Increasing donor support for TB control

With enhanced political stability in Tajikistan resulting from the ongoing successful peace process, donors and aid agencies are stepping up efforts to contain tuberculosis (TB), which continues to figure as a major public health emergency there. "Now there is increased attention to TB in the whole region, and here in Tajikistan," Tom Mohr, the programme manager for the international NGO Project Hope. told IRIN from the Tajik capital, Dushanbe, on Thursday. Aid workers believe that with improved stability and security after the end, in 1997, of the country's five-year civil war, donors are more confidently investing in longer-term and more diverse programmes. Such programmes are important as even an uncomplicated case of TB can take up to nine months to treat. According to Mohr, based on his organisation's experience in the field, some 10 of every 100,000 Tajiks die of TB annually – a very high percentage in global terms. The government and aid agencies estimate the annual new-notification rate for TB at 127 per 100,000. However, according to David Zappa, the country manager of the British NGO Merlin, it is acknowledged that many cases never reach medical services. Mohr observed that determining whether infection rates were increasing or decreasing was difficult. "We are using different diagnostic methods than used previously, so the trend for the next couple of years should show an increase. But that is not what is necessarily happening with the epidemic," he said, adding that establishing to total number of TB cases was necessary was an essential to the task of effecting a reduction. He asserted that TB was a major issue, which needed to be addressed. "At least until TB treatment is available throughout the country, the epidemic will remain a problem," he said, adding that it was likely that by 2010 the notification rate would increase to 160 per 100,000 people. Funded by US Agency for International Development, Project Hope initiated the first Directly Observed Treatment Short Course (DOTS) TB treatment programmes in Dushanbe and the Leninsky District around the city, covering a population of 900,000. "We are the first international agency addressing TB here," Mohr said. DOTS is the World Health Organisation-recommended, universally recognised method of TB control. The programme involves hospitalisation for about three months as opposed to one year of hospitalisation and heavy reliance on injections in other treatment methods. Working with existing medical services, free TB drugs are being obtained through the Global Drug Facility, laboratories have been equipped and refurbished, and staff had been trained in TB management using the DOTS guidelines. Merlin has rehabilitated and re-equipped the diagnostic laboratories in the southern Khatlon and Kulyab districts. Together with the northeastern Rasht Valley, these are the areas with a high prevalence of the infection. The Swiss Development Agency and German donors are also active in TB control in Tajikistan. Mohr noted that extending medical facilities to the dispersed rural communities in the mountainous country remained a challenge. "There is a shortage of trained medical personnel," he said, adding that more coordination in treating the disease was needed in isolated areas. While Tajikistan continues to use old Soviet methods of diagnosis with X-rays and admission to specialised TB hospitals for lengthy periods of treatment, the combination of expensive drugs and the cost of transport and food renders completion of the TB treatment out of the reach of most patients in this country where over 80 percent of its 6.2 million people still live in poverty. Experts believe that the switch to DOTS was necessary. Although the Tajik government adopted the DOTS protocol a few years ago, it did not officially accept it until December 2001. Zappa maintained that an increase in Multi-Drug Resistant TB (MDR-TB) and the possibility of a rise in HIV infection rates remained Merlin's major concerns. "These will both have adverse effects on TB control in Tajikistan," he said. While the diagnosis and treatment of MDR-TB remains complex and expensive, HIV greatly increases vulnerability to TB in the community. Experts estimate that 70 percent of HIV infected persons die of TB globally. He added that prisoners remained the most vulnerable social group, as conditions in jails were highly conducive to the transmission of TB, HIV and sexually transmitted diseases. "A comprehensive prison health service is required," he said, adding that such a service should include proper TB management.