Three major diseases in Myanmar

JAPAN International Cooperation is leading the fight against three major diseases in Myanmar. The Myanmar Times’ Khin Myat met with JICA project leader and tuberculosis specialist, Mr Kosuke Okada, and malaria expert Mr Masatoshi Nakamura to ask about their activities.

1. How much money is JICA spending annually to control these diseases?
Our project period is from January 2005 to January 2010. We have been spending around ¥150 million per year on long- and short-term experts, international and domestic training, provision of equipment such as vehicles, lab equipment, microscopes, mosquito nets, lab test kits, local training and consumables.

2. What activities has JICA undertaken in Myanmar?
For TB, we concentrate on two model areas, Yangon and Mandalay. We don’t work at the township level except for PPP (public-private partnership) model areas. We support work at the division level, and provide training for township medical officers and lab TB staff.

For HIV/AIDS, there are three sub-components - blood safety at the National Blood Center, external quality assessment for HIV testing at the National Health Laboratory and HIV test kit supply and staff training under the national AIDS program. For blood safety, we have introduced seven computer registration systems at main blood centres in the National Blood Center and at Mandalay, Myitchina, Magway, Pathein, Taunggyi, Mawlamyine, and around 130 laboratories have been participating.

For malaria, we have been working in eight townships in western Bago and seven in eastern Bago, where malaria is endemic. We focus on early diagnosis and appropriate treatment at all levels of health facility, provide insecticide-treated mosquito nets, anti-malaria medicine for the prevention of malarial infection, and also provide training for malaria staffs and all levels of health workers, as well as logistics support for model townships.

3. What action is needed to control these disease?
To reduce TB, we need to strengthen lab capacity, provide supervision to the township level, implement referral systems, enhance cooperation between the national TB program and the national AIDS program for TB and HIV activities and improve public awareness on TB.

To provide care and prevention for HIV/AIDS, we have been facilitating HIV testing and counselling, providing clinical care and support for people living with HIV/AIDS, strengthening HIV prevention through safer sex and prevention of mother-to-child infection, and blood safety.

For malaria, we need to improve access to quality diagnosis and treatment, especially at the sub health-centre level and introduce an effective supply management and monitoring system.

4. Why do malaria and tuberculosis patients experience drug resistance? How can we solve the problem?
According to a national survey on tuberculosis in 2002, 4 percent of new smear-positive patients and 15.5pc of re-treatment cases were multi-drug resistant (MDR) TB. The reason is that although TB treatment has become widely available, 8pc of patients interrupt treatment for various reasons. Some of them are at high risk of developing MDR TB in the future.

We need to strengthen patient care and supervise their activities in order to prevent MDR TB development, as well as to provide MDR TB treatment.
For malaria, the situation of drug resistance has been monitored consistently at six sites since 2002, with chloroquine and SP resistance over 25pc, mefloquine less than 10pc, and artesunate and mefloquine less than 5pc. Resistance levels have varied between sites and over time at the same site.

It has to be noted that a wide variety of drugs with limited quality control is accessible as monotherapy and incomplete doses to patients through the private sector and increasing resistance to combination drugs can be expected if timely action is not taken to contain the problem.

5. Is the rate of infection of these diseases increasing, static or decreasing? Why? What is the main weakness in fighting the diseases?
WHO estimates that the TB situation is stable, neither increasing nor decreasing, in spite of the tremendous efforts made by National Tuberculosis Program (NTP).

For HIV, official surveillance data from 2004 show a slight decrease in infection rates among high-risk groups, but seemingly rising trends between 2004 and 2005.

For malaria, during 1995-2004 the number of reported cases of clinically suspected malaria fluctuated between 600,000 and 650,000. The annual incidence rate of reported cases of suspected malaria has fallen steadily since 1990, with a small (17pc) upsurge from 1999 to 2003. The data needs to be interpreted cautiously because of the lack of information on cases that are self-treated or treated in the private sector. Reported cases and deaths relate to the malaria patients that seek care in the public health sector, estimated to be 25 to 40 per cent of the total. On the other hand, not all cases are malaria, since many are likely to be fevers due to virus or other causes. Many high malaria transmission areas are still inaccessible for all or part of the year. The use of public health services depends on the availability of effective drugs.

6. What do you think of the performance in fighting these diseases in Myanmar by the Ministry of Health and other organisations like NGOs?
For TB, I think NTP have been trying to do their best under constrained settings. To increase and strengthen their activities, much more funding might be necessary. In addition, public-private partnerships should be strengthened in collaboration with INGOs and NGOs, so that TB suspects can be diagnosed at an earlier stage of the disease before its transmission to others. The role of Ministry of Health is quite crucial in coordination and harmonization among INGOs and NGOs and in developing a joint plan of action.

For malaria, village voluntary groups like members of the Myanmar Maternal and Child Welfare Association (MMCWA), Red Cross and school teachers are playing a good role in mobilizing the community for disease control, including malaria. They have been working with BSH in mobilizing bed net impregnation and malaria education sessions. The members of MMCWA are committed and could help to empower groups of villagers in malaria prevention and control. Their capacity needs to be strengthened and appropriate malaria educational tools need to be provided to ensure effective mobilization and community education.

Six INGOs directly contribute to malaria control: CESVI, Malteser, Merlin (recently closed), Médicins Sans Frontières (Holland, Switzerland) and Population Services International (PSI), and five others contribute through general community health programmes. The International Committee of the Red Cross (ICRC) and Federation of the Red Cross are well positioned to support malaria control. INGOs participate in early diagnosis and appropriate treatment through fixed and mobile clinics and support to public health systems. They also engage with private-sector general practitioners through franchising. Some support is extended for ITN promotion and access to re-treatment of nets through the private sector.

7. How important is awareness-raising?
Raising awareness for TB is definitely important because NTP need to provide proper treatment before a patient spreads TB bacilli to others in the community. Anyone who has a cough for more than two weeks should see a doctor and be tested for sputum. In addition, after being diagnosed for TB, he or she should complete TB treatment till end even if the symptoms have disappeared. Such information should be provided through public awareness.

For HIV, I think although good medicines are available, prevent-ion is still the top priority, because current treatment with Anti Retroviral Therapy cannot kill the HIV virus, but only inhibits the production of virus particles. So the treatment is life-long at present. Therefore, raising awareness on prevention, reducing discrimin-ation and highlighting the signific-ance of HIV testing are very important in controlling HIV/AIDS, as well as medical care.

For malaria, taking into consideration that these interventions will be working in synergy with stronger general health services, improved malaria awareness, economic growth, deforestation and inter-sectoral cooperation, which will change the control of epidemics from re-active to pro-active, it is reasonable to assume that the program in its totality will be associated with a reduction of malaria morbidity of at least 50pc and a reduction of mortality of at least 25pc by the year 2010.

http://www.mmtimes.com/feature/healthcare/health018.htm