Tim Cummings, Almaty
As Directly Observed Therapy Short-course (DOTS), the tuberculosis treatment system recommended by the World Health Organization, is introduced in Central Asia, a growing public health concern is the large numbers of patients who fail to complete their course of treatment.
As the entire treatment is over six months long, getting people to finish all their medication can be a challenge, because once patients begin to feel better, it becomes very tempting for them to stop.
Incomplete treatment is suspected to be one of the major causes for the spread of multi-drug resistant (MDR) forms of tuberculosis in the region. MDR forms of TB are difficult and costly to treat and can create a huge burden on health care systems in developing countries.
The number of multi-drug resistant tuberculosis cases in Central Asia and Central Europe is ten times higher than in other parts of the world. The problem has been compounded by the rapid spread of HIV in these regions.
In Kyzyl-Orda, Kazakhstan there is a serious tuberculosis epidemic and the issue is being taken seriously.
To address the public health crisis there, the Kazakh Red Crescent Society, supported by the American Red Cross and the International Federation, has joined the US-based Centers for Disease Control and Prevention and USAID to carry out a research study on the effectiveness of multiple forms of low cost, patient-oriented incentives for improving patient compliance rates with DOTS.
These incentives include a hot meal, a small cash payment and visits from specialized Red Crescent nurses, who support patients with education and advice throughout the treatment period.
According to WHO data, in areas of minimal or no MDR-TB, DOTS achieves cure rates of up to 95 per cent, rates high enough to dramatically reduce the TB burden while preventing the emergence of drug-resistant TB.
The Red Crescent Red Cross study in rural and urban areas of Kyzyl-Orda province will contribute to public health knowledge of effective strategies for ensuring that TB patients take their drugs regularly, on time and for the full duration of their treatment.
One of the problems that increases the rates of DOTS treatment non-compliance is poverty, which is widespread in some areas of Central Asia.
“DOTS treatment is intensive and requires on-going commitment and responsibility from each patient,” says Dr K. Iskakov, Chief Doctor of Kazalinsk TB Hospital.
“During the intensive phase we keep patients in hospital, provide them with necessary medication and food. Often patients don’t want to leave the hospital after two months of intensive treatment to return to their poor living conditions. Sometimes if the hospital has an opportunity, it keeps them institutionalized because people cannot afford healthy food or to keep their houses warm.”
Because the study provides incentives for people to continue their treatment, they are more likely to finish it and get cured. “Now I can have at least one hot meal after I take my medication. I live alone and it is hard for me to cook. The food is very good, tasty and always hot,” says Farkhad Aliakbarov, one of the participants of the study.
Giving out 50 tenge, equivalent to 30 US cents, to a patient for each visit to the DOTS corner mainly helps to cover transportation expenses. Kozhatmekhkyzy Aliya, who lives close to the clinic, says she uses the money for buying basic food - bread, rice, noodles. “We should be very thankful for the treatment and assistance that are free of charge,” she says.
To prevent a patient halting their treatment prematurely, the Red Crescent Society of Kazakhstan together with the American Red Cross provides a visiting nurse service for those who are housebound and cannot visit the DOTS centre to take their medication.
The nurse brings the medication to their home and makes sure it is taken, offering educational or moral support, as well as psychological counselling to patients and their families, who often have to endure months of hardship while members of their family undergo treatment.
Raising public awareness is also a key factor in the campaign to halt the spread of TB. To remind commuters about the risk of infection, the Kyzyl-Orda Red Crescent branch has placed on each public transport minibus the WHO’s slogan for this year’s World TB Day: “Every breath counts. Stop TB now!”
“It is through public awareness and understanding of the disease, that we can mobilize the community to reduce its impact,” said Olga Kim, American Red Cross TB study manager.