Mohammad Razai discusses the fight against TB in Afghanistan and the need to focus on new shorter treatment for MDR TB through involvement of all healthcare providers
Afghanistan is one of 22 countries with a high burden of tuberculosis (TB) according to the World Health Organisation (WHO). The estimated number of new cases each year is a staggering 53,000 and as many as 12,000 afflicted by this curable infection lose their lives each year. For a large number of those infected, a timely diagnosis and effective treatment is out of reach due to high levels of poverty, lack of access to effective healthcare, and ongoing conflict in large parts of the country. It is not a surprise that a significant number of victims are women and children due to their vulnerable status in a society ravaged by decades of war, drought and migration. Some of these challenges such as poverty and lack of access to healthcare facilities are not unique to Afghanistan, but it is the only country, out of 22 that account for 80% of TB cases in the world, that has been utterly decimated by over four decades of war and migration.
Despite the challenges, the Afghan government and its international partners have made some progress with the implementation of the National Tuberculosis Control Porgam (NTCP). In 2011 an estimated 97% of people had access to TB facilities. But access to facilities is one small part of the answer. The quality of diagnosis, treatment and outreach is much more important when dealing with one of the most persistent diseases known. The causative pathogen, mycobacterium tuberculosis, can remain in an asymptomatic form for a long time. Even after treatment is started, bacteria can easily develop resistance to drugs if they are not administered appropriately. In practice, this would mean patients have not been given the correct treatment regimens and there is no mechanism to ensure that the whole course of treatment is completed. This is particularly the case in the private sector where most patients present to for initial diagnosis and treatment.
The public health challenge of treating TB in Afghanistan is that most of those affected are extremely hard to reach, public awareness of the illness and its mode of transmission is very poor, and treatment programmes are quite ineffective giving rise to a large burden of multi-drug resistant TB (MDR-TB). According to WHO, in 2014, one in four of the estimated 480,000 people worldwide with a new MDR infection received a diagnosis. The persistence of the disease in Afghanistan is in part explained by MDR-TB as those with this strain can easily infect other people.
Treatment of MDR-TB has also been extremely difficult both for patients who have to endure a long and unpleasant treatment regimen but also for healthcare workers who must ensure patient compliance, broaden access to treatment and reduce transmission rates.
Fortunately, the recently updated WHO guidelines offers hope for patients in countries like Afghanistan with shorter, cheaper treatment regimens and rapid diagnostic tests. This is an opportunity to focus all efforts on improving the quality of diagnosis as an important public health matter and tackling the MDR-TB through this novel treatment regimen with better reported success rates.
Inadequate treatment of MDR-TB is part of the problem in fact a big part. All stakeholders must work together to address the increasing prevalence of MDR-TB and the slow progress in its detection and access to care. MDR-TB cannot be managed through national programme alone without addressing the issue of private and other healthcare providers in Afghanistan. Initiatives such as the one by the WHO to engage all healthcare providers in the fight against drug resistant TB should be rolled out across the country. Evidence has consistently shown that in countries with high burden of TB engaging all healthcare providers working in partnership through Public-Private Mix (PPM) have improved all aspects of patient care including better case detection, improved treatment outcomes, increased cost-effectiveness and more effective outreach.
The hope is that by rapid diagnosis, shorter treatment regimen and involvement of all providers through PPM initiative, Afghanistan will make significant progress towards achieving the WHO’s End TB Strategy.
Author biography: Dr Mohammad Razai BSc BA MB BChir MA, FRSA is a medical doctor and global health researcher. He was born in Afghanistan, trained at University of Cambridge and is currently practicing in London, UK.
Featured Image credit: David Rochkind, WHO