Community-based MDR-TB care project improves treatment initiation in patients diagnosed with MDR-TB in Myanmar

<div><p>Background</p><p>The Union in collaboration with national TB programme (NTP) started the community-based MDR-TB care (CBMDR-TBC) project in 33 townships of upper Myanmar to improve treatment initiation and treatment adherence. Patients with MDR-TB diagnosed/registered under NTP received support through the project staff, in addition to the routine domiciliary care provided by NTP staff. Each township had a project nurse exclusively for MDR-TB and 30 USD per month (max. for 4 months) were provided to the patient as a pre-treatment support.</p><p>Objectives</p><p>To assess whether CBMDR-TBC project’s support improved treatment initiation.</p><p>Methods</p><p>In this cohort study (involving record review) of all diagnosed MDR-TB between January 2015 and June 2016 in project townships, CBMDR-TBC status was categorized as “receiving support” if date of project initiation in patient’s township was before the date of diagnosis and “not receiving support”, if otherwise. Cox proportional hazards regression (censored on 31 Dec 2016) was done to identify predictors of treatment initiation.</p><p>Results</p><p>Of 456 patients, 57% initiated treatment: 64% and 56% among patients “receiving support (n = 208)” and “not receiving support (n = 228)” respectively (CBMDR-TBC status was not known in 20 (4%) patients due to missing diagnosis dates). Among those initiated on treatment (n = 261), median (IQR) time to initiate treatment was 38 (20, 76) days: 31 (18, 50) among patients “receiving support” and 50 (26,101) among patients “not receiving support”. After adjusting other potential confounders (age, sex, region, HIV, past history of TB treatment), patients “receiving support” had 80% higher chance of initiating treatment [aHR (0.95 CI): 1.8 (1.3, 2.3)] when compared to patients “not receiving support”. In addition, age 15–54 years, previous history of TB and being HIV negative were independent predictors of treatment initiation.</p><p>Conclusion</p><p>Receiving support under CBMDR-TBC project improved treatment initiation: it not only improved the proportion initiated but also reduced time to treatment initiation. We also recommend improved tracking of all diagnosed patients as early as possible.</p></div

Baseline characteristics of patients diagnosed with MDR-TB between January 2015 and June 2016 in 33 CBMDR-TBC project supported townships in Myanmar.

<p>Baseline characteristics of patients diagnosed with MDR-TB between January 2015 and June 2016 in 33 CBMDR-TBC project supported townships in Myanmar.</p

Patients with MDR-TB on domiciliary care in programmatic settings in Myanmar: Effect of a support package on preventing early deaths

<div><p>Background</p><p>The community-based MDR-TB care (CBMDR-TBC) project was implemented in 2015 by The Union in collaboration with national TB programme (NTP) in 33 townships of upper Myanmar to improve treatment outcomes among patients with MDR-TB registered under NTP. They received community-based support through the project staff, in addition to the routine domiciliary care provided by NTP staff. Each project township had a project nurse exclusively for MDR-TB and a community volunteer who provided evening directly observed therapy (in addition to morning directly observed therapy by NTP).</p><p>Objectives</p><p>To determine the effect of CBMDR-TBC project on death and unfavourable outcomes during the intensive phase of MDR-TB treatment.</p><p>Methods</p><p>In this cohort study involving record review, all patients diagnosed with MDR-TB between January 2015 and June 2016 in project townships and initiated on treatment till 31 Dec 2016 were included. CBMDR-TBC status was categorized as “receiving support” if project initiation in patient’s township was before treatment initiation, “receiving partial support” if project initiation was after treatment initiation, and “not receiving support” if project initiation was after intensive phase treatment outcome declaration. Time to event analysis (censored on 10 April 2017) and cox regression was done.</p><p>Results</p><p>Of 261 patients initiated on treatment, death and unfavourable outcomes were accounted for 13% and 21% among “receiving support (n = 163)”, 3% and 24% among “receiving partial support (n = 75)” and 13% and 26% among “not receiving support (n = 23)” respectively. After adjusting for other potential confounders, the association between CBMDR-TBC and unfavourable outcomes was not statistically significant. However, when compared to “not receiving support”, those “receiving support” and “receiving partial support” had 20% [aHR (0.95 CI: 0.8 (0.2–3.1)] and 90% lower hazard [aHR (0.95 CI: 0.1 (0.02–0.9)] of death, respectively. This was intriguing. Implementation of CBMDR-TBC coincided with implementation of decentralized MDR-TB centers at district level. Hence, patients that would have generally not accessed MDR-TB treatment before decentralization also started receiving treatment and were also included under CBMDR-TBC “received support” group. These patients could possibly be expected to sicker at treatment initiation than patients in other CBMDR-TBC groups. This could be the possible reason for nullifying the effect of CBMDR-TBC in “receiving support” group and therefore similar survival was found when compared to “not receiving support”.</p><p>Conclusion</p><p>CBMDR-TBC may prevent early deaths and has a scope for expansion to other townships of Myanmar and implications for NTPs globally. However, future studies should consider including data on extent of sickness at treatment initiation and patient level support received under CBMDR-TBC.</p></div

Flow chart showing treatment initiation cascade stratified by CBMDR-TBC status among diagnosed MDR-TB patients in 33 CBMDR-TBC project supported townships of upper Myanmar, January 2015-June 2016.

<p>*MDR-TB: Multi drug resistant tuberculosis^{. a}Patient considered receiving support if date of project initiation in patient’s township was before the date of MDR-TB diagnosis, date of MDR-TB diagnosis is missing for 20 patients and therefore could not be classified. ^bwhether patients were under CBMDR-TBC project or not cannot be ascertained as date of diagnosis was missing. cfollow-up period from diagnosis ranged from 6 months to 2 years.</p

Factors associated with treatment initiation among patients diagnosed with MDR-TB between January 2015 and June 2016 in thirty three CB MDR-TBC project townships in Myanmar.

<p>Factors associated with treatment initiation among patients diagnosed with MDR-TB between January 2015 and June 2016 in thirty three CB MDR-TBC project townships in Myanmar.</p

Package of support to patients diagnosed with MDR-TB for treatment initiation by NTP’s PMDT in Myanmar, 2015–16 [7].

<p>Package of support to patients diagnosed with MDR-TB for treatment initiation by NTP’s PMDT in Myanmar, 2015–16 [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0194087#pone.0194087.ref007" target="_blank">7</a>].</p

Criteria to identify presumptive MDR-TB under programme setting who were referred to X-pert MTB/RIF testing facilities, Myanmar, 2015–16.

<p>Criteria to identify presumptive MDR-TB under programme setting who were referred to X-pert MTB/RIF testing facilities, Myanmar, 2015–16.</p

Support package to all MDR-TB patients from diagnosis to treatment initiation under the community-based MDR-TB care (CBMDR-TBC) project in Myanmar, 2015–16.

<p>Support package to all MDR-TB patients from diagnosis to treatment initiation under the community-based MDR-TB care (CBMDR-TBC) project in Myanmar, 2015–16.</p

Map of Myanmar showing 33 CBMDR-TBC project supported townships across four states/regions of upper Myanmar, 2015–16.

<p>*CBMDR-TBC project–community-based multi-drug resistant tuberculosis care project.</p

Demographic characteristics of patients with MDRTB registered for treatment between January 2015 and June 2016 in 33 community-based MDR-TB care (CBMDR-TBC) project supported townships in Myanmar.

<p>Demographic characteristics of patients with MDRTB registered for treatment between January 2015 and June 2016 in 33 community-based MDR-TB care (CBMDR-TBC) project supported townships in Myanmar.</p