Dr. Tauseefullah Akhund M.B.B.S, MPH (Sydney), (Australia) October 20, 2004
Tuberculosis is one of the dreadful diseases affecting a number of people in developing countries including Pakistan. It is one of the most common diseases causing a high mortality and morbidity. The total number of cases is rising every year because of rapidly growing population, socio-cultural reasons, increasing number of HIV cases, a high number of Afghan refugees, increasing number of poor people and non-compliance to the treatment. Another emerging issue is widespread dissemination of multiple drug resistant cases of tuberculosis, which has raised the eyebrows of public health experts because it not only makes the disease condition more lethal, it also required very high costs to curb the condition. Pakistan, in its already not so good economic condition and reducing health costs in budgets, may not afford this. From the early 1990s Pakistan Government started Directly Observed Treatment (DOT) strategy to control tuberculosis. However, the cases of tuberculosis have continued to rise. The effectiveness of DOTS strategy has certainly put a question mark and has forced public health professionals and policy makers to revise and review it.
Tuberculosis is one of the endemic diseases in the Indian subcontinent countries from years. One third of the world’s population is infected by tuberculosis (TB) out of which 95% of cases are in developing countries (Maher, Chaulet, Spinaci and Harries, 1997, p. 13). Most people are of young age group which makes a huge impact on the productivity of less developed countries. Such a huge impact of TB in the developing countries is of great public health concern. Pakistan, in its already dooming economy can not afford to handle a huge burden of such communicable diseases.
Tuberculosis, caused by acid fast bacteria (AFB), affects mainly lung causing symptoms like cough, fever in the evening, sweating at night and sometimes bleeding in the cough; it, sometimes, also affects several other organs like liver, kidney, skin and intestine. It spreads by the respiratory droplets and close contact with tuberculosis patients. A poor nutritional, housing and sanitation condition is responsible for TB. It is important to improve these conditions to prevent new cases of TB. Nonetheless, the most important way of preventing TB is to cure the infected patients.
In past, BCG vaccination to prevent TB was highly practiced with some success. The governments in developing countries then greatly ignored the serious consequences of this very less sensitive vaccination. Moreover, the case detection process was also slow because culture of TB bacteria took weeks before diagnosed and the X-Ray, despite being sensitive was not very specific. However, after the introduction of sputum cytology for AFB the detection of TB became very sensitive, specific and relatively easy. Also, the curative drugs became available, but none of them completely curing and required dose was for months.
The impact of disease and availability of newer technologies and treatment required to make a policy which would cover a widespread population with a very high cure rates. WHO implemented a TB control policy in early 1990s aimed to detect maximum number of cases and curing the patients (Maher et al, 1997). The main aims were to detect 70% of smear-positive TB cases and to treat 85% of smear-positive new cases successfully. This Directly Observed Treatment Strategy (DOTS) used sputum smear microscopy for diagnosis and short course chemotherapy (SCC) for the treatment of TB. This tool used combination of several drugs in SCC to be more sensitive and short duration to improve the compliance. Under DOTS, the treatment to each person would be given by the health professional directly on daily or on alternate day bases. Either health worker would go to the patient to supply him his drugs or patient would come to the health worker to take his dose daily (Maher et al, 1997). Governments of most countries including Pakistan have implemented this policy in their countries and have succeeded to control TB to a large extent.
DOTS has become an important part of National TB Programs in Pakistan. The main framework of DOTS in Pakistan is to reach at every part of Pakistan, rural and urban, in terms of diagnosis and treatment; accountability and supervision of health care workers; and evaluation of new and relapsed cases (Maher et al, 1997). Under DOTS, categories have been made according to new cases, relapsed cases, treatment failure cases, site and severity of TB, chronic cases, interruption of treatment and so on. The treatment is based and differs according to the categories. The DOTS policy, which looks very effective on paper, hasn’t worked up to the mark in Pakistan because of several reasons. WHO’s TB control policy is too general and does not consider local and cultural factors into account.
The leaping rise in Pakistan’s population along with increasing density and less housing management have raised the threat of TB. Although the percentage of poor people is reducing, the total number of poor has increased substantially over past decades. It is not easy for DOTS to reach all people. The rural population is increasing, not being able to access DOTS. People in the slums of urban areas are the worst affected. In the absence of any registry of such people, their continuous movement from one place to another and increasing homeless people are worries for one hundred percent coverage of all people under DOTS. Participating in NTP is one of the least important things for such people no matter how severe the impact of disease may be in their lives. The most important reason of such frequent moving people is their poor financial conditions. For the successful registering of such people and their coverage it is important to offer them monetary incentive to stick to the DOTS program. It can also be advised that some of these specific areas with slums and poor housing conditions should be segregated and converted into target health sectors so that special attention can be given and the health services can be re-oriented according to the need of specific health sectors.
Another factor, socio-cultural, is also a hindrance in the success of DOTS. Lack of education and religious preponderance has led to several misperceptions regarding TB. A study carried out by Liefooghe et al (1995) in a hospital of Sialkot district of Pakistan suggested that people consider TB as a lethal and incurable disease. Some of them also linked TB with ‘sins’. These misbelieves cause social isolation of the persons having TB and sometimes their families. Young people can’t find proper match for their marriage; engagements are often broken and divorces are reported. The study reveals that the condition of women is even worse. Women are completely dependent on their husbands and family-in-laws and need their support. There is also some fear that pregnancy leads to the relapse of TB. These misperceptions and social stigma have led to denial of diagnosis and rejection of treatment. The times have come when DOTS address such issues. There is no doubt that education and awareness for such misperceptions is inevitable, but this education should not be anti-religion. Rather, the religious leaders should be encouraged to motivate people to take active part in the TB campaign. Although, DOTS involves health workers at several levels, it should also involve these religious leaders. Their role in removing these social taboos is vital to overcome socio-cultural obstacles.
Since past couple of decades Pakistan is having a huge influx of refugees from Afghanistan. There is no data of them; who comes who goes. TB has been highly prevalent in these people and highly ignored too. The exponential influx of refugees in last five to seven years has made the coverage of DOTS very difficult. There are more than 3 million Afghan refugees situated in Pakistani state North West Frontier Province (NWFP) with annual rate of TB infection 1.7% (Ibrahim and Laaser, 2002). Ibrahim and Laaser (2002) also describe that NTP covers only 8% of population and condition is getting worse with continuing influx of refugees. A tuberculin survey carried out in 1985 among 4108 Afghan refugee children suggested that there were 13.8% children with TB, though the figure matched with similar incidence in Afghani children in Afghanistan (Spinaci et al, 1989). In 1998, an Italian NGO counted 20,000 cases of pulmonary TB and 40,000 extra pulmonary TB cases (Ibrahim and Lasser, 2002).
The increasing number of refugees has also created high number of drug resistant cases due to their non-compliance or lack of interests. DOTS highly relies on government of Pakistan to reach to the millions of refugees. The stringent laws and military interruption not only affects NTP to reach to the refugees, they also stop refugees to come to NTP. The similar condition like refugees is seen in prisoners in Pakistan, where utterly poor infrastructure, poor hygienic condition and ignorance by health workers have made TB a common disease among inmates. The surveillance should be improved in refugee camps. The refugee camps should be registered and so should be refugees. Regular health check ups should be carried out in these enlisted camps. In case of exchange of refugees Afghanistan government and their health department should be approached by Pakistan for not missing out a single person treatment.
TB is one of the opportunistic infectious diseases in HIV/ AIDS patients. With the widespread pandemic of HIV the number of TB cases have risen. TB in HIV patients is also difficult to treat. Eleven million adults are estimated to suffer from both TB and HIV (Ferrari, 2004). HIV or AIDS decreases immunity of a person making vulnerable for the infectious diseases. The worrisome picture of TB in HIV is that it is difficult to treat TB in HIV patients and it often causes drug resistance. The overlap of TB and HIV suggests that for the success of DOTS, NTP has to collaborate with anti-HIV or anti-AIDS agencies.
Surveillance is one of the most important obstacles in the success of DOTS and NTP. In WHO’s goal of detecting 85% cases and treating 70% of them, the treatment is close to 85% goal, but the case detection is as low as 37% (Hampton, 2004). The situation in Pakistan is bad for the case detection. The conditions like refugees, civil conflicts, poverty, overcrowding and so forth are making the detection of TB cases very difficult. Dye et al (2003) reviewed the growth of case detection from 1995-2000 and estimated case detection by year 2010. The figure for most developing countries shows that the case detection rate is very low. Pakistan had also very bad figure, only 9% cases detected in DOTS in year 2000. Although it is estimated to reach as high as 40-50% in next five years, Dye et al (2003) fear that then the figure will plateau rather than reaching WHO estimated detection rate. There are several hypotheses responsible for such low case detection in Pakistan. The study argued that the missing TB cases might not exist at all; cases are not registered in private or public health systems; or if they are, they don’t get referred to DOTS. However, there are some other factors responsible for the reduced detection of TB cases. One such important factor is expertise of the health professionals who carry out the smear tests/ sputum tests. The lack of their training often leads to miss out TB cases.
In Pakistan, there is a huge gap between Public Health system and Private. A large population including rural people relies on private health system and doctors. Private health service providers are not the part of DOTS. It has been observed that their knowledge and training often lack in TB. They often under-diagnose or over-diagnose cases of TB. Frequently they prescribe the wrong treatment or inadequate treatment. Often the private practitioners themselves lack enough knowledge about DOTS and specific anti-TB treatment. Many people visit the private practitioners at first hand in Pakistan. Their exclusion from the NTP or DOTS could well hamper the condition. It is rather needed to understand the roles of private practitioners in prevention of TB. They should be included in NTP, should be trained for diagnosing, treating and referring the patients properly.
All these factors above have made TB an urgent public health condition. The lack of enough diagnosis, poor adherence to the treatment, injudicious use of drugs by private practitioners, and so forth have made the condition of TB even worse. The emergence of multiple drug resistance is the most worrisome picture. The study in 1989 carried out by Aziz et al in Lahore described that out of 256 people, in the study, having been on treatment for TB, one third showed resistance to isoniazid and pyrazinamide; and the resistance was rising for rifampicin. In past decade the condition of multiple drug resistance have increased. Multiple drug resistance (MDR) is not only difficult to treat as it results into severe form of TB, but it is also an expensive business.
Multiple drug resistance is now defined as having resistance to isoniazid and rifampicin, which requires the need of second line drug treatment for treating TB (Mukherjee et al, 2004). While treating TB costs less than 10 US$, treating MDR TB costs between 500 and 6000 US$ (Brown, 2004). Frequent interruption in the treatment, lack of supply of drugs, poor infra-structure, diagnostic delays, pandemic of HIV and AIDS etc are the main reasons of MDR TB. Developed countries themselves find the MDR TB very expensive to treat spending millions of dollars. Pakistan, on the other hand can not afford to do so, neither can its people. This might well lead to MDR TB endemic. To deal with MDR TB in Pakistan, NTP and government should conduct a survey of the affected areas and identify them as “hot-spots”. Many European countries have declared such hot spots according to the endemic of MDR TB, so that they can concentrate their DOTS program in these areas (Brown, 2004).
DOTS is undoubtedly the best available tool all over the world to prevent TB or to keep it under control. But it hasn’t reached up to the mark and there is a long way to reach the goal in Pakistan. A randomized control trial carried out in Pakistan among 497 people resulted in almost same cure rate in DOTS and in self administered treatment group people (Walley et al, 2001). Although, the study said that the results differed in other countries where DOTS was superior to self administered treatment, the efficacy of DOTS has some issues to be addressed. The DOTS program is too universal to be applied to people worldwide. It has to reach to local involvement rather than sticking to global or national. DOTS, under which people or health workers have to attend each other on daily bases is not very practical attitude. Many people can not afford the travel costs, mainly women who have to be escorted by some family members in Pakistan increase the travel costs. The need is to decentralize NTP and reach to each province, each district, and every corner of Pakistan. Monitoring the health workers is also important thing to do in Pakistan as the corruption and fraud are very common in most parts.
The treatment of TB is a long process involving months of treatment at a stretch. Moreover, BCG vaccine hasn’t shown satisfactory prevention especially in adults due to its lack of sensitivity and specificity. More funding is required in the research of new drugs and vaccines. Very short course drugs, which are affordable and accessible to everyone, should be developed; the same with research of new vaccine. Pakistan, of course, can not afford to fund such research; however, the developed countries, which are not out of the dangers of TB, have taken the initiatives to do proper research to invent new drugs or vaccines. According to BBC World (2004) the first TB vaccine which was invented 80 years ago has now passed safety trials United Kingdom. The study suggests that this could be a useful find for those countries where TB is endemic and numbers of cases are on rise. It is also said by oxford university reasearchers that this vaccine can enhance the potency of already existing vaccine as well. Researcher are still not sure about efficacy of vaccine, some says that it can protect only 66% people, where as in other cases it might protect only 30 percent people.
In the end, Directly Observed Treatment strategy (DOTS) and NTP (National Tuberculosis Program) have done reasonably effective job in controlling TB, but there are some factors which are yet to be addressed and considered to achieve the desired outcome in curbing TB. Pakistan’s population growth and distribution, the socio-cultural and religious hindrance, condition of Afghan refugees, rapidly spreading HIV, influence of private practitioners and poor surveillance system are affecting the efficacy of DOTS. The outbreak of multiple drug resistance is very rapid and this condition is a huge burden on Pakistan economy if not considered promptly.
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