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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 cases.

"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, Kabul.

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 others.

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 we’ll have a better idea if it’s rising or whether it’s 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 said.

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 – 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 aren’t clinics, there aren’t roads. People don’t 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 develop.

"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 patients’ progress throughout, and the final outcome of treatment.

Zarabi described DOTS as the key to thwarting the disease’s spread in Afghanistan, but conceded that keeping patients on board for the full term (in Afghanistan – 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," Mezzabotta said.

Nonetheless he remained hopeful. "We are confident donors will respond as this is a major priority – both because it is a big issue, and secondly, it’s 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, that’s about 50,000. Of these, we plan to treat 85 percent of these cases. Additionally, we hope to halve prevalence."

Echoing the need for more resources, Morgan said that to stem the disease’s 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 doesn’t have any kind of lab or anything suitable to run a TB programme," she said. "It’s a combination between access and facilities for the diagnosis of treatment, combined with health education that’s 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 worldwide.

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 – if further control is not strengthened.

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