Abstract
There is no published evidence on contact investigation among multidrug-resistant tuberculosis (MDR-TB) patients from Myanmar. We describe the cascade of contact investigation conducted in 27 townships of Myanmar from January 2018 to June 2019 and its implementation challenges. This was a mixed-methods study involving quantitative (cohort analysis of programme data) and qualitative components (thematic analysis of interviews of 8 contacts and 13 health care providers). There were 556 MDR-TB patients and 1908 contacts, of whom 1134 (59%) reached the health centres for screening (chest radiography and symptoms). Of the latter, 344 (30%) had presumptive TB and of them, 186 (54%) were investigated (sputum microscopy or Xpert MTB/RIF®). A total of 27 TB patients were diagnosed (six bacteriologically-confirmed including five with rifampicin resistance). The key reasons for not reaching township TB centres included lack of knowledge and lack of risk perception owing to wrong beliefs among contacts, financial constraints related to loss of wages and transportation charges, and inconvenient clinic hours. The reasons for not being investigated included inability to produce sputum, health care providers being unaware of or not agreeing to the investigation protocol, fixed clinic days and times, and charges for investigation. The National Tuberculosis Programme needs to note these findings and take necessary action.
Highlights
Tuberculosis (TB) is one of the top ten leading causes of deaths in the world
Barring one patient who died, all the remaining 26 (96%) patients started on the treatment (Figure 2)
Failure to do TB investigation was significantly higher among the contacts who were less than 15 years old, those who were registered in health facilities without an Xpert MTB/RIF® machine, and those who were referred when compared with those whose sputum was collected and transported to health facilities by project staff (Table 2)
Summary
Tuberculosis (TB) is one of the top ten leading causes of deaths in the world. In 2017, there were an estimated 10 million TB patients including 558,000 with resistance to rifampicin (RR-TB), of which 82% had multidrug-resistant TB (MDR-TB, defined as resistance to at least rifampicin and isoniazid) [1]. The WHO recommends ‘contact investigation’—systematic investigation of all household contacts of source TB patients for active and latent tuberculosis and institution of appropriate curative and preventive treatment, respectively [8] This strategy is endorsed by the NTP in Myanmar and it has been recommended that household contacts of MDR-TB patients with TB symptoms are investigated using Xpert MTB/RIF® assay since 2016 [9]. The International Union Against Tuberculosis and Lung Disease (The Union), an international non-governmental organization, started implementing a community-based MDR-TB care project in selected townships of Myanmar [11] As part of this project, community volunteers have been trained and incentivized to conduct many activities including ‘contact investigation’ among MDR-TB patients. We undertook a mixed-methods operational research study with the following objectives: (1) Among the household contacts of MDR-TB patients registered from January 2018 to June 2019, to assess (i) the number and proportion of presumptive TB patients identified, investigated, diagnosed, and treated for TB; (ii) demographic and clinical factors associated with getting or not getting investigated; and (iii) the median duration between the various steps in the cascade. (2) To explore the barriers in implementing contact investigation from the perspective of household contacts and health care providers
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