title: 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: BACKGROUND
  Although 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.
  
  
  METHODS
  From 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.
  
  
  RESULTS
  Overall, 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%.
  
  
  CONCLUSIONS
  Our 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.
authors.affiliation: Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Satharanauskwisit Building, 420/1 Rajwithi Road, Bangkok, 10400, Thailand. Mishal.Khan@lshtm.ac.uk.|Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore. Mishal.Khan@lshtm.ac.uk.
authors.forename: M S
authors.initials: MS
authors.lastname: Khan
authors.affiliation: National Tuberculosis Programme, Yangon, Myanmar.
authors.forename: T M
authors.initials: TM
authors.lastname: Khine
authors.affiliation: Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Satharanauskwisit Building, 420/1 Rajwithi Road, Bangkok, 10400, Thailand.
authors.forename: C
authors.initials: C
authors.lastname: Hutchison
authors.affiliation: Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Satharanauskwisit Building, 420/1 Rajwithi Road, Bangkok, 10400, Thailand.|Faculty of Public Health, Mahidol University, Bangkok, Thailand.
authors.forename: R J
authors.initials: RJ
authors.lastname: Coker
authors.affiliation: Family Health International Myanmar Office, Yangon, Myanmar.
authors.forename: K M
authors.initials: KM
authors.lastname: Hane
authors.affiliation: Family Health International Asia Pacific Regional Office, Bangkok, Thailand.
authors.forename: A L
authors.initials: AL
authors.lastname: Innes
authors.affiliation: National Tuberculosis Programme, Yangon, Myanmar.
authors.forename: S
authors.initials: S
authors.lastname: Aung
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D002052:Myanmar / Q000453:epidemiology; D015995:Prevalence; D011795:Surveys and Questionnaires; D014376:Tuberculosis / Q000175:diagnosis / Q000453:epidemiology; D055815:Young Adult