Prevalence of Tuberculosis in Nepal on South East Asian Perspective
Nepal is a landlocked country lying along the Himalayan chain. Rectangular in shape, the country is 885 kilometers in length (east to west) and 193 kilometers in width (north to south). It shares its northern border with the Tibetan autonomous region of the People?s Republic of China and its eastern, southern, and western borders with India. The total land area is 147,181 square kilometers and the population, according to the 2001 Census preliminary report, is approximately 23.2 million. The population has doubled in 30 years. The population growth rate increased from 2.1 in 1971 to 2.6 in 1981, and then declined to 2.1 in 1991. The population density has doubled over the last three decades from 79 persons per square kilometer in 1971 to 158 persons per square kilometers in 2001. Nepal is predominantly rural; nevertheless, the urban proportion has increased steadily over the last 30 years, from 4 percent in 1971 to 14 percent in 2001.
Topographically, Nepal is divided into three distinct ecological zones. These are the mountains, hills and Terai (or plains). Of the total population, 49% live in the Terai, 44% in the hills, and 7 % in the mountains. For administrative purposes, Nepal is divided into 5 development regions, 14 zones and 75 districts. Districts are further divided into village development committees (VDCs) and urban municipalities. At present, there are 3,914 VDCs and 58 municipalities in Nepal. Nepal is a multi-ethnic and multi-lingual society. The 1991 Census identified 60 caste or ethnic groups and sub groups of the population and 60 different languages or dialects prevalent in the country.
Nepal?s economic development has been severely constrained by challenging geographic, topological and socio-cultural environments. Latterly the unstable political situation has further fuelled the difficulties facing the nation. Nepal is defined as a poor country where the estimated per capita gross domestic product (GDP) for the year 1999/2000 is US $244. About 80% of Nepal?s rely on agriculture for their livelihood. Forty-eight percent of GDP comes from the service sector, 42% from the agricultural sector and the remaining 10% from manufacturing.
Tuberculosis remains a world wide public health problem despite the fact that the causative organism was discovered more than 100 years ago and highly effective drugs and vaccines are available making tuberculosis a preventable and curable disease.
Tuberculosis is a specific infectious disease caused by M. tuberculosis .Robert Koch found out mycobacterium tuberculosis in 1882. TB affects mainly lungs called as pulmonary tuberculosis. 80% of the tuberculosis cases are pulmonary. It also affects the other organs except lungs called extra pulmonary tuberculosis. The organs other than lungs are bones, intestine, female pelvic organs (ovaries, endometrium), skin, brain and glands.
Tuberculosis is a contagious, airborne infection. A patient with pulmonary tuberculosis can spread bacilli when exhaling, coughing, sneezing, talking or spitting. Infection occurs when these bacilli are inhaled by a susceptible human.
A person infected with TB bacilli incurs a 10% risk of developing active TB. Though most can carry TB bacilli without becoming sick, any weakening of the immune system, e.g. caused by HIV infection or malnutrition, increases the chance that the TB bacilli will become active.
On average, each infective person will infect 10-15 people each year. Although inhalation is the primary mode of transmission, infections can occur through ingestion and direct inoculation.
Tuberculosis is one of the major public health problems in world. According to WHO, there are approximately 20 million active cases in the world today, and they infect 50-100 million people annually. The mortality due to disease is approximately 3 million annually and at least 80 per cent of them are in the developing countries. Tuberculosis accounts for 26 per cent of all avoidable deaths in Third World countries. These statistics are surely alarming as tuberculosis is a curable disease if properly managed. It is estimated that
About one-third of the current global population is infected asymptomatically with TB of whom 5-10 per cent will developed clinical disease during their life time. The South East Asia Region countries carry 38 per cent of the global burden of TB, with 3 million new cases and nearly 0.6 million deaths occurring every year.
Tuberculosis is one of the major public health problems in the SAARC region with immense socio-economic impacts. Almost 50% the adult population of this region has already been infected with Mycobacterium tuberculosis and is at risk of developing tuberculosis disease. In the year 2003 an estimated 2.5 million people newly developed TB disease (177/100 000 population), of which about 1.12 million (79/100000) were smear positive and capable to spread the disease to others. 1 According to this estimate SAARC region was bearing 28.31% of the total global new TB cases (with 22.43% of population share). India, Bangladesh and Pakistan are occupying the 1st, 5th and 6th position in the list of 22 high burden nations {according to estimated incidence (absolute number) of TB: high burden countries.2003} with India revealing the highest (20.3%) global absolute burden of TB. These 3 SAARC nations account for 27.55% of the total global new TB cases. An estimated 511679 people (36/ 100 000) died from TB in 2003, including those co-infected with HIV (22969). 1 More than 75% of these cases and deaths occur among 15-54 years age group, economically the most productive age group. As a result the social and economic loses due to TB are huge.
Tuberculosis is one of the foremost public health problems in Nepal, causing a significant burden of morbidity and mortality. About 45 percent of the total population is infected with TB, out of which 60 percent are adult. Every year, 40,000 people develop active TB, of whom 20,000 have infectious pulmonary disease. These 20,000 are able to spread the disease to others. TB causes estimated 8,000-11,000 deaths per year
Introduction of treatment by Directly Observed Treatment Short course (DOTS) in Nepal since 1995. Expansion of this cost effective and highly successful treatment strategy of DOTS which already has proven its efficacy in Nepal will have a profound impact on mortality and morbidity. By achieving the global targets of diagnosing 70 percent of new infectious cases and curing 85 percent of these patients we will prevent 50,000 deaths over the next five years.
High cure rates will reduce the transmission of TB and lead to a decline in the incidence of this disease. DOTS have been successfully implemented throughout the country since April 2001. By July 2005 DOTS had been expanded to 462 treatment centers with 2428 sub centers. The treatment success rate in DOTS is now 88 percent. Nationally, this year over 34,000 TB patients have been registered and are being treated under the NTP.
In Nepal, tuberculosis in children represents 5-15% of all TB cases. Gender-wise, no significant difference has been found in the number of reported TB cases in children. The reports of the World Health Organization (WHO) did not show any differences between reported cases of tuberculosis between males and females from 1997 to 2000.
Tuberculosis is the biggest infectious and single agent killer disease causing more than three millions deaths per year. DOTS are the most cost effective strategy available for TB control today. It has been suggested that DOTS works better in certain situation and countries perhaps not all other depending on local condition. If we study the progress report of NTP, the effectiveness of DOTS in TB treatment is increasing but could not meet the optimal point or focal point.
The Burden of Tuberculosis: Global aspect
Nearly one-third of the global population (2 billion persons) is infected with Mycobacterium tuberculosis bacillus and is at risk of developing active clinical TB disease.2 Estimate suggest that there were 8.8 million new cases of TB (all types) in 2003 (140/100 000 population), of which 3.9 million (62/ 100 000) were smear-positive and 674000 (11/100 000) were infected with human immunodeficiency virus (HIV). 1 There were 15.4 million people suffering from active TB disease (245/100 000 population) of which 6.9 million were smear positive (109/100 000) .1 TB is the biggest curable infectious killer of young people and adults in the world. 3 An estimated 1.7 million people (28/ 100 000) died from TB in 2003, including those co-infected with HIV (229 000). 1 The fact is that deaths from TB are avoidable.
TB is the leading infectious killer among people living with HIV/AIDS. Globally, TB is still the leading infectious disease cause of death among women of child-bearing age and killing more women than all combined causes of maternal mortality. Each year approximately 2.5 million women get ill from TB and one million die.3,4 Moreover, worldwide, over 250 000 children develop TB and 100 000 children die from TB every year.4 By the end of 2003, 77 percent of the world?s population were covered by Directly Observed Treatment Short-course (DOTS). 1 DOTS programmer notified 3.7 million new and relapse TB cases in 2003. Among these notified cases 1.8 million were new smear-positive which represent a case detection rate of 45% (of the estimated incidence). A total of 17.1 million TB patients, and 8.6 million smear-positive patients were treated in DOTS programmes between 1995 and 2003. Treatment success rate for the TB patients registered in 2002 was 82% on average, unchanged since 2000 .1 There were 4 .4 million (4392118) cases of TB (all forms) notified in 2003, representing 50% of the estimated 8.8 million new cases.
Tuberculosis Burden within SAARC Countries
Tuberculosis is one of the major public health problems in the SAARC region with immense socio-economic impacts. Almost 50% the adult population of this region has already been infected with Mycobacterium tuberculosis and is at risk of developing tuberculosis disease. In the year 2003 an estimated 2.5 million people newly developed TB disease (177/100000 population), of which about 1.12 million (79/100000) were smear positive and capable to spread the disease to others. According to this estimate SAARC region was bearing 28.31% of the total global new TB cases (with 22.43% of population share). India, Bangladesh and Pakistan are occupying the 1st, 5th and 6th position in the list of 22 high burden nations {according to estimated incidence (absolute number) of TB: high burden countries.2003} with India revealing the highest (20.3%) global absolute burden of TB. These 3 SAARC nations account for 27.55% of the total global new TB cases. An estimated 511679 people (36/ 100 000) died from TB in 2003, including those co-infected with HIV (22969). More than 75% of these cases and deaths occur among 15-54 years age group, economically the most productive age group. As a result the social and economic loses due to TB are huge.
By adopting DOTS strategy this region has been started to show success in TB control. By the year 2003 this region has covered over 70% of its population with DOTS and detected 47% of the total estimated new smear positive cases. This region has already achieved the target of 85% treatment success rate of detected new smear positive cases. The treatment success rate for the 2002 cohort was 86%. Major challenges are however there in control of TB, such as
? Sustainability of quality in diagnosis and case management
? Spreading HIV infection
? Emergence of MD-R TB
? Migration & cross border issue
? Expansion of DOTS in hard to reach areas
? Improving the quality of implementation and making it more accessible in order to increases case detection
There is obviously commitment within this region for achieving TB control targets and nationwide DOTS coverage in each country by 2005. Given the current impetus and the additional resources required, the SAARC region will reach global targets between 2005 and 2006.
TB is a major barrier to social and economic development. More than 90% of global TB cases and deaths occur in the developing world, where 75% of cases are within the economically most productive age-group (15-54 years). An adult with TB (in the developing world) loses on average 3-4 months of work time and the economic losses to the family and community are staggering. The estimates suggest a loss of 20-30% of annual household income and, if the person dies of the disease, an average of 15 years of lost income5. Within India, every year, more than 300,000 children are forced to leave school because of their parents? illness due to TB, and approximately 100,000 women lose their status as mothers and wives i.e., abandoned by their families because of TB illness.
Prevalence of tuberculosis is defined as the proportion of population having tuberculosis expressed as percentage of total population. Service statistics data i.e. Annual Report produced by Department of Health Services is the only available source of data on
Tuberculosis. Data shows that prevalence rate was 0.09% in the year 1997. However, it remains constant (0.07%) from the year 1998-2000.
Similarly, proportions of tuberculosis cases detected under DOTS and cured under DOTS are also increasing over the years. Data shows that in 1997, only 50% of the cases were detected under DOTS which increased to 70% in the year 2001. Similarly, 61% cured rate under DOTS was found in the year 1997 which increased to 89% in the year 2001.
According to Annual Report 2003/2004, NTP, Nepal, the country has expanded the DOTS strategy to all the districts by July 2001 and now in the process of expansion of DOTS in each and every health institution. The programme has achieved the TB control targets of case detection and treatment success; as of July 2004 the case detection rate was 71%. The cure rate and the success rate for the previous Year?s (2003/2004) were 86% & 87% respectively.
Current Status of TB Control:
Following a review of the national tuberculosis programme in 1994, DOTS demonstration sites were established in April 1996. Impressive achievements have been made since then. The NTP has rapidly expanded the DOTS strategy from 1.7% in 1996 to 94% by July 2003. In fact, by July 2001, the DOTS strategy has been expanded to al the districts of Nepal. DOTS is now ( July 2004) running through the integrated general health services in 384 treatment centers and 1872 sub centers throughout the country. Now almost all diagnosed TB patients are getting treatment under DOTS strategy with more than 85% treatment success rate. The high treatment success rate of new smear positive cases has been sustained from the very beginning. The defaulter rate is declining now (3.6% in this year Vs 5% in the last fiscal year).
Further expansion of the programme covering the more inaccessible mountainous areas poses a challenge. Different types of approaches have been adopted in those areas. DOT by community volunteers, family members and I/NGOs has been found effective in some hill and mountain districts. A strong community base for DOTS has been achieved through the establishment of district and village DOTS committees that have been set up involving people outside the health sector. The NTP has coordinated with private sector, local government bodies, NGOs, social workers and other sectors of society to expand DOTS and sustain the present appreciable results achieved by the programme.
Recommendation:
♦Secure adequate external resources from donor countries and from NGOs.
♦ Ensure full staffing at all health facilities (especially at microscopy centers).
♦ Establish quality control for regional laboratories.
♦ Strengthen partnership with the private sector, medical schools and industry to further enhance DOTS implementation.
♦ Evaluate the impact of HIV/AIDS on the TB epidemic.
♦ Increase access to DOTS in the hard-to access mountainous regions.
♦ Establish, through bilateral and multilateral consultations, cross-border disease control services including DOTS in the border districts.
References:
1. WHO report 2005, Global TB control, Surveillance, planning, financing; communicable diseases, WHO, Geneva.
2. Treatment of Tuberculosis: Guidelines for national programmes, 3rd edition, WHO, Geneva 2003, p11.
3. World Health Organization, Fight AIDS, fight TB , fight now information pack, 2004, distributed in Stop TB Partners? Forum, New Delhi, 25 March 2004
4. Information Folder, World TB Day, 24 March 2005, WHO, SEARO, New Delhi. India
5. SAARC TB Centre, (January 2002), gender differences among TB patients in NTPs within SAARC member countries.
6. Ahlburg D. The economic impacts of tuberculosis. Geneva, WHO, 2000 (document WHO/CDS/STB/2000.5, http://www.stoptb.org/conference/ahlburg.pdf
7. TB in India 2001. RNTCP Status Report, Central TB division, DGHS, MoH&FW, Nirman Bhavan, New Delhi 110011, p7.
8. SAARC TB Centre, (October 2004), Tuberculosis in the SAARC region, an update 2004
9. WHO report 2004, Global TB control, Surveillance, planning, financing; communicable diseases, WHO, Geneva
10. Annual Report 2002/2003, NTP, Nepal
11. Country presentation (Sri Lanka ) at regional Managers? meting 2004, 9-11 Feb 2005, New Delhi)
12. Country presentation (Bangladesh ) at regional Managers? meting 2004, 9-11 Feb 2005, New Delhi)
13. Country report, Bhutan, presented in trainers training on TB control Programme management, 10-19 May 2004, Dhaka.
14. Tuberculosis in the South ?East Asia Region- An Update. WHO, SEARO, New Delhi, November 2002
15. Country presentation (Bhutan ) at regional Managers? meting 2004, 9-11 Feb 2005, New Delhi)
16. Country presentation (Maldives ) at regional Managers? meting 2004, 9-11 Feb 2005, New Delhi)
17. Country Report, Maldives, Presented during Work shop on TB drug management and Guidelines for MDR-TB , 29-31 July,2004, Kathmandu
18. Annual Report 2003/2004, NTP, Nepal
19. SAARC- A Profile, SAARC Secretariat, Kathmandu. Updated: July 2003, Published by Media, Publications and Human Resources Development Division, SAARC Secretariat, P.O. Box 4222, Kathmandu, Nepal. P-1
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