IRIN Focus on Tuberculosis

Tuberculosis (TB), a disease long considered in check, is now a public health emergency in Tajikistan. The disease has been on the rise ever since the dissolution of the Soviet Union and the subsequent five-year civil war, which led to a sharp drop in Tajik living standards. With TB claiming nearly 500 deaths a year in Tajikistan, health specialists warn that rapid action is needed to counter its spread. The Tajik health ministry states that the number of TB cases is increasing at an annual rate of 13 percent, with 480 deaths officially recorded in 1999. Due to the number of home deaths which go unrecorded, international health experts contend that the real growth rate is probably twice as high. Head of the Presidential Administration on Health Care and Social Policy Fayziddin Sayfulloyev told IRIN that TB was especially prevalent among the homeless and those displaced by the recent civil war. He said 616 new cases had been reported between January and May, of which 182 were in the southern agricultural region of Khatlon. Sayfulloyev said Khatlon was particularly badly affected, because the region had seen the return of 635,000 refugees from the civil war. Also, as TB spreads much in the same way as the common cold, it thrives in overcrowded and squalid conditions under which many returnees now live. With the cost of TB medication prohibitive for most, many of those infected left it late before seeking medical attention, making it harder to treat them effectively, he said. Doctors at the tuberculosis unit in a government hospital near the Tajik capital, Dushanbe, estimate that over 8,000 Tajiks were currently suffering from TB. The head physician, Qurbongul Zokirova, told IRIN that a single untreated case could infect up to 15 people a year. The health services were ill-equipped to deal with this onslaught, he said. The two main TB hospitals in Kofarnihon District, 20 km to the east of Dushanbe, have suffered years of neglect and civil war plunder. Zokirova explained there were shortages of materials, including supplies for Mantoux tests and fluorographic examinations. With a lack of funds, patients barely received adequate treatment or nutrition to fight off TB infections. In Kulob District, 195 km southwest of Dushanbe, tuberculosis has already killed 11 people this year. The head physician at the Kulob anti-TB centre, Hanifa Abdualimova, told IRIN that there was an acute rate of TB infection in the area, with an incidence of over 80 per 100,000 people - double the official national rate. “There is a lack of medicines and nutrition, and people refuse to be hospitalised. The centre doesn’t receive financial support, and patients are obliged to purchase all necessary medicines themselves,” she said. The reasons for the infection rate being so acute in Kulob are unclear, as similar conditions prevail across the country. Having worked in the country over a number of years, Dr Lyubomir Ivanov, the head of WHO in Tajikistan, is all too familiar with the rise in TB. He names malnutrition, poor living conditions, overcrowding and a lack of medicines and laboratory supplies as the main factors contributing to the spread of the disease since the late 1980s. The return of civil war refugees was equally a significant in spreading the contagious disease. Tackling TB TB requires an especially rigorous treatment protocol to ensure that patients do not develop multi-drug resistant strains of the bacilli, which would then require expensive treatment. The WHO-approved treatment regime has an 85 percent success rate. Known as the Directly Observed Treatment, Short Course (DOTS), the community-based approach involves health workers or nurses observing a daily prescribed treatment of antibiotics. “The old approach was to isolate the TB patient in rural areas, often for months. The DOTS system treats people in the community with the help of visiting nurses who are there to observe regular treatment,” said one international health worker. Provided patients complied with DOTS, they could usually recover within six months, if not sooner, he added. Ivanov said his first challenge had been to convince Tajik doctors that the unfamiliar treatment regime actually worked. “In the beginning, when I started to explain that short-term courses of treatment for TB were available, the professors looked at me as if I was mad,” he said. Convinced that there was a cadre of local staff trained to implement DOTS effectively, the Tajik Ministry of Health (MOH) authorised the treatment protocol a few years ago. “Now there is a full understanding of modern strategy treatment, with all the documents and regulations for the MOH prepared,” said Ivanov. He added that the nongovernmental organisation Global Drug Facility (GDF) had decided to press ahead with its free anti-TB drug supply programme to two pilot projects near Dushanbe. Wanted - a committed health consortium With local health authorities committed, progress now appears to depend on the long-term commitment and expertise of a host of international agencies and donors. Alex Brans, operations manager of Merlin, a British NGO present in Tajikistan, told IRIN that a health consortium was vital if TB was to be tackled at the national level. “You need a concerted approach: an agency to provide drugs, another with the expertise to set up a laboratory, [and] a portfolio of donors that understand the complexities of TB and the slow progress that will be made. Most importantly, you need a long-term commitment by all involved,” he said. Although local initiatives were under way, he said that negotiations were still in progress to determine who was planning to do what. “So even if we had half a million dollars offered to us, we still wouldn’t want to start until a few things were firmly in place,” he said. With parliament hesitating over the cost of the proposed national health care reform plan for 2000-2003, it looked as though TB would need to be implemented as a stand-alone project. Although integrating TB treatment into a national health plan should remain an objective, Brans said that well-defined pilot programmes at a district level were often preferable to implementing a nationwide treatment protocol. “Once seen to be successful, the pilot programme can be replicated elsewhere in the country by the Ministry of Health,” he added. Merlin’s experience with TB in the Tomsk region of central Siberia demonstrated the need for a twin-track approach that would treat patients in prisons and the community simultaneously. Coming from poor, cramped and unhygienic quarters, recently released prisoners were a major source of infection in a community. Brans said a social-support network was needed for the treatment of infected prisoners in jail, and after their release. “Otherwise you have a situation where your efforts in the community are being undermined by prison patients coming through the back door,” he said. A decision also had to be taken on whether to undertake the costly treatment of multi-resistant strains of TB. According to the WHO, a standard treatment costs between US $11 and US $25 per patient for six months. However, the cost of treating a patient for multi-resistant strains could be as high as US $2,500 for an 18 to 24 month course. Time-consuming and labour-intensive, individual sputum samples had to be analysed separately, with treatment protocols designed for specific individuals. With antibiotics prescribed simultaneously, secondary drugs were often administered to counteract side effects. Brans said this had added to the cost of the treatment, and encouraged agencies to lobby pharmaceutical companies to mass-produce and thereby to reduce the cost of TB drugs. Success was not always guaranteed. “In Tomsk, we found that four percent out of about 3,000 people with multi-resistant strains were resistant to eight different types of antibiotics. The only solution in these cases appears to be isolation of the patient, to stop them walking about with unbreakable strains of TB,” he said. Ignoring multi-resistant TB strains was not an option, Brans maintained. In the age of modern travel, patients with resistant strains represented a global health threat. “It’s so easy for an infected person to get into Europe and end up working in one of London’s restaurants, coughing up over your food,” he said. In the absence of a concerted approach, Brans warned that temporary responses could actually accelerate the spread of the disease. Interruptions to the drug supply could encourage the development of resistant strains, as patients resort to whatever drugs are available in local pharmacies. “If funding falls away in the middle of a programme, then you can end up contributing to the TB problem in that country,” he said.