Background

1. Comparison between treatment outcome of TB patients treated in DOTS centres and in the community in Afghanistan GP Mezzabotta, K Inaba, A Zarabi, E Tacconi, A Seita, S Baghdadi, S Rahemi, H Ataul, S Nadeeb, M Rasooli, A Bahman

2. Background The country, still in the aftermath of a prolonged conflict, just recently started moving towards a process of reconstruction of the civil society. Transitional government, in power since July 2002, promulgated a year ago an interim health policy which entails the delivery of a Basic Package of Health Services (BPHS). DOTS is one of the components of BPHS. PHC delivered through 4 main levels: District Hospital; Comprehensive Health Centre, Basic Health Centre and Health Post. The first two have laboratory. NGOs deliver 70-80% of PHC services, especially in rural areas. WFP provides food for TB patients. WHO, JICA, MEDAIR, LEPCO, MSF, CIDA, Italy and Global Fund major partners of MoH in TB control.

3. Health profile of Afghanistan • Area: about 636,000 Km2 • Population: approx. 25 million • Infant/<5 mortality rate: 155/230 x 1000 live births • Maternal mortality rate: 1600 x 100,000 live births • Life expectancy at birth: 47.3 (males); 45.9 (females) • Immunization coverage (DPT3): 30.1% • Adult literacy rate: 51% (males); 21% (females) • PHC services coverage: 35% • Chronic malnutrition: 40-60%

4. This is whera large graphic or chart can go. (At the end of 2002)

5. Tuberculosis in Afghanistan TB perceived as a major public health problem: WHO estimates 70,000 new cases (all types) and 20,000 TB-related deaths every year. 65% of all registered cases occur in females between the age of 15 and 45. Causes not yet clear. New cases detected in 2003*: S+ 6411 (49.4%); S- 3408 (26.2%); E/P 3173 (24.4%); Tot 12992 + 598 Relapses * = data still uncompleted, as some districts are not accessible for data collection till May Poor access to PHC and DOTS due to various factors: Low health services geographic coverage (DOTS coverage 54%) Cultural stigma, traditional beliefs and economic constraints Political and social instability and low travel security Harsh climate and rough landscape Widespread and highly competitive private for-profit sector High indirect cost of treatment to patients

6. Objectives of the study • To compare the effectiveness of anti-TB treatment administered in DOTS centers (located either in PHC units or in specialized TB clinic) and in community settings. • To explore specific characteristics of patients treated in each of the two conditions • To identify pros and cons of community TB treatment • To make recommendations for expansion of Community Based DOTS in Afghanistan

7. Methodology of the study Data on indicators of treatment outcome have been collected by WHO and NTP team from patients register book during supervisory visits to 4 DOTS projects (Kunduz, Jalalabad Provincial Hospital, ATA-AP in Eastern Region, Faizabad) with support from the project coordinators. Results of the study have been presented to TB coordinators from all of Afghanistan during the last ICC meeting held on March 16, 2004 in Kabul. Majority of RTCs and PTCs agreed on most conclusions and pointed out that incentives to health cadres (esp. laboratory technicians) would improve their performance (!).

8. Community TB treatment in Afghanistan Different approaches adopted by various projects: In Kunduz, patients who insist they live too far from DOTS centre for daily supervised treatment, are asked to bring a letter from either a health worker or any other reliable person (mullah, teacher, elderly) in the village who accepts to be responsible for their treatment. Every 7-10 days patients receive tablets from DOTS centre and give them to the supervisor, who is instructed in writing or in person by the TB coordinator how to administer DOT. ATA-AP has established in 27 districts and about 400 villages of Eastern Region a network of trained Community Health Volunteers and paid Community Health Educators (supervisors). At least 1 CHV per village and 1 CHE every 10-15 villages. The latter visits TB patients at home and supervises the CHV, making sure they provide appropriate DOTS. CHVs are currently mostly males, thus making somehow difficult for women to see them unaccompanied. Female CHVs hard to recruit. In Faizabad, patients unable to adhere to DOTS are treated with 12 month standard therapy in their community.

11. Considerations on findings Sex:higher female:male ratio in community setting (2.2:1 vs 1.6:1 in clinic) may reflect difficulties faced by women in traveling and staying away from home. Category of treatment: Cat. II patients should be carefully monitored, so theirproportion in the community (48% of all cat.II cases) seems too high. Actually only 2 of the 14 failures reported occurred in cat. II pts treated in the community. Conversion of sputum at 2 months (94.5/92.3%): suspiciously high, even in Faizabad under standard treatment regimen. Success-rate (96.4/90.8%):Very high everywhere, including Faizabad. Death, defaulter and failure rate:very low.

12. Conclusions & recommendations There is apparently no substantial difference between TO of patients treated in clinic and community. However, currently available data show that possible differences may be obscured by lack of reliable laboratory support. Community DOTS seems to be already an essential component of TB treatment in Afghanistan: where feasible and well organized, already caters for the majority of patients with satisfactory results. Urgent need to train clinic staff and CHWs of all type on data recording, reporting and analysis to make figures more reliable and useful for project monitoring and management. Establishment of laboratory performance quality control system an important and urgent need. Need for more operational research on the feasibility of DOTS expansion through community-based approach.