This report does not necessarily reflect the views of the United
An Afghan woman with pulmonary TB
KABUL, - Tuberculosis (TB), a contagious disease
transmitted via the atmosphere, continues to be of major concern to health
experts in Afghanistan. While there are no precise statistics due to
problems of access, reports indicate an increase in the number of reported
"There are an estimated 150,000 people suffering from TB in
Afghanistan today," Dr Giampaolo Mezzabotta, a TB medical officer for
the World Health Organisation (WHO), told IRIN in the Afghan capital,
About 80 percent of all cases worldwide occur within a group of 22
countries, with Afghanistan having one of the highest rates of incidence.
"Based on epidemiological calculations, we estimate 70,000 new cases
annually, with some 20,000 people dying each year," Mezzabotta said,
adding, however, that the notification rate was much lower as many people
lacked adequate access to treatment, and therefore simply sickened and
died. In 2001, some 10,000 cases had been reported to governmental and
NGO-run health facilities, he noted.
The health expert said that of every 100 patients infected with TB today
and left without treatment for two years, 50 would die, 25 would recover,
and 25 percent would survive as chronic cases and potential infectors of
According to the WHO, left untreated, each person with active TB will
infect on average between 10 and 15 people every year. But people infected
with TB will not necessarily get sick with the disease. The immune system
"walls off" the tubercle bacillus, which is protected by a thick
waxy coat and capable of lying dormant for years. When the host
individual's immune system is weakened, however, the chances of activating
the bacilli increase accordingly.
Transmitted through the atmosphere like a common cold, only people who are
sick with pulmonary TB are infectious. When infectious people cough,
sneeze, talk or spit, they propel the bacilli into the atmosphere. An
individual needs only to inhale a small number of these to be infected.
In Afghanistan, much like the rest of the world, the disease is mainly
fuelled by poverty and malnutrition. "If you are well fed and well,
you tend to be able to fight off TB. However, if you are poor, living in
overcrowded, dark, poorly ventilated living conditions - and you are
malnourished - once exposed, you are more likely to be infected," Dr
Sarah Morgan of the Swiss-based NGO Medair, which has actively been
working on the TB issue in Afghanistan since 1997, told IRIN. In
Afghanistan, reeling from two decades of war and a devastated health
infrastructure, such circumstances are common.
Morgan noted that while there was a seasonal variance, with more cases
being reported in the summer, each year between 1,000 and 1,500 new cases
were being reported in the central region alone, while in the north, a
similar number was being identified. "In other regions, there is a
limited number of NGOs on the ground, so the reported incidence could be
less," she said.
She noted, however, that the increasing number of new cases could be
partly due to improving political stability enabling people to travel more
freely to seek treatment. "Probably next year weíll have a better
idea if itís rising or whether itís due to changes within the
country," she said.
What is unique about Afghanistan, however, is the overwhelming proportion
of women infected by the disease. "In other parts of the world, TB is
a disease of young men, and here we see that 70 percent of the cases are
female - a fact that has yet to be satisfactorily explained," Morgan
Asked to comment, Mezzabotta noted some of the social reasons that might
be relevant. "We know, for instance, that women are segregated in the
house, have several and frequent deliveries, are often undernourished and
live in close quarters Ė all of these can be factors as to why women are
more prone," he observed. "This is worth studying further and we
are going to do that."
But it is the problem of access that most concerns experts today. Dr
Ataullah Zarabi, a national TB expert for WHO, told IRIN from his office
in Kabul that whereas the disease occurred country-wide, areas of the
north, many of them remote with no access to health care, had been
particularly hard hit.
Morgan concurred, adding once you travelled beyond Kabul, access to health
care was "appalling". "There arenít clinics, there
arenít roads. People donít have the ability of getting to clinics to
be diagnosed," she asserted.
She cited stories often told of valleys and places where 90 percent of the
population was infected, but reaching such places to verify these reports
was next to impossible. "There are large pockets of the population
that are not reached at this moment in time. For them, the only option is
to travel to Kabul," she said.
Indeed, it is this fact that has become the focus of both the United
Nations and the handful of NGOs working in the field.
The WHO approach is twofold. Firstly, to continue to provide drugs and
other essential medical supplies to the health system in the provinces and
throughout the region, while at the same time, helping the system to
"We are concentrating a lot on the national TB programme, both at the
central and regional levels," Mezzabotta explained. "What we
have done is to develop with the Ministry of Health and all regional
offices a strategic plan, as well as set up an inter-agency coordination
committee where all the stakeholders, comprising donors, NGOs, academics,
prison health officials, etcetera, play their role."
Meanwhile TB prevention is still in its infancy in Afghanistan. Until
2001, there were only 32 TB centres in the country. That figure increased
to 76 in 2002. "Working in collaboration with the Ministry of Health,
in 2003 we hope to have 183 centres established," Zarabi said.
According to WHO, the recommended strategy for detection and cure of TB is
Directly Observed Treatment Short-Course - otherwise known as DOTS. The
treatment method combines five elements: political commitment, diagnosis
by means of microscopy services, regular drug supplies, surveillance and
monitoring systems and direct observation of treatment.
Once patients with infectious TB (bacilli visible in a sputum smear) have
been identified using microscopy services, health and community workers
and trained volunteers observe patients ingesting the full course of the
correct dosage of anti-TB medicines (treatment lasts six to eight months).
The most common anti-TB drugs are isoniazid, rifampicin, pyrazinamide,
streptomycin and ethambutol; a six-month supply of drugs for DOTS costs as
little as US $10 per patient in some parts of the world.
Sputum smear testing is repeated after two months to check progress, and
again at the end of treatment. A recording and reporting system documents
patientsí progress throughout, and the final outcome of treatment.
Zarabi described DOTS as the key to thwarting the diseaseís spread in
Afghanistan, but conceded that keeping patients on board for the full term
(in Afghanistan Ė eight months), particularly those who had travelled
long distances to come, was proving difficult. "Approximately 15
percent of all infected people have access to treatment. This is not
enough. We need to improve this access significantly," he stressed.
But doing so costs money, and donors will have to do more than what they
have committed themselves to so far. Although the Canadian International
Development Agency contributed some US $2 million to the cause last year,
with a follow-up donation from the Italian government of $800,000, much
more is needed. "We foresee to spend about US $12.5 million by the
end of 2005, so you can see there is a large gap to be filled,"
Nonetheless he remained hopeful. "We are confident donors will
respond as this is a major priority Ė both because it is a big issue,
and secondly, itís a way to improve the quality of health
services," he said. "By expanding DOTS through the health
services, we create more confidence among the population in the health
service - making it a double target."
As to WHO's long-term objectives, Mezzabotta said that its target for 2005
was "to detect 70 percent of all cases. In other words, if we
estimated 70,000 cases, thatís about 50,000. Of these, we plan to treat
85 percent of these cases. Additionally, we hope to halve
Echoing the need for more resources, Morgan said that to stem the
diseaseís spread, there needed to be better access and facilities for TB
treatment to be integrated into existing clinics.
"People are travelling for hours or even days on the backs of donkeys
to get to the nearest clinics, and yet it doesnít have any kind of lab
or anything suitable to run a TB programme," she said. "Itís a
combination between access and facilities for the diagnosis of treatment,
combined with health education thatís needed."
According to WHO statistics, TB kills approximately two million people
worldwide each year and the global epidemic is growing and becoming more
dangerous. The breakdown in health services, the spread of HIV/AIDS and
the emergence of multi-drug resistant TB are contributing to its spread
Between 2002 and 2020, about 1,000 million more people will be infected,
over 150 million will get sick, and 36 million will die of TB Ė if
further control is not strengthened.
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