Treatment Outcomes of Pulmonary Tuberculosis at Population Services International Clinic Networks, Myanmar: A Retrospective Cohort Study from 2012-2016 Público

Abstract

Introduction: Myanmar is among the 30 highest tuberculosis (TB) burden countries globally, with an estimated TB prevalence of 467/100,000 population in the National TB Prevalence Survey (2017-2018). Activities to reach, cure, and prevent tuberculosis have been implemented through Public-Public Mix and Public-Private Mix Models (PPM). In 2016, the National TB Program (NTP) and Population Services International (PSI) contributed 82.5% and 11.6% of bacteriologically confirmed TB patients, respectively. We sought to examine the TB trends and treatment outcomes of patients diagnosed and treated within the PSI network of clinics.

Methods: This is a retrospective cohort study examining TB treatment outcomes and risk factors associated with unsuccessful outcomes using clinical and public health data collected by PSI Myanmar from 2012 to 2016. Public health and sociodemographic risk factors were examined using multivariate regression. Multinomial regression models were used to examine independent variables with more than two categories of dependent outcomes and give both crude and adjusted Relative Risk or Risk Ratio (RR).

Results: A total of 62,664 tuberculosis patients were seen in PSI Myanmar facilities (93.4% new patients and 6.6% re-treated patients) from 2012 to 2016. A majority, or 38,848 (62%) were male. Patients who were 35-54 years old (38%), and male gender had highest percentage of TB compared to other age groups and sex. Smear positive, negative, and smear not done accounted for 31,679 (50.6%), 29,889 (47.7%), and 1,096 (1.7%), respectively. Of all patients, 31,433 (50.2%) had negative HIV test, 1,871 (2.9%) had positive test, and 29,360 (46.8%) had an unknown HIV test result. There were 58,544 (93.4%) new patients, and 4,120 (6.6%) re-treated patients. Among all patients treated at PSI, 90.9% were successfully treated (35.1% cured and 53.4% completed), and 9.1% were unsuccessfully treated (0.5% lost to follow-up during the initial phase of treatment, 7.1% lost to follow-up during the continuation phase, and 4.0% failed treatment). The risk factors statistically associated with unsuccessful treatment outcomes included male sex (aRR=1.41, CI:1.33-1.50), age over 55 years old (aRR=1.25, CI:1.17-1.34), smear-positive TB (aRR=1.03, CI:0.98-1.10), HIV positive status (aRR=1.65, CI:1.42-1.85), and those who sought retreatment after initial loss to follow-up (aRR=1.99, CI:1.14-3.49). Nutrition support was found to significantly decrease the risk of having unsuccessful treatment (aRR=0.91, CI:0.86-0.96).

Conclusions: During the five-year study period, PSI achieved considerably high treatment success rate in the context of the PPM model where PSI provided diagnosis and treatment services for people with TB (Scheme III) and reached a large number of patients with the use of incentive and support programs, such as nutritional and travel support. These findings suggest that the PPM model used by PSI can successfully implement the NTP goals and significantly contribute to successful treatment outcomes for most people served.

Table of Contents

Table of Contents

Abstract ............................................................................................................................................4

Acknowledgements............................................................................................................................6

Glossary of Terms [1] .........................................................................................................................9

Abbreviations ..................................................................................................................................10

Chapter I: Introduction

1.1 Tuberculosis clinical presentation .................................................................................................11

1.2 Myanmar: Country Profile ............................................................................................................12

1.3. Study Objective ..........................................................................................................................14

Chapter II: Literature Review

2.1. Public-Private Mix model (PPM) and Population Services International ......................................... 15

2.2. TB Case detection and notification ..............................................................................................17

2.3. TB Diagnosis ..............................................................................................................................18

2.4. TB Treatment Outcomes .............................................................................................................19

2.5 Gaps in Knowledge and the Impact of this Study ...........................................................................20

Chapter III: Manuscript

Abstract ..........................................................................................................................................22

Background .....................................................................................................................................23

Methods .........................................................................................................................................24

Data and Data Source ......................................................................................................................24

Statistical Analysis ..........................................................................................................................25

Results ...........................................................................................................................................26

Characteristics of TB patients ........................................................................................................26

Treatment Duration and Treatment Outcomes ................................................................................29

Newly and Re-treated Cases, and Risk Factors of Being Re-treated ................................................... 33

Treatment Success Rate .................................................................................................................37

Risk Factor Associated with Unsuccessful Treatment........................................................................38

Discussion ......................................................................................................................................40

Limitations .....................................................................................................................................43

Appendix .......................................................................................................................................44

Tables ..........................................................................................................................................44

Table 1. Characteristics of TB Patients .........................................................................................44

Table 2. Treatment Duration and Treatment Outcomes ................................................................ 45

Table 3. Weight Group, Smear, HIV, Successful Treatment .............................................................46

Table 4. Risk Factor of Being Re-treated .......................................................................................47

Table 5. Risk Factor of Unsuccessful Treatment ............................................................................48

Figures ........................................................................................................................................49

Figure 1. Percent of TB cases cared by PSI by year .........................................................................49

Figure 2. Treatment Outcomes by Different Categories of Patients .................................................50

Figure 3. Treatment Successful Rate at PSI ...................................................................................51

Figure 4. Treatment Outcomes and Success Rate by Year ...............................................................52

List of Variables ..............................................................................................................................53

Bibliography ..................................................................................................................................54

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Epidemiology
Palabra Clave	Population Services International Myanmar Tuberculosis Treatment Outcomes Tuberculosis
Committee Chair / Thesis Advisor	Kenneth G. Castro, Emory University
Committee Members	Sarita Shah, Emory University

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