THE CHALLENGES OF COMBATING TB IN BURMA

UNCLAS SECTION 01 OF 04 RANGOON 000278 SENSITIVE SIPDIS DEPT FOR EAP/EX; EAP/MLS; EAP/EP; EAP/PD DEPT FOR OES/STC/MGOLDBERG AND PBATES; OES/PCI/ASTEWART; OES/IHA/DSINGER AND NCOMELLA DEPT PASS TO USAID/ANE/CLEMENTS AND GH/CARROLL CDC ATLANTA FOR COGH SDOWELL and NCID/IB AMOEN USDA FOR OSEC AND APHIS USDA FOR FAS/DLP/HWETZEL AND FAS/ICD/LAIDIG USDA/FAS FOR FAA/YOUNG, MOLSTAD, ICD/PETTRIE, ROSENBLUM DOD FOR OSD/ISA/AP FOR LEW STERN PARIS FOR FAS/AG MINISTER COUNSELOR/OIE ROME FOR FAO BANGKOK FOR REO OFFICE, USAID/RDMA HEALTH OFFICE - JMACARTHUR, CBOWES TOKYO FOR HEALTH OFFICER PACOM FOR FPA E.O. 12958:N/A TAGS: ECON TBIO EAID SOCI PGOV AMED BM SUBJECT: THE CHALLENGES OF COMBATING TB IN BURMA REF: A) 07 RANGOON 1027 B) 07 RANGOON 1120 C) 07 RANGOON 588 RANGOON 00000278 001.22 OF 004 ¶1. (SBU) Summary. Tuberculosis is a growing HEALTH concern in Burma, with more than 130,000 new cases of TB diagnosed a year. The WHO estimates that more than 40 percent of Burma's population could be infected with the disease. The Burmese Government, through its National TB Program (NTP) is working hard to meet the current TB burden, but falls short. HEALTH experts warn that any increase in the TB incidence rate, particularly of multi-drug resistant TB (MDR-TB) and TB/HIV co-infection, will overburden an already overstretched and underfunded NTP. During a two-week assessment of Burma's TB program, we observed several weaknesses -- including securing first-line TB drugs past 2009, strengthening the NTP, enhancing surveillance, implementing infection control measures, improving national laboratory capacity for culture and drug sensitivity testing, and expanding education and outreach efforts -- before the NTP can successfully prevent and treat TB. End Summary. Conducting a TB Assessment -------------- ¶2. (SBU) The World HEALTH Organization (WHO) considers Burma to be one of 22 tuberculosis high-burden countries in the world. While the true prevalence of TB in the country is unknown, the Ministry of Health reported that the National Tuberculosis Program (NTP) diagnosed more than 130,000 new TB cases in 2007 (Ref A); however, a recent prevalence survey in Rangoon estimates the numbers to be three times higher. The WHO estimates that 40 percent of Burma's population may have TB, although NGOs working in the HEALTH sector argue that the incidence rate is much higher, around 60 percent. Burma's high TB rates have implications for the region; there have been several instances in the past year of Burmese migrants with MDR-TB traveling to neighboring countries to find work (Ref B). USAID HEALTH Officer John MacArthur traveled to Burma March 30-April 10 to conduct a gap analysis of Burma's TB program. During meetings with officials from the Ministry of Health, NTP, WHO, and NGOs, as well as site visits to public and private medical clinics, we observed that while the NTP and private sector are working hard to meet the current TB burden, they have fallen short. Several weaknesses must be addressed before the NTP can successfully prevent and treat TB. Mind the Gaps -------------- ¶3. (SBU) Dr. Frank Smithious, Country Director of MSF-Holland (which runs 24 full-service medical clinics in Burma),told us that one of Burma's greatest challenges is raising awareness about the RANGOON 00000278 002.12 OF 004 dangers of TB. Most TB cases in Burma go undetected, as the Burmese tend to not seek medical treatment for mild symptoms. Only when TB symptoms become worse do people seek treatment, even though TB treatment in both the NTP and private sector clinics is free. More education and outreach about the disease is needed, he stressed. The NTP spends only 7 percent of its $400,000 annual budget on outreach and instead relies on NGOs to conduct education awareness. Until 2008, Population Services International (PSI),an international NGO that treats approximately 10 percent of Burma's TB patients annually, conducted the majority of TB awareness campaigns throughout the country. However, because PSI's TB funding under the 3 Diseases Fund ended on March 31, 2008 (Ref C),PSI was forced to halt its awareness programs and reprogram resources to cover its TB patients, PSI Country Director John Hetherington explained. Without funding for its programs, PSI will suspend its communications program, creating a large gap in TB education. Awareness programs have been shown to reduce the number of TB cases, Smithious emphasized. Cutting TB education programs will only exacerbate the current situation. ¶4. (SBU) During visits to medical clinics and the Aung San TB Hospital in Rangoon, we observed how the country needed to improve its infection control measures. Most clinics in Burma, including the NTP clinics and PSI's Sun Clinic network, are small ONE or two room offices where patients come for diagnosis and treatment. Patients, regardless of their symptoms, wait with others in small, often unventilated, rooms before seeing a doctor. During ONE visit to a clinic, we saw a patient with MDR-TB waiting with several HIV/AIDS patients - there was no concern about whether the TB patient would infect the other patients or even the doctor. During a separate visit to the Aung San Hospital, we met an MDR-TB patient who had contracted the disease from her late husband; he had worked in the TB hospital only to contract and die from the disease. Dr. Pino, Director of the Aung San TB Hospital, admitted that due to poor infection control, several of his staff have contracted and died from TB during the past several years. The TB hospitals, NTP, and most of the private clinics all lacked basic infection controls, including the use of N95 masks and the ability to separate patients by disease. Without good infection control practices, the rate of TB infection is likely to increase, WHO TB Officer Dr. Hans Kluge told us. ¶5. (SBU) Burma has two national reference TB labs in Rangoon and Mandalay, which provide culture and sputum tests for the NTP and private clinics throughout the country. During our tour of the Rangoon laboratory, we noticed that the laboratory was well-equipped with up-to-date technology, a donation from the International Union Against TB and Lung Disease (IUATLD) in 2003. The Rangoon laboratory does need some technological upgrades, such as a new RANGOON 00000278 003.12 OF 004 centrifuge or generator, Reference Laboratory Director Dr. Ti Ti told us. However, strengthening the laboratory through improved capacity building training is a more urgent need, she emphasized. Officials from the WHO, PSI, and MSF-Holland all noted with some concern that Dr. Ti Ti, who ensures quality control at the lab, will retire in late 2008. While she is currently training her successor, the WHO and NGOs argue that as the laboratory increases its case detection, it will need to hire additional qualified staff to handle the work load. Improving the National Reference Laboratory's staff capacity will benefit not just the Ministry of HEALTH and the NTP, but every private clinic that uses the lab, Hetherington underscored. ¶6. (SBU) Dr. Kluge confirmed that while the NTP has been successful at detecting and treating new cases of TB, there remains room for improvement. The NTP, which is active in all 324 townships, has increased the number of staff to 1028, but approximately 24 percent of positions are vacant due to budgetary limitations. The Ministry of HEALTH has increased its TB budget by more than 2,500 percent since 1995, from $14,500 to $400,000 in FY2008. However, this amount, coupled by substantial contributions by international donors, does not cover the amount needed to run a successful TB program. -------------- -------------- Burma's TB Budget (FY06-FY08*) In US Dollars -------------- -------------- Available Funding FY06 FY07 FY08 -------------- -------------- Burmese Govt 421,111 421,111 421,111 GDF 3,587,277 4,186,700 -- JICA 93,000 93,000 93,000 WHO 239,200 239,200 239,200 IUATLD 200,000 200,000 200,000 3D Fund 4,000,000 4,000,000 4,000,000 -------------- -------------- Total Funding 8,540,588 9,140,011 4,953,311 -------------- -------------- Amount Required 13,467,871 18,809,752 18,477,025 Funding Gap 4,927,283 9,669,741 13,523,714 -------------- -------------- Source: WHO, 2008 *Burma's Fiscal Year runs from April 1-March 31. ¶7. (SBU) However, during the course of our meetings, we learned that the greatest challenge to Burma's TB program is the unavailability of first-line TB drugs after 2009. Burma currently receives TB drugs for 150,000 patients annually, worth $4 million, RANGOON 00000278 004.10 OF 004 through a grant from the Global Drug Facility (GDF). GDF's commitment to Burma will end in 2009 and there are currently few options for drug procurement (More details to be provided septel.) Without first-line drugs, which both the public and private clinics provide to TB patients free of charge, TB patients would be forced to either purchase inferior quality drugs on the local market or forgo treatment due to the expense. (Note: First-line TB drugs cost approximately $20 per patient while second-line drugs for MDR-TB costs up to $3000 per person. End Note.) Thus, the first priority should be to secure first-line drugs after 2009, as they are necessary to prevent the spread of TB. The GOB is considering applying for a Round 9 grant from the Global Fund, which would start in 2011. However, even if it receives a commitment from the Global Fund, there will still be a two-year gap for TB drugs, Kluge emphasized. Comment -------------- ¶8. (SBU) The NTP has had some success at combating TB with its limited resources, but continues to rely heavily on foreign-funded NGOs to fill the gaps in the National Program's outreach activities and HEALTH services. This funding and service gap prevents Burma from successfully managing its ever-growing TB problem. Outbreaks of TB, including MDR-TB, are a growing regional HEALTH risk. Failure to properly address Burma's TB epidemic could lead to a regional epidemic, as more Burmese migrate abroad looking for work or leave to flee abuses. Embassy Rangoon recognizes the politically charged debate surrounding humanitarian assistance to Burma, including in the HEALTH sector. Through the 3D Fund, the Europeans are assisting the Burmese to address in part the TB epidemic. We note that ASSK's NLD party approved the 3D Fund's activities in Burma. Sick and dying people are in no condition to fight for democracy in Burma. The U.S. should consider increasing our humanitarian assistance to address the growing regional threat of Burma's TB epidemic and assisting those Burmese most in need. By taking this opportunity to help the WHO, NGOs, and NTP combat and prevent TB outbreaks in Burma, we can halt the spread of infection and increasing drug resistance from Burma to the region and ultimately to the wider world, including the United States. VILLAROSA