Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey

Abstract

BackgroundAlthough there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34 % of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women.MethodsFrom October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres.ResultsOverall, only 514 (30 %) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21 % to 37 %, p = 0.0172), month of diagnosis (37 % in February 2015 and 23 % in March 2015 p = 0.0004) and age group (26 % in 25–64 years and 49 % in 18–25 years, p < 0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36 % from 30 %.ConclusionsOur study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women.

Age and sex distribution of Mycobacterium tuberculosis infection and rifampicin resistance in Myanmar as detected by Xpert MTB/RIF

“…This population-based Xpert MTB/RIF analysis followed expected gender distributions [ 21 ]; 70% of individuals diagnosed with Mtb were males, and overall, the proportion of males who were Mtb positive out of all males tested (47%) was higher than the proportion of females who were positive for Mtb (39%), replicating previous smaller scale regional reports from Myanmar [ 15 ]. Examination by age category revealed that Mtb test positivity differed significantly over life course with the highest proportion of individuals who tested positive for Mtb among those aged 16–20 (Fig.…”

“…Recent scale up of in-country rapid testing capacity using a national network of Xpert MTB/RIF (Cepheid, Sunnyvale, CA, USA) linked to the Myanmar Data Utilization Project has further increased testing capacity and diagnosis of TB and MDR-TB. This expansion of national rapid diagnostic capability and connectivity provides a unique opportunity to explore the characteristics of TB disease by both age and sex, and to identify at-risk sub-populations for additional diagnostic targeting [ 15 – 18 ]. The primary aim of this study was to utilize the electronically captured data to uncover demographic risk factors and patterns associated with TB diagnosis and rifampicin resistance specific to Myanmar.…”

High use of private providers for first healthcare seeking by drug-resistant tuberculosis patients: a cross-sectional study in Yangon, Myanmar

“…In our study, we found that women were more likely to use private providers, consistent with other research that also found that male TB patients outnumbered females in Yangon’s public health sector [ 23 ]. Evidence from other settings indicates that women may experience greater stigma from TB or challenges in travelling long distances to reach healthcare, and private providers may be perceived to allow greater patient privacy and be more conveniently located [ 24 – 26 ].…”