The chart below shows the good-news-bad-news scenario that is the decades-long fight against TB in Afghanistan. TB is still a crushing problem there; the country has among the world’s highest rates of the disease, which killed some 10,000 people in 2017. But if you glance at this chart and think that we haven’t made much progress, look again. We’re finding and treating more people with TB in Afghanistan than ever before. In 2001, we were missing three quarters of presumptive TB patients — that is a whopping 75% gap in case detection.
Meanwhile, the same two decades saw the country’s population grow from 20 to 35.5 million. That’s a 78% increase, and it happened mostly in urban settings where TB tends to spread more easily, making diagnosis and treatment even more difficult. Still, by 2017 the country was able to diagnose and treat 70% of estimated patients. This is a huge success, as we have been able to catch up with the population increase and help close the gap.
Urban DOTS: A detection and treatment network
How did we do it? Through the implementation of DOTS (Directly Observed Treatment, Short Course) — a leave-no-stone-unturned systems strengthening strategy the World Health Organization (WHO) recommends to improve treatment outcomes and increase case detection. Thanks to generous support from and partnerships with USAID and WHO, MSH has led the implementation of urban DOTS in Afghanistan through the Challenge TB program since 2009. While national trends are on the uptick, outcomes are even better in the areas in which DOTS has a foothold.
Here’s how it works in Kabul. In 2009, MSH conducted a baseline assessment to determine whether DOTS would be an effective strategy. We found that despite receiving nearly half of all patients seeking primary health care, few private-sector providers had been trained on national TB clinical guidelines, resulting in missed cases, misdiagnosis, misclassification, improper treatment combinations, and incorrect prescribing. This, coupled with a number of other factors — the city’s health infrastructure was among the weakest in the country — led to abysmal TB outcomes. All TB indicators for the city consistently fell below national targets.
The DOTS model is surprisingly straightforward. It combines health systems strengthening approaches with specific TB-related activities. The model works on the premise that engaging with patients to help them stay on track with the arduous treatment regimen is key to ensuring that people are cured; preventing more aggressive, drug-resistant strains of TB from developing; and putting an end to the spread of this disease. The urban DOTS model focuses on four major intervention areas:
● Building the capacity of the National Tuberculosis Program (NTP) and private and public health care providers to identify symptoms, diagnose patients, and link them to immediate treatment
● Expanding DOTS coverage by building strong partnerships among organizations and health workers at all levels in public and private facilities throughout the city
● Improving medicine management and supply at health facilities
● Improving surveillance, supervision, and monitoring of TB activities and patients
MSH teams work with the NTP and local stakeholders to train city-based staff on identifying people with TB symptoms, providing timely testing and treatment, and registering and reporting related data. Using the new NTP guidelines and standard operating procedures, 681 physicians, laboratory technicians, and nurses from health centers and private and public hospitals were trained on DOTS between 2009 and 2015.
A comprehensive strategy brings success in key areas
Key to the success of DOTS in urban settings has been the close partnership with local health providers. The comprehensive urban DOTS program greatly improved service accessibility, TB case finding, and treatment outcomes in Kabul, especially in private health facilities. While the treatment success rate increased significantly, it remains lower than the national average, and more effort is needed to improve treatment outcomes in Kabul.
By the end of 2018, Challenge TB logged the following results:
A strong beginning, but a long task
Urban DOTS still has far to go. According to 2015 Challenge TB data, the case notification rate for all TB patients is still only two-thirds of the estimates, and for new sputum-smear positive patients, it is only 42%. This translates to an estimated 3,000 TB patients undetected, untreated, and contagious. The treatment success rate in 2017 was 88%, closing in on the national target of 89%.
Although Afghanistan continues to be wracked by conflict, the results we’ve seen so far suggest DOTS can be effective, even in a challenging environment. With improved diagnostic tools, better drugs, and a continued commitment from both international donors and Afghan authorities, we are on the right path to end this disease, which remains a major barrier to health and prosperity in Afghanistan.
Watch our webinar “Meeting the Challenge of TB in Urban Afghanistan” to hear more about what we’ve learned from the expansion of DOTS in Kabul and other urban areas in Afghanistan. Leaders from the Challenge TB program outline accomplishments and lessons and open a discussion around what remains to be done.