BURMA: TRACKING TB CASES IN THE DELTA

UNCLAS SECTION 01 OF 03 RANGOON 000531 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 FOR CA/OCS/ACS/EAP 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, USAID/OFDA PACOM FOR FPA E.O. 12958:N/A TAGS: ECON TBIO EAID SOCI PGOV AMED BM SUBJECT: BURMA: TRACKING TB CASES IN THE DELTA REF: A) RANGOON 282 B) RANGOON 278 RANGOON 00000531 001.2 OF 003 ¶1. (SBU) Summary. Cyclone Nargis, which struck Burma May 2-3, destroyed much of the Irrawaddy Delta, including more than 125 many public and private health facilities. Consequently, many tuberculosis (TB) patients living in the delta lost access to their medications and stopped treatment. Officials from the World Health Organization (WHO) and the Ministry of Health (MOH),concerned that prolonged lack of access to TB medications could cause patients to develop multi-drug resistant TB (MDR-TB),traveled June 11-18 to three cyclone-affected townships - Laputta, Bogalay, and Ngapudaw - to track down TB patients. TB officials, after identifying 162 TB patients registered with the National TB Program who had defaulted on their treatment protocol, successfully traced all but 48 patients. Three patients refused to continue their treatment and could develop MDR-TB. Population Services International (PSI), which runs 71 private clinics in Irrawaddy Division, confirmed that all but four of its 345 TB patients in the three affected townships had access to medicines immediately after the storm. These four patients have since resumed taking their medications. WHO, MOH, and NGO staff continue to trace missing TB patients in Irrawaddy and Rangoon Divisions. End Summary. TB: A Priority Disease -------------- ¶2. (SBU) The World Health Organization (WHO) considers Burma to be one of 22 tuberculosis (TB) high-burden countries in the world. The Ministry of Health (MOH) reported more than 130,000 new TB cases last year, up from 107,991 cases in 2006 (Ref B). Burma's rate of multi-drug resistant TB (MDR-TB) is the highest in Southeast Asia. While a 2003 WHO study showed that 4 percent of new TB cases and 15.5 percent of previously treated TB cases were multi-drug resistant, a 2006 study of MDR-TB in Rangoon showed the rates to be higher, at 4.2 percent of new cases and 18.8 percent among previously treated cases (Ref A). The true burden of TB and thus of MDR-TB in Burma is unknown, but the rates are likely to be three times higher than previous estimates, WHO TB Medical Officer Dr. Hans Kluge told us. ¶3. (SBU) The MOH's National Tuberculosis Program (NTP),which is active in all 324 townships, monitors and treats TB cases throughout Burma, running the country's DOTS program. NGOs and private clinics also provide DOTS services to patients, PSI Deputy Country Director Dr. Nyo Nyo Minn explained. Some TB patients prefer to seek treatment at private clinics rather than NTP sites because the service is more personalized and the quality of care is higher. PSI alone treats more than 10 percent of Burma's TB cases, she noted. TB in the Delta RANGOON 00000531 002.3 OF 003 -------------- ¶4. (SBU) TB is prevalent in the Irrawaddy Delta, particularly in Labutta, Bogalay, and Ngapudaw, WHO TB Officer Dr. Osman Eltayeb declared. (Note: official estimates on the number of TB cases in the delta remain unavailable. End Note.) In the weeks after the cyclone, MOH staff assessed the damage to medical clinics in the delta, verifying that 17 rural health centers and 120 sub-rural health centers were destroyed and 186 rural health centers and 588 sub-rural health centers were partially destroyed. NTP staff also confirmed whether registered TB patients had access their TB medicines. While exact figures are unavailable, Dr. Eltayeb estimated that 20 percent of TB patients lacked access to medicines after the cyclone. Concerned that the TB patients would default on their treatment (defaulting occurs after two months of with no medicines) and could potentially develop MDR-TB, staff from the WHO and NTP conducted a joint trip to Labutta, Bogalay, and Ngapudaw June 11-18 to trace missing TB patients. ¶5. (SBU) NTP data showed that 723 TB patients had sought treatment at NTP facilities in three townships, Dr. Eltayeb explained. The teams determined that the destruction of local TB clinics and supplies of TB drugs caused the interruption of treatment for 162 of these patients. During the week in the delta, the teams searched for the missing patients, using registration data to track down patients or family members. They traced 106 of the patients: 56 continued their treatment, 54 had died, and 3 refused to continue their treatment, arguing that they had other issues to worry about. NTP continues to search for the missing 48 patients, despite lack of information about their location. Assuming that NTP cannot find these patients, a total of 51 TB patients in the three townships will be classified as defaulters. The probability that they will develop MDR-TB is high, Dr. Kluge admitted. However, there is no mechanism under Burmese law to force TB patients to take their medicines. Thus, all that NTP staff can do is try to track them down, conduct new sputum tests to determine their TB status, and provide them with drugs. Whether or not the TB patients take the medications is up to them, he stated. -------------- -------------- Missing TB Patients in Three Delta Townships after Cyclone Nargis As of June 27, 2008 -------------- -------------- Township Registered Interrupt No. No. Still Patients Treatment Traced Missing -------------- -------------- Labutta 245 100 68 32 Bogalay 280 38 25 13 Ngapudaw 198 24 20 3 RANGOON 00000531 003.2 OF 003 -------------- -------------- Total 723 162 113 48 -------------- -------------- Source: World Health Organization ¶6. (SBU) PSI, the largest private provider of DOTS in Burma, successfully traced all of its TB patients from the delta after the storm, Dr. Nyo Nyo Minn confirmed. (Note: TB patients who seek care in private clinics are not included in the NTP figures above. End Note.) While the cyclone destroyed six of the Sun Clinics that provided DOTS, only four of the 345 TB patients stopped their treatment due to lack of access to medicines. Immediately after the storm, PSI sent TB drugs through its Sun Clinic networks to the affected areas, ensuring that the four patients could resume treatment within days. Sun Clinic doctors in the delta continue to treat TB patients, and have diagnosed several new TB cases in the past month, Dr. Nyo Nyo Minn stated. Comment -------------- ¶7. (SBU) Burma already has the highest rate of MDR-TB in Southeast Asia; disruptions in TB treatment will only exacerbate the situation. Ministry of Health and NTP officials are cognizant of this fact, resulting in strong efforts to track down missing TB patients living in the delta before they defaulted on their treatment. Despite GOB efforts, whether a TB patient decides to continue his or her treatment remains a personal decision, one based on an understanding of the consequences of the disease. That three patients opted to forgo TB drugs can be explained in part by the disaster they experienced, but it also indicates a need for more rigorous efforts by health officials to explain the potential dangers of TB. While the NTP remains committed to combating the spread of TB, the GOB needs to develop efforts to ensure TB patients complete DOTS treatment. A strong DOTS program, and a strong commitment on the part of both the NTP and the patient, will help prevent the spread of MDR-TB in Burma. VILLAROSA