281.7 2.32 3.92 7.58 0.00 2.04 1.46 2.85 0.000Smoking

Never smoked 135 33 547 402.4Reference Reference Ex-smoker 49 3 065 1 598.7 4.02 2.89 5.59 1.55 1.06 2.25 0.023Current smoker 127 14 755 860.7 2.15 1.69 2.74 0.00 1.16 0.88 1.55 0.295AlcoholNever 191 40 268 474.3Reference Reference

Ex-drinker 49 3 006 1 630.1 3.48 2.53 4.77 1.27 0.87 1.84 0.211

Current drinker 71 8 093 877.3 1.86 1.41 2.44 0.00 0.96 0.69 1.34 0.798

Predictors such as CXR suggestive of having TB, Chest symptoms, and BMI are associated with bacteriologicallypositive TB and significant in the random effects model.

Health seeking practice

First Action when having chronic coughWith

Chronic Cough

Traditional Medicine, Pharmacy

Visit Medical facility

Visit PublicFacilities

Total(41,374)

10,85626%

8,03819%

4,25110%

TB CASES(265)

5722%

6625%

3614%

Symtomatic(1663)

51431%

36322%

19712%

First Action when having chronic cough among TB cases

S+C+ % S‐C+ % CXR+ %Go to traditional healer + pharmacy 20 17.4 30 16.2 141 25.8

Go to private sector 11 9.6 17 9.2 33 6.0

Go to public sector 13 11.3 17 9.2 54 9.9

Self medication 31 27.0 44 23.8 119 21.8

Neglect and others 40 34.8 77 41.6 200 36.6

Total 115 185 547

Discussion

Survey in 1994Sputum collection from TB suspects by symptoms/all age (10y or more)

Examined S+cases

Per 100,000

Urban 10,946 08 73

Rural 26,478 31 117

Total 37,424 39 104(132)

Has TB Situation become worse as we observed higher prevalence?

National TB Prevalence Surveys, Myanmar

0

50

100

150

200

250

300

350

400

15- 25- 35- 45- 55-Age Group

Smea

r Pos

itive

TB

/ 100

K a

ged

15 o

r mor

e

1972

1994

2009/10

Do we have younger patients than previous surveys?

Comparison between Myanmar National TB Prevalence Survey results, 1994 and 2000-2010

(Direct comparison of survey findings)

Survey findings adjusted with screening and diagnostic algorithm

35% reduction in prevalence was observed over 15 years, when the same screening and Dx algorithm was applied for 2 surveys

Comparison with the past surveys and Case notification data 2009smear positive case

0

100

200

300

400

500

600

15- 25- 35- 45- 55-

1972

1994

2006Y

2009/10

2009/10symp

2009Notifi

Yangon 2006

National 2009

Symptomatic 2009

High Prevalence and Gap between prevalence and Notification

0

50

100

150

200

250

300

350

400

15- 25- 35- 45- 55-

2009/10

2009Notif i

2009/2010 Survey

2009 Notification

Notification and PrevalenceS+ in 2009

0

20

40

60

80

100

120

140

160

15- 25- 35- 45- 55-

S+/1

00,0

00

Notification 2009

S+ with cough >3w Prevalence 2009

Smear Positive Bac Confirmed Cambodia 2002 10y- 362 (284-461) 1208 (997-1483)Philippines 2007 10y- 260 (170-360) 660 (510-810)Viet Nam 2007 15y- 197 (149-254) 307 (248 -367)*Myanmar 2009 15y- 242 (186-315) 613 (502 -748)

*Viet Nam: one culture only

National TB Prevalence Survey in ASEAN countries

(Surveys with CXR and Culture)

Limitations

Operational aspectsDelay in logistic procurement: quality of CXRSputum cups used in survey were not appropriateIn few urban clusters and remote clusters with ethnic minorities had a relatively low participation rateFewer participation in maleSome positive subjects may be missed by screening especially those with milder symptoms without detectable CXR abnormality A few positive subjects might not submit sputum samples

Design of the study• TB in children and EP could not be assessed• HIV, MDR-TB data are not available

LimitationsOperational aspects

Cross contamination in the laboratory in MandalayLanguage barrieer

Analysis• Removing possible TB cases : one S+ or one culture positive without other evidence of disease from the survey case list without imputation of missing value may lead to an underestimation of the prevalence by around 10-15%.

Summary of the 3rd National TB Prevalence Survey Myanmar

Fie ld Ope rat ion From June 2009- Apr il 2 010

No o f c lu ste rs 70

No o f Eligible (>15y) 57 ,607

No o f part ic ipated 51 ,367 89 .2%

No de tec ted /100K 95% C.I .

Smear posit ive TB 123 242 .3 186-315

(all age* ) 171 .0

S-C+ TB 188 370 .5 293-468

Bac+ TB 311 612 .8 502-747

*Assuming that 73% o f popu lat ion are aged 15y o r more

and that the re is no smear posit ive case in Ch ildren

Quality survey confirmed the high prevalence of TB

Only 1/3 of S+ reported cough >3 weeks

35% decline of S+TB with Chronic cough compared with 1994 survey

It seems that DOTS has worked in the target group (S+ with chronic cough)

However, no-decline was observed in younger age groups: Migration and HIV?

Summary

Urban-Rural discrepancies (R>U in 1994 )

Urban areas are having high prevalence cases than rural in current survey

Male-Female differences

State had higher prevalence than Division

Visiting medical facilities as first action for chronic cough is not common.Difference between urban and rural is large. Lower proportion of people visit medical facilities in rural areas: Mainly access problem?

Summary cont…

Implication for the programme Higher prevalence in States with fewer notification suggests challenge in access

High prevalence in urban with high notification rate suggests higher burden of TB in urban, congestive areas

"Gap between prevalence and notification" and "recent decline of notification rate" suggest a slow decline of TB incidence and limitations of current case finding strategy

Removing serious cases from community, impact on TB mortality might be significant. However, the impact of control efforts on TB incidence might not be sufficient

Most TB symptomatics have not received appropriate TB screening and diagnosisLimitation of access even in urban areasLimitation of the screening criteria by symptomsLimitation of smear microscopy diagnosis Limitation of CXR diagnosis in routine practice (Are smear negative cases really TB? Under-diagnosis as healed TB?)

Speculations

Probable 2nd wave of TB epidemic in two decades

Possible spread of 2nd epidemic wave from Urban to Rural

Low prevalent clusters: the 2nd wave not reached yet

Population 59,000,000

Estimated incidence all forms 384/100,000 (Global TB control: a short update to the 2010 report, WHO, Geneva. 2011)

Estimated TB prevalence 525/100,000Estimated TB mortality 49/100,000

HIV sero-positive among TB patients 4.5% (1997) (For 20 sentinel sites) 10.4% (2010)

MDR-TB (2007-08 country wide 2nd DRS) 4.2 % (new cases)10% (treated cases)

TB control achievement for 2010 CDR = 76% & TSR = 85%Case Notification Rate for 2010 279/100,000 pop.Smear + TB Notification Rate for 2010 99/100,000 pop.

AcknowledgementNTP Myanmar appreciates to multiple partners (MOH/DOH, WHO, JICA/RIT, PSI, USAID, 3DF, MHAA) involved in this survey contributing either technical or financial support for the making the survey successful.The support of local health authorities and basic health staff, local volunteers, local communities was also a great value in data collection phase.Special thanks to Dr. Hans, H. Kluge, WHO, Dr. Ikushi Onozaki, WHO  and Dr. Norio Yamada, RIT were recorded for their tremendous contributions.

Thank you

To improve access to diagnostic serviceRemote States: Distance, Engaging Pharmacies and Traditional Healers Congestive urban areas: Private, Service Hours

Aggressive service in collaboration with private sector and partners seems to be essential

Active case detection, mobile servicesTB screening in HIV service and Anti-natal care

To improve TB screeningAppropriate use of CXRWidening CXR screening criteriaWidening symptom screening criteriaImproving quality of CXR

To improve TB diagnosisGive up the expansion plan of culture serviceIntroduce new molecular technology to detect S- TB Pilot the direct administration of new technology among high risk/predictive TB suspectsDevelop and pilot the transportation system of sputum specimens and feedback mechanismReview diagnostic algorism of smear negative subjects in settings where only smear MS and CXR are available

Pilot and Study the impact of One time clean up operation on TB incidence in community in high burden areas of both urban and rural

Discuss to plan next survey to measure changes after 2015

With strong leadership and partnership, Myanmar will be able to show the impact of new interventions and strategy.A quality survey was carried out to provide the base line data and scientific evidencesQuality of routine surveillance is essential to follow the future change

Quality of diagnosis Coverage of surveillanceData of Children HIV DataMDR Surveillance data

Prevalence of TB among aged 15 or moreSmear Positive case Bacteriologically confirmed case

n /100,000 95% CI n /100,000 95% CIAll participants 123 242.3 (186.1-315.3) 311 612.8 (502.2-747.6)

StrataDivision 70 191.6 (137.4-267.3) 192 522.8 (420.9-649.1)

State 53 369.0 (235.6-577.5) 119 838.0 (560.3-1251.5)

Urban/RuralUrban 38 330.7 (216.2-505.7) 103 903.2 (661.8-1231.5)Rural 85 216.1 (153.6-304.0) 208 526.8 (410.1-676.5)

All age 172/100,000 434+/100,000

(NTP Notification: 0.7% of S+ are Children) (No data)

Smear Positive Subjects132 Smear Positive Subjects

118 Definite Cases: Culture+ for Mycobacterium TB5 Probable Cases without culture confirmation

Two slides positiveCXR TB consistent findings

7 Possible Case: One slide positive without any other evidence suggesting TB disease –: exclude from the study case2 Mycobacterium Other Than TB by Culture

Culture Positive Subjects

223 Smear Negative Culture Positive Subjects 188 Definite Case with Mycobacterium TB Isolates

Positive with >5colonies or other evidence of TB

0 Probable Case: No confirmation of M TB13 lab contamination susp: possible cases (non-study cases)

12: <5 (1-2) colonies without other evidence of disease1 : 10 colonies with a possible lab accident

22 with MOTT isolates without M TB

TB history of Prevalent Cases

118 S+C+110 Not on treatment (91.5%)

89 New Cases (75.4%)21 Previously Treated

7 First Treatment1 Retreatment 

5 S+C‐2 New1 Previously treated

2 On Tx1 On 1st treatment1 On Retreatment

188 S‐C+167 New (88.8%)18 Previously treated

3 On treatment 2 on 1st treatment1 on retreatment 

Survey Population and Status

Abbrevi-ation Number Proportion

Identified TB casesS+TB S-C+TB B+TB

Population under census N 93 806

Eligible population N1 57 607

61.4% of population under census

Participants N2 51 36789.2% of eligible population 123 188 311

Received symptom screening N3 51 367Received CXR N4 50 241

Not received CXR 1 126Received both N5 50 241

Eligible for sputum exam based on symptoms and CXR N6 12 165 123 186 309

At least two smears examinedN7 11 937

98.1% of those eligible for sputum exam

At least one culture doneN8 11 957

98.3% of those eligible for sputum exam

Ineligible for sputum examination N6b 39 202 0 2 2

At least two smears examined N7b 80At least one culture done N8b 80

Categorization of survey population and TB screening implementation (based on variables of sputum request)

[1] Judged as TB symptomatic and/or as having CXR shadow eligible for sputum examination or having no CXR examination.[2] All participants except those meeting the criteria of note 3 above.

Survey Population and Status

Abbrevi-ation Number Proportion

Identified TB casesS+TB S-C+TB B+TB

Population under census N 93 806

Eligible population N1 57 607

61.4% of population under census

Participants N2 51 36789.2% of eligible population 123 188 311

Received symptom screening N3 51 367Received CXR N4 50 241Not received CXR 1 226Received both N5 50 241Eligible for sputum examination based on symptoms and CXR N6 12 194 123 186 309

At least two smears examined N7 11 951

98.0% of those eligible for sputum exam

At least one culture done N8 11 971

98.2% of those eligible for sputum exam

Ineligible for sputum examination N6b 39 173 0 2 2At least two smears examined N7b 56At least one culture done N8b 56

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)

Prevalence Estimates were done with deferent methodologiesMost have similar resultsConsidering the participations by age and sex, estimate changes 1-2%Some scenarios with counting those with missing value may increase the prevalence around 10% However Central Review and CXR QA reading suggest that those who missed examinations are less likely to be positive than those who submitted, few major error in screening reading was observed by audit.

ex. No symptomatic subject with TB suggestive CXR was missed

Use of Medical facility among symptomatic

With Chronic Cough

Visit Traditional

Healer, Pharmacy

Visit Medical facility

Visit PublicFacilities

TB CASES(265)

4718%

6625%

3614%

Symtomatic(1663)

41325%

36322%

19712%

Comparison with the past surveys and Case notification for smear positive case in 2009

Yangon 2006

National 2009

Symptomatic 2009

Prevalence* 95% CI

Notification2009 N/P 95% CI

Total 171.5 131.7 223.2 81 0.47 0.62 0.36SexMale 275.9 209.0 364.1 110 0.40 0.52 0.30Female 88.1 55.5 140.1 53 0.60 0.96 0.38Age15-24 43.2 9.2 88.6 63 1.23 5.77 0.6025-34 189.6 110.3 271.9 108 0.53 0.91 0.3735-44 349.7 232.6 457.4 127 0.35 0.53 0.2745-54 304.2 184.9 421.7 142 0.48 0.79 0.3555-64 372.8 183.6 502.5 146 0.39 0.79 0.2965+ 394.5 193.4 557.6 120 0.26 0.54 0.19StrataState 249.6 159.3 390.6 69 0.32 0.50 0.20Division 138.6 99.3 193.3 85 0.71 0.99 0.51Upper 147.5 95.9 226.6 59 0.46 0.71 0.30Lower 192.9 136.6 272.4 102 0.61 0.86 0.43

Notification/ Prevalence ratios by different groups

Notification/Prevalence ratios for smear-positive TB by different groups, Myanmar National TB Prevalence Survey, 2009-2010

Further studies and analysis Further bacteriological exams in RIT/JapanFollow up in‐depth interview to detected casesSocio‐Economic, Risk, and Predictive factorsPilot and Operational Researches from survey findings

Smear-positive casesSmear-negative,

culture-positive casesBacteriologically confirmed cases

n % n /100 000 95% CI n /100 000 95% CI n /100 000 95% CISex and Age

Male 22 394 44% 88 397.8 301.3 524.9 118 532.8 407.2 696.9 206 930.6 742.6 1 165.5

15-24 5 404 11% 3 57.7 19.4 171.6 5 94.5 33.1 269.3 8 152.2 65.3 354.5

25-34 4 808 9% 15 317.3 200.9 500.9 17 361.6 205.7 634.7 32 678.9 464.8 990.5

35-44 4 526 9% 24 537.4 345.5 834.9 26 583.0 385.7 880.4 50 1 120.4 832.0 1 507.2

45-54 3 606 7% 18 504.3 290.4 874.4 30 845.8 534.1 1 337.0 48 1 350.1 917.0 1 983.8

55-64 2 231 4% 15 683.8 421.6 1 107.3 14 634.2 369.7 1 086.1 29 1 318.1 905.8 1 914.2

65+ 1 819 4% 13 716.8 403.9 1 268.8 26 1425.8 917.2 2 210.2 39 2 142.6 1 539.5 2 974.8

Female 28 973 56% 35 122.2 76.9 194.2 70 245.2 181.7 330.8 105 367.4 287.7 469.1

15-24 6 495 13% 2 31.0 7.6 126.0 1 15.7 2.1 115.6 3 46.7 15.0 145.1

25-34 6 416 12% 6 94.0 42.2 209.1 14 218.2 119.8 397.2 20 312.2 196.7 495.1

35-44 5 936 12% 12 206.9 108.2 395.2 14 242.6 143.3 410.3 26 449.5 301.0 670.8

45-54 4 674 9% 7 149.9 75.1 299.1 11 244.7 145.3 411.9 18 394.6 260.8 596.7

55-64 2 936 6% 4 136.3 52.5 353.6 11 372.4 200.1 692.0 15 508.7 299.6 862.3

65+ 2 516 5% 4 162.2 60.4 434.8 19 767.3 479.4 1 226.2 23 929.6 606.2 1423.0

TB Prevalence Among Survey Participants (age ≥15 years) by Sex and Age Groups

Smear Positive: M/F = 88/35=2.5

0

5

10

15

20

25

30

15-24 -34 -44 -54 -64 65+Age Group

Smear Postive Cases

Male Female

B confirmed Cases M/F=1.96

0

10

20

30

40

50

60

15-24 -34 -44 -54 -64 65+Age Group

Bacteriologically Confirmed Cases

Male Female

Impact of control effortsDecline of S+ with Chronic Cough

50% decline of S+ Prevalence if we don't have CXR in 2009/10 survey

0

50

100

150

200

250

300

350

400

15- 25- 35- 45- 55-

S+/1

00,0

00

S+ with cough >3w Prevalence 2009

1994 National Survey

1972 National Survey

Age Group

Sex

Area

First Action when having chronic cough

0% 5% 10% 15% 20% 25% 30%

U rban

R ural

M ale

Fem ale

15-24

25-34

35-44

45-44

55-65

65+

Education

First Action when having chronic cough

0% 5% 10% 15% 20% 25% 30% 35%

Illiterate

literate

P rim ary

M iddle

H igher

U niversity

G raduate