Outcomes of Community-Based Systematic Screening of Household Contacts of Patients with Multidrug-Resistant Tuberculosis in Myanmar.

Screening of household contacts of patients with multidrug-resistant tuberculosis (MDR-TB) is a crucial active TB case-finding intervention. Before 2016, this intervention had not been implemented in Myanmar, a country with a high MDR-TB burden. In 2016, a community-based screening of household contacts of MDR-TB patients using a systematic TB-screening algorithm (symptom screening and chest radiography followed by sputum smear microscopy and Xpert-MTB/RIF assays) was implemented in 33 townships in Myanmar. We assessed the implementation of this intervention, how well the screening algorithm was followed, and the yield of active TB. Data collected between April 2016 and March 2017 were analyzed using logistic and log-binomial regression. Of 620 household contacts of 210 MDR-TB patients enrolled for screening, 620 (100%) underwent TB symptom screening and 505 (81%) underwent chest radiography. Of 240 (39%) symptomatic household contacts, 71 (30%) were not further screened according to the algorithm. Children aged <15 years were less likely to follow the algorithm. Twenty-four contacts were diagnosed with active TB, including two rifampicin- resistant cases (yield of active TB = 3.9%, 95% CI: 2.3%-6.5%). The highest yield was found among children aged <5 years (10.0%, 95% CI: 3.6%-24.7%). Household contact screening should be strengthened, continued, and scaled up for all MDR-TB patients in Myanmar.

Capacity building for health inequality monitoring in Indonesia: enhancing the equity orientation of country health information system.

BACKGROUND: Inequalities in health represent a major problem in many countries, including Indonesia. Addressing health inequality is a central component of the Sustainable Development Goals and a priority of the World Health Organization (WHO). WHO provides technical support for health inequality monitoring among its member states. Following a capacity-building workshop in the WHO South-East Asia Region in 2014, Indonesia expressed interest in incorporating health-inequality monitoring into its national health information system. OBJECTIVES: This article details the capacity-building process for national health inequality monitoring in Indonesia, discusses successes and challenges, and how this process may be adapted and implemented in other countries/settings. METHODS: We outline key capacity-building activities undertaken between April 2016 and December 2017 in Indonesia and present the four key outcomes of this process. RESULTS: The capacity-building process entailed a series of workshops, meetings, activities, and processes undertaken between April 2016 and December 2017. At each stage, a range of stakeholders with access to the relevant data and capacity for data analysis, interpretation and reporting was engaged with, under the stewardship of state agencies. Key steps to strengthening health inequality monitoring included capacity building in (1) identification of the health topics/areas of interest, (2) mapping data sources and identifying gaps, (3) conducting equity analyses using raw datasets, and (4) interpreting and reporting inequality results. As a result, Indonesia developed its first national report on the state of health inequality. A number of peer-reviewed manuscripts on various aspects of health inequality in Indonesia have also been developed. CONCLUSIONS: The capacity-building process undertaken in Indonesia is designed to be adaptable to other contexts. Capacity building for health inequality monitoring among countries is a critical step for strengthening equity-oriented national health information systems and eventually tackling health inequities.

The potential of task shifting selected maternal interventions to auxiliary midwives in Myanmar: a mixed-method study.

BACKGROUND: An estimated 282 women die for every 100,000 live births in Myanmar, most due to preventable causes. Auxiliary Midwives (AMWs) in Myanmar are responsible for providing a package of care during pregnancy and childbirth to women in rural hard to reach areas where skilled birth attendants (Midwives) are not accessible. This study aims to examine the role of AMWs in Myanmar and to assess the current practices of three proposed essential maternal interventions (oral supplement distribution to pregnant women; administration of misoprostol to prevent postpartum haemorrhage; management of puerperal sepsis with oral antibiotics) in order to facilitate a formal integration of these tasks to AMWs in Myanmar. METHODS: A mixed methods study was conducted in Magwe Region, Myanmar involving a survey of 262 AMWs, complemented by 15 focus group discussions with midwives (MWs), AMWs, mothers and community members, and 10 key informant interviews with health care providers at different levels within the health care system. RESULTS: According to current government policy, AMWs are responsible for identifying pregnant women, screening for danger signs and facilitating early referral, provision of counselling on nutrition and birth preparedness for women in hard-to-reach areas. AMWs also assist at normal deliveries and help MWs provide immunization services. In practice, they also provide oral supplements to pregnant women (84%), provide antibiotics to mothers during the puerperium (43%), and provide misoprostol to prevent postpartum haemorrhage (41%). The current practices of AMWs demonstrate the potential for task shifting on selected essential maternal interventions. However, to integrate these interventions into formal practice they must be complemented with appropriate training, clear guidelines on drug use, systematic recording and reporting, supportive monitoring and supervision and a clear political commitment towards task shifting. CONCLUSION: With the current national government's commitment towards one AMW in one village, this study highlights the potential for shifting specific maternal lifesaving tasks to AMWs.

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

BACKGROUND: 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). OBJECTIVES: To determine the effect of CBMDR-TBC project on death and unfavourable outcomes during the intensive phase of MDR-TB treatment. METHODS: 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. RESULTS: 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". CONCLUSION: 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.

Prevention of postpartum haemorrhage by community-based auxiliary midwives in hard-to-reach areas of Myanmar: a qualitative inquiry into acceptability and feasibility of task shifting.

BACKGROUND: In Myanmar, postpartum haemorrhage is the leading cause of maternal mortality and contributes to around 30% of all maternal deaths. The World Health Organization recommends training and supporting auxiliary midwives to administer oral misoprostol for prevention of postpartum haemorrhage in resource-limited settings. However, use of misoprostol by auxiliary midwives has not formally been approved in Myanmar. Our study aimed to explore community and provider perspectives on the roles of auxiliary midwives and community-level provision of oral misoprostol by auxiliary midwives. METHODS: A qualitative inquiry was conducted in Ngape Township, Myanmar. A total of 15 focus group discussions with midwives, auxiliary midwives, community members and mothers with children under the age of three were conducted. Ten key informant interviews were performed with national, district and township level health planners and implementers of maternal and child health services. All audio recordings were transcribed verbatim in Myanmar language. Transcripts of focus group discussions were fully translated into English before coding, while key informants' data were coded in Myanmar language. Thematic analysis was done using ATLAS.ti software. RESULTS: Home births are common and auxiliary midwives were perceived as an essential care provider during childbirth in hard-to-reach areas. Main reasons provided were that auxiliary midwives are more accessible than midwives, live in the hard-to-reach areas, and are integrated in the community and well connected with midwives. Auxiliary midwives generally reported that their training involved instruction on active management of the third stage of labour, including use of misoprostol, but not all auxiliary midwives reported using misoprostol in practice. Supportive reasons for task-shifting administration of oral misoprostol to auxiliary midwives included discussions around the good relationship and trust between auxiliary midwives and midwives, whereby midwives felt confident distributing misoprostol to auxiliary midwives. However, the lack of clear government-level written permission to distribute the drug was perceived as a barrier to task shifting. CONCLUSION: This study highlights the acceptability of misoprostol use by auxiliary midwives to prevent postpartum haemorrhage, and findings suggest that it should be considered as a promising intervention for task shifting in Myanmar.

How women are treated during facility-based childbirth: development and validation of measurement tools in four countries - phase 1 formative research study protocol.

BACKGROUND: Every woman has the right to dignified, respectful care during childbirth. Recent evidence has demonstrated that globally many women experience mistreatment during labour and childbirth in health facilities, which can pose a significant barrier to women attending facilities for delivery and can contribute to poor birth experiences and adverse outcomes for women and newborns. However there is no clear consensus on how mistreatment of women during childbirth in facilities is defined and measured. We propose using a two-phased, mixed-methods study design in four countries to address these research gaps. This protocol describes the Phase 1 qualitative research activities. METHODS/DESIGN: We will employ qualitative research methodologies among women, healthcare providers and administrators in the facility catchment areas of two health facilities in each country: Ghana, Guinea, Myanmar and Nigeria. In-depth interviews (IDIs) and focus group discussions (FGDs) will be conducted among women of reproductive age (15-49 years) to explore their perceptions and experiences of facility-based childbirth care, focused on how they were treated by healthcare workers and perceived factors affecting how they were treated. IDIs will also be conducted with healthcare providers of different cadres (e.g.: nurses, midwives, medical officers, specialist obstetricians) and facility administrators working in the selected facilities to explore healthcare providers' perceptions and experiences of facility-based childbirth care and how staff are treated, colleagues and supervisors. Audio recordings will be transcribed and translated to English. Textual data will be analysed using a thematic framework approach and will consist of two levels of analysis: (1) conduct of local analysis workshops with the research assistants in each country; and (2) line-by-line coding to develop a thematic framework and coding scheme. DISCUSSION: This study serves several roles. It will provide an in-depth understanding of how women are treated during childbirth in four countries and perceived factors associated with this mistreatment. It will also provide data on where and how an intervention could be developed to reduce mistreatment and promote respectful care. The findings from this study will contribute to the development of tools to measure the prevalence of mistreatment of women during facility-based childbirth.

Promoting antenatal care services for early detection of pre-eclampsia.

A prospective, quasi-experimental study was carried out in 2009 at urban health centres (UHCs) of five townships of Mandalay, Myanmar, to improve the skill of midwives (MWs) in diagnosis and referral of pre-eclampsia (PE) from UHC to the Central Women's Hospital (CWH) and to enhance the supervision of midwives by lady health visitors (LHVs). The intervention was training on quality antenatal care focusing on PE using an updated training manual. Altogether, 75 health care providers (MWs & LHVs) participated. In this study, data were extracted from patient registers and monthly reports of UHCs and CWH. Interviewers were trained regarding the conduct of semi-structured questionnaires to elicit knowledge and to use checklists in observation of skills in screening of PE, measuring blood pressure and urine protein (dipstick test). A guide for LHVs was also used to obtain data, and data was collected six months prior to and after the intervention. Significant improvements from baseline to endline survey occurred in the knowledge (p<0.001) and skill levels (p<0.001) including skills for screening, measuring blood pressure and urine protein. At CWH, there was an increase in referred cases of PE after the intervention, from 1.25% to 2.56% (p<0.001). In conclusion, this study highlights the early detection of pre-eclampsia by widespread use of quality antenatal care, education and training of health-care providers to improve their performance and increase human resources for health care, in order to enable women in our society to have healthy pregnancies and healthy babies.

Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar.

BACKGROUND: In Myanmar a large proportion of antenatal and intrapartum care in rural areas is provided by skilled birth attendants (SBAs), this study assessed the coverage by these health workers of all births, their adherence to service guidelines, and community opinion on the antenatal and delivery care they give in two rural health centres in Pathein Township, Ayeyarwaddy Region to identify the challenges and improve antenatal and intrapartum service delivery provided by the SBAs. METHOD: A structured questionnaire was used to interview 304 women who had infants under one year of age, and in-depth interviews were held with 12 SBAs and 10 community members. RESULTS: Of the 304 pregnancies, 93% had received antenatal care (ANC); 97% of these were covered by SBAs at an average 15 weeks' gestation. The average frequency of ANC visits was 9. Rates of home and hospital deliveries were 84.5% and 13.8% respectively. Among home deliveries, use rate of SBA was 51.4%, while for postnatal care, 31.3% was given by unskilled providers (traditional birth attendants (TBAs) 17.5%, auxiliary midwives (AMWs),13.8%). Multivariate analysis showed that interviewees aged 30 years and below (OR=0.468, P=0.046), with an education at primary level and below that of husband (OR=0.391, P=0.007) or not residing in the village of the rural/station health centre (OR=0.457, P=0.011) were significantly less likely to use SBAs. The categories of supervision, referral, and health education activities of SBAs were not in line with service guidelines. The main reasons were lack of access and community acceptance of TBAs. CONCLUSION: Heavy workload, geographical location, transportation and financial concerns were major challenges for SBAs, along with community compliance and mutual coordination. Good communication and service management skills were important to overcome these challenges.

Glycation proceeds faster in mutated Cu, Zn-superoxide dismutases related to familial amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) involves the progressive degeneration of motor neurons in the spinal cord and motor cortex. It has been shown that 15-20% of patients with familial ALS (FALS) have defects in the Sod1 gene that encodes Cu, Zn-superoxide dismutase (SOD). To elucidate the pathological role of mutated Cu, Zn-SODs in FALS, the susceptibility of mutants to glycation was examined. Mutated Cu, Zn-SODs (G37R, G93A, and I113T) related to FALS and wild type were produced in a baculovirus/insect cell expression system. Glycated and nonglycated proteins were separated on a boronate column, and the nonglycated fraction was then incubated with glucose. The mutated Cu, Zn-SODs were found to be highly susceptible to glycation compared with the wild-type enzyme as estimated by Western blot analysis using an anti-hexitol lysine antibody. The mutated Cu, Zn-SOD incubated with glucose generated higher levels of hydrogen peroxide than the wild-type enzyme. Mutated Cu, Zn-SODs were also shown to be highly susceptible to fructation, and the fructated mutant also produced higher levels of hydrogen peroxide than the wild type. These results suggest that high susceptibility of mutated Cu, Zn-SODs to glycation could be the origin of the oxidative stress associated with neuronal dysfunction in FALS.