Despite Bhutan’s laudable progress in the TB control programme

WHO: Despite Bhutan’s laudable progress in the Tuberculosis (TB) control programme over the years, the increasing number of multi-drug resistant TB (MDR-TB) poses a threat to the achievements made so far.

Therefore, to review the National TB Control Programme (NTCP), a joint external review mission comprising of experts from CDC, Atlanta and the World Health Organisation SEAR office are in the country as requested by the health minister.

The team accompanied by NTCP officials visited several dzongkhags to review present policies, organisational structure, planning, management and financing of TB programmes, and evaluate performance and progress of the implementation of NTCP activities. Besides, the team also reviewed monitoring and supervision, quality assurance of sputum microscopy, logistics and supplies including drugs, infection control, MDR-TB and HIV/TB interventions.

Simultaneously, the NTCP also updated its guidelines and strategic plan to ensure alignment with recent WHO recommendations and guidelines.

WHO Bhutan’s country representative, Dr Ornella Lincetto said that MDR-TB is dangerous for the patient and expensive for the health system. “In Bhutan, we’ve to change the strategy and reach out to each and every case of TB and ensure proper treatment and follow up,” she said. “Better case identification will be possible soon with the arrival of the geneXpert machines.”

Dr Ornella Lincetto said that WHO is fully committed to technically support the health ministry towards the battle against TB.

TB situation in Bhutan

Bhutan has a well-functioning health system and TB services are integrated within the overall health services covering the entire population and are free of charge.

WHO estimates TB prevalence rate based on the existing cases at around 196/100,000 population while the TB incidence rate of new cases is 169/100,000 population per year. The mortality rate due to TB is 12/100,000 population. The case detection rate for all forms of TB is 87 percent. Treatment success rate among NSP (new sputum positive) stands at 90 percent while for MDR-TB, it is achieved at 100 percent for a cohort of 10 cases. TB prevalence and mortality reduced by half as compared to 1990 figures achieving the Millennium Development Goals last year.

According to health officials there is a substantial increase in number of MDR-TB cases diagnosed and initiated on treatment today. Records show that in 2014, 61 MDR-TB cases were detected while last year 49 cases were detected and put on treatment.

Challenges

However, challenges remain. According to WHO, the proportion of MDR-TB among the new and re-treatment is five percent and 35 percent respectively and is significantly higher than the regional average of 2.2 percent and 16 percent.

Besides, TB patients are not completing the entire treatment course dutifully thus leading to MDR-TB. Slow progress in scaling up programmatic management of drug resistant TB and need for reliable TB estimates and revisiting quality of basic DOTS (Direct Observation Treatment, Short-Course) also pose challenges.

NTCP officials said that MDR-TB cases have been increasing every two to three years.

NTCP’s chief programme officer Tshewang Rinzin said that they wondered as to why there was an increase in cases but the epidemiological assessment findings revealed that the MDR-TB strain has been in the country for a long time and was now being detected with new technology in the public health laboratory.

“Cross transmission of MDR-TB is also taking place given the inadequate infection control measures in hospitals and by patients,” he said. “Before detection was based on the judgment of the treating physicians or clinicians.”

Health officials said it was difficult to manage MDR-TB as the drugs caused severe side effects, and in some cases, the treatment continued for more than two years. MDR-TB treatment is 100 times more expensive than the cost of treating normal TB. The treatment costs about Nu 180,000 per patient.

Causes and symptoms

According to WHO, TB is an infectious bacterial disease caused by Mycobacterium tuberculosis, which most commonly affects the lungs. It is transmitted from person to person via droplets from the throat and lungs of people with the active respiratory disease. In healthy people, infection with Mycobacterium tuberculosis often causes no symptoms, since the person’s immune system acts to “wall off” the bacteria.

The symptoms of active TB are coughing, sometimes with sputum or blood, chest pains, weakness, weight loss, fever and night sweats. Usually TB is treatable with a six-month course of antibiotics. However, if the patients discontinue treatment before the completion of six months, when TB is not fully cured, he/she can develop MDR-TB, which is a much more severe form of TB requiring expensive and long-term treatment.

Therefore, health officials said it is extremely important for the patients to be fully informed and supported in order to complete the treatment as prescribed.

The WHO SEAR is home to 26 percent of the world’s population, but accounts for 41 percent of the global burden of TB incidence. In the region in 2014, TB prevalence was estimated at 5.4 million (M) cases while around 4M new TB cases emerged in the year. Controlling the disease epidemic in the region is critical to ending the global TB epidemic, according to WHO.

Kinga Dema