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Viewing cable 08RANGOON282, BURMA: COMBATING MDR-TB IN RANGOON AND MANDALAY

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Reference ID Created Released Classification Origin
08RANGOON282 2008-04-23 10:22 2011-08-25 00:00 UNCLASSIFIED//FOR OFFICIAL USE ONLY Embassy Rangoon
VZCZCXRO3484
RR RUEHCHI RUEHDT RUEHHM RUEHLN RUEHMA RUEHNH RUEHPB RUEHPOD
DE RUEHGO #0282/01 1141022
ZNR UUUUU ZZH
R 231022Z APR 08 ZDK TO ALL CTG NUM SVCS
FM AMEMBASSY RANGOON
TO RUEHC/SECSTATE WASHDC 7421
RUCNASE/ASEAN MEMBER COLLECTIVE
RUEHZN/ENVIRONMENT SCIENCE COLLECTIVE
RUEHBJ/AMEMBASSY BEIJING 1821
RUEHBY/AMEMBASSY CANBERRA 1072
RUEHKA/AMEMBASSY DHAKA 4830
RUEHLO/AMEMBASSY LONDON 2019
RUEHNE/AMEMBASSY NEW DELHI 4620
RUEHUL/AMEMBASSY SEOUL 8160
RUEHTC/AMEMBASSY THE HAGUE 0673
RUEHKO/AMEMBASSY TOKYO 5721
RUEHRO/AMEMBASSY ROME 0157
RUEHFR/AMEMBASSY PARIS 0576
RUEHCN/AMCONSUL CHENGDU 1424
RUEHCHI/AMCONSUL CHIANG MAI 1514
RUEHCI/AMCONSUL KOLKATA 0282
RUEAUSA/DEPT OF HHS WASHDC
RHHMUNA/CDR USPACOM HONOLULU HI
RUEHPH/CDC ATLANTA GA
RUCLRFA/USDA WASHDC
RUEHRC/USDA FAS WASHDC
RHEHNSC/NSC WASHDC
RUCNDT/USMISSION USUN NEW YORK 1475
RUEKJCS/SECDEF WASHDC
RUEHBS/USEU BRUSSELS
RUEKJCS/JOINT STAFF WASHDC
UNCLAS SECTION 01 OF 03 RANGOON 000282 
 
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 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 HEALTH OFFICE - JMACARTHUR, 
CBOWES 
TOKYO FOR HEALTH OFFICER 
PACOM FOR FPA 
 
E.O. 12958:N/A 
TAGS: ECON TBIO EAID SOCI PGOV AMED BM
SUBJECT: BURMA: COMBATING MDR-TB IN RANGOON AND MANDALAY 
 
REF: A ) RANGOON 278 B) 07 RANGOON 1120 C) 07 RANGOON 1027 
 
RANGOON 00000282  001.14 OF 003 
 
 
1. (SBU)  Summary.  Tuberculosis is a growing concern in Burma, with 
the Ministry of Health ranking it as the second priority disease 
after HIV/AIDS.  As the TB prevalence rate increases throughout the 
country, the risk of multi drug resistant (MDR) and extensively drug 
resistant (XDR) TB also increases.  Recognizing that MDR-TB rates 
are likely three times higher than previous estimates - 4.2 percent 
and 15.5 percent MDR among new and previously treated cases in 2003 
- the GOB plans to launch a three-year MDR-TB treatment pilot 
program in 2008.  Using second-line TB drugs procured from the Green 
Light Committee, the National TB Program (NTP) will collaborate with 
the WHO and MSF-Holland to provide treatment to 100 patients in 
Rangoon and Mandalay in 2008 and extend the program to an additional 
175 patients in mid-2009.  Additionally, in the next few weeks the 
GOB plans to establish a second-line treatment protocol based on the 
results of 100 Category II TB failures analyzed in Belgium.  If the 
pilot program is successful, the GOB and WHO plan to expand the 
program to the national level in the next five years.  End Summary. 
 
Growing Concern About MDR-TB 
---------------------------- 
 
2.  (SBU)  Burma is one of 22 TB high burden countries in the world. 
 As the rate of TB prevalence increases throughout Burma, so does 
the rate of MDR-TB.  A 2003 WHO study on National Drug Resistance 
showed that 4 percent of new TB cases and 15.5 percent of previously 
treated TB cases were multi drug resistant - these figures are the 
highest in Southeast Asia (Ref B).  A 2006 MDR study in Rangoon 
showed higher MDR-TB prevalence rates - 4.2 percent among new cases 
and 18.8 percent among previously treated cases, which indicate 
higher rates at the national level.  WHO TB officer Dr. Hans Kluge 
acknowledged that the true TB burden in Burma remains unknown but 
that the TB prevalence rate, and thus the rate of MDR-TB rate, are 
likely to be three times higher than previous estimates (Ref C). 
While health officials cannot pinpoint exactly why the rate of 
MDR-TB in Burma is so high, they note that both the availability of 
inferior TB drugs on the local market, as well as higher default 
treatment rates, play a role in creating new MDR-TB cases.  The NTP 
Reference Lab, under the guidance of Lab Director Dr. Ti Ti, is 
currently conducting the Second National Drug Resistance survey. 
Results are expected by late 2008. 
 
3.  (SBU)  In addition to the National Drug Resistance Survey, the 
Burmese Government, working with the WHO, sent samples from 100 
Category II TB failures to the National Reference Lab in Antwerp for 
analysis in 2007.  While the results of the survey are not yet 
finalized, Dr. Kluge and Dr. Win Maung from the NTP informed us that 
almost all of the 100 cases were resistant to first-line TB drugs. 
 
RANGOON 00000282  002.13 OF 003 
 
 
Additionally, the Antwerp lab confirmed that one of the cases was 
XDR-TB, which proves that XDR-TB does exist in Burma, albeit at an 
unknown magnitude.  The GOB and WHO will use the results of the 
Antwerp study to establish a protocol of second-line drugs to treat 
MDR-TB cases.  According to Kluge, the Ministry of Health should 
approve the protocol by the end of April. 
 
GOB Efforts to Combat MDR-TB 
---------------------------- 
 
4.  (SBU)  WHO and NTP officials agree that MDR and XDR-TB are 
serious threats not just to Burma, but also the region, as Burmese 
migrants with TB travel to neighboring countries to find work. 
Indeed, a MSF-France clinic in Mae Sot, Thailand diagnosed several 
cases of MDR and XDR-TB among Burmese migrants working in Thailand 
in 2007 (Ref B).  Thus, MDR and XDR-TB cases in Burma potentially 
pose serious threats to the health of the region, Dr. Kluge 
declared.  The GOB recognizes the seriousness of TB, Dr. Kluge 
stated.  Although healthcare for Burmese citizens remains woefully 
under funded, the GOB has increased its TB budget significantly - 
from $14,500 in 1995 to $400,000 in FY08 - but the budget is still 
far short of what is needed.  In 2006, the GOB established the 
National Drug Resistant TB Committee, comprised of officials the 
NTP, Food and Drug Administration, National Health Lab, WHO, PSI, 
and MSF-Holland.  This committee created the National Response to 
MDR-TB in Burma and helped establish a pilot protect to treat 
MDR-TB, which will begin in late 2008.  The GOB has also taken steps 
to improve the NTP in recent years, recognizing that a strong DOTS 
program is key to preventing MDR and XDR-TB.  In the past two years, 
the Ministry of Health created 13 additional posts to strengthen the 
TB control activities at the State and Division level.  It also 
created a new MDR-TB consultant position to work with the WHO and 
coordinate activities and draft the MDR-TB operational plan. 
 
DOTS Plus Pilot Project 
----------------------- 
 
5.  (SBU)  The GOB has done more than just establish MDR-TB 
treatment protocols, Dr. Kluge emphasized.  In 2007, the NTP and the 
WHO jointly applied for a grant from the Greenlight Committee to 
fund a pilot project to treat MDR-TB.  The Greenlight Committee 
approved the grant in late 2007 and will provide second-line drugs 
for 275 MDR-TB patients over three years.  Second-line TB drugs are 
much costlier than the drugs for first-line treatment and cost an 
average of $3,000 per patient.  To prepare for the pilot, the NTP 
and WHO have established a national second-line drug treatment 
protocol based on the results of the 100 Category II TB failures; 
the National TB Committee should approve the protocol by the end of 
April.  Once the protocol is approved, the NTP and WHO will order 
 
RANGOON 00000282  003.6 OF 003 
 
 
the drugs, which should arrive within six months. 
 
6.  (SBU)  NTP, in collaboration with the WHO and MSF-Holland, plan 
to launch the MDR-TB pilot program by October 2008.  Under the 
program, the NTP will provide second-line drugs to 100 MDR patients 
in five townships in Rangoon and Mandalay during the first year and 
expand the program to an additional 175 patients by mid-2009. 
During the first year, the National TB Committee will select 25 
MDR-TB patients from Mandalay and 50 patients from Rangoon to 
receive the drug protocol at either the Pathengyi TB Hospital or 
Aung San TB Hospital.  MSF-Holland will also select 25 of its 
patients from Rangoon, who will be treated at Aung San Hospital. 
MDR-TB treatment takes substantially longer than normal TB treatment 
- 18 to 24 months compared to six to nine months.  During the year, 
patients will spend the first four months at either of the two TB 
hospitals, where they will be monitored daily.  For the remaining 
months, patients will receive daily outpatient care.  Because the 
MDR-TB treatment is so time consuming, the NTP will rely on 
community volunteers and health workers from Population Services 
International (PSI), MSF-Holland, and World Vision to monitor 
patients' treatment.  NTP officials will be responsible for the 
monitoring and evaluation of the program.  It will be challenging, 
Kluge declared, but he believes the NTP is committed to treating 
MDR-TB and containing the problem within Burma. 
 
Comment 
------- 
 
7.  (SBU)  The Ministry of Health is not the obstacle to tackling 
Burma's TB problem.  It is staffed with low-paid but dedicated civil 
servants who comprehend the growing problem and are trying their 
best to treat it with the minimal resources the senior generals 
allocate to them.  While the national program and private sector 
appear to be handling the current TB case load, an increasing number 
of MDR-TB cases will overburden the program's capacity.  This pilot 
program will enable the NTP and Ministry of Health to show that they 
can handle more difficult TB cases.  However, Burma also needs to 
focus on preventing MDR-TB as well as treating it.  The best way to 
prevent MDR-TB and XDR-TB outbreaks is to strengthen the exiting NTP 
and DOTS program and promote educational outreach to ensure that new 
cases are treated properly.  Burma's growing TB problem is a danger 
to the region, and eventually to the world, if it cannot be 
contained soon. 
 
VILLAROSA