DOTS implementation in complex emergencies –Somalia’s experience

( Dr Firdosi R Mehta, MO STB & Dr N. Mojadidi WR, WHO Somalia)

Background and Epidemiology

Tuberculosis is endemic in Somalia and is one of the leading causes of morbidity and mortality. Aside from security TB in Somalia is reported as the greatest barrier to stability and economic development. The civil war caused an unprecedented collapse of the national TB Control Programme.

The Programme was supported in its initial stages by FINDA (Finish International Development Agency). Subsequent attempts to support TB have been supported by WHO in collaboration with International NGOs. In 1986 FINDA conducted a Tuberculin survey in Kismayo, Burao and a refugee health unit. The results for children over 10 years showed a high annual risk of infection – 3.66%, 3.08% and 4.9% (Clinic Infect Dis. 1994 Jan; 18(1): 106).

In a refugee camp in 1989,  of all adult deaths were due to TB. In two camps in eastern Sudan in 1990, 38% and 50% of all adult deaths were due to TB (WHO/TB/97.221).

Somalia is estimated to have one of the highest incidence rates of TB in the world. It is estimated that each year, around 12,000 sputum positive cases occur, out of which only  are detected and receive treatment in a supervised DOTS Programme. TB can be considered a major public health problem in Somalia, affecting the most productive age groups of the community.

TB Control Strategy

The strategy used at all the TB centres is DOTS. All 5 components of the DOTS strategy are implemented in Somalia; WHO and INGOs are committed to TB control in Somalia. WHO appointed a full time MO for TB in '98. WHO produced and distributed TB treatment guidelines in 1994.

Case finding is mainly passive, though smear microscopy and DOTS is practiced strictly in all implementing centres. Patients are observed daily by a health worker at the clinic. A system of appointing a guarantor at the start of treatment helps in assuring compliance. Quality drugs are procured by WHO and distributed to all centres. WHO recommended recording and reporting procedures are in place.

TB Control activities.

Ten international NGOs and one individual presently support and operate 16 TB centres in 11 out of 18 regions giving a DOTS coverage of approximately 56%. DOTS coverage has increased from 45% in ’98 to 56% in end ’99 under the leadership of WHO’s revitalization policy for the TB program in Somalia. Using regular budget funds WHO has been providing laboratory support, training, anti-TB drugs and limited laboratory quality assurance to these programs. All these programs have fully implemented the DOTS strategy and have achieved remarkable results under extremely difficult situations. The location and population covered is given in table 1 below.

Table 1: Location and catchment Population of TB centres

Location / Region / NGO /
Est. Population

Adale

/ Middle Shabelle / ADRA/SAACID / 451,300
Boroma
/ Awdal / Annalena Tonelli / 147,300
Berbera / Galbeed / COOPI / 336,000
Burao / Togdheer / COOPI / 248,400
Bosasso

Gardo

/ Bari / Mercy Intl.
AAH / 247,400
Hargeisa
/ Galbeed / KJRC
Las Anod / Sool / NPA / 66,300
Mogadishu / Benadir / Mercy Intl. / 752,000
Mogadishu
/ Benadir / ADRA/SAACID
Jilib / Middle Juba / Mercy Intnl / 205,900
Kismayo / Lower Juba / MSF- B / 300,200
Luuq
/ Gedo / AMREF / 358,400
Abuudwaq / Galgadud / AMREF / 200,800
Garbahare
/ Gedo / MEMISA
Belethawa / Gedo / TROCAIRE
Total (16) / 11 / 10+1 / 3,314,000

Case notification and trends.

During 1999, a total of 4784 cases of TB (all forms) were reported (table 2). During 1995, 1996, 1997 & 1998, 2504, 3920, 4450 & 4320 cases were reported (all forms).

DOTS is practiced strictly in all implementing centres. A system of appointing a guarantor at the start of treatment helps in assuring compliance.

As can be seen from the notification figures in table 2, the number of SS+ cases being detected and put on treatment, (the infectious pool) is increasing over the years.

The highest number of cases are in the most productive age groups of 15-44 years, and the ratio of males to females is 2:1.

Table 2: Case notifications

Year / Smear+ve / Smear-ve / Ex-pulm / Relapse / Others / Total
1995 / 1572 / 582 / 247 / 103 / 0 / 2504
1996 / 2894 / 366 / 394 / 266 / 0 / 3920
1997 / 3093 / 423 / 453 / 143 / 338 / 4450
1998 / 3121 / 442 / 328 / 172 / 249 / 4320
1999 / 3449 / 424 / 524 / 204 / 183 / 4784
The most productive age groups of the community (15-44 years) are most affected. Women seek treatment less than men.

DOTS Outcome

Remarkable progress has been made in a short span wherever TB centres are present, with average smear conversion rates of 92%, cure rates of 88% and success rates of 90%, reported in 1998 (Table 3) despite some centres being located in areas of conflict and insecurity. Table 4 shows that the overall cure rates have increased from 71% in 1996 to 88% in 1998.

Table 3: Treatment outcome reported by centre for all 4 Quarters

of 1998 (Jan – Dec).

TB centre/NGO /

Cured

(No./%) / Treatment completed /

Died

/ Failure / Defaulters / Transferred out / Total evaluated

Abudwak/AMREF

/ 37/97% / 0 / 0 / 0 / 0 / 1 / 38
Adale/ADRA / 11/92% / 0 / 1 / 0 / 0 / 0 / 12
Belethawa/TROCAIRE / 123/98% / 2 / 1 / 0 / 0 / 0 / 126
Berbera/COOPI / 217/76% / 29 / 16 / 3 / 13 / 7 / 285
Boroma/A. Tonelli / 849/91% / 3 / 40 / 2 / 28 / 7 / 929
Bosasso/Mercy Intnl / 103/80% / 0 / 11 / 4 / 10 / 1 / 129
Garbaharey/MEMISA / 103/90% / 0 / 4 / 0 / 4 / 3 / 114
Kismayo/MSF(B) / 185/84% / 1 / 9 / 15 / 3 / 7 / 220
Luuq/AMREF / 123/90% / 1 / 7 / 0 / 3 / 2 / 136
Mogadishu/Mercy Intl. / 386/90% / 0 / 17 / 8 / 17 / 0 / 428
Hargeisa/KJRC / 222/84% / 9 / 3 / 3 / 14 / 13 / 264
TOTAL / 2359
(88%) / 45
(2%) / 109 (4%) / 35
(1%) / 92
(4%) / 41
(1%) / 2681

Table 4: Treatment outcome results 1996-98.

Year

/

Success Rate

/

Cured

/

Treatment completed

/

Died

/

Failure

/

Default

/

Transferred out

1996

/

83%

/

71%

/

12%

/

5%

/

3%

/

8%

/

1%

1997

/

90%

/

84%

/

6%

/

4%

/

1%

/

4%

/

1%

1998

/

90%

/

88%

/

2%

/

4%

/

1%

/

4%

/

1%

Recording and Reporting

Treatment registers, treatment cards and laboratory registers are well maintained at most centres. In 1998, second half, new TB and laboratory registers were printed and distributed, in addition a wall chart on case definitions etc., was printed and distributed to all centres as a ready reference. An innovative quarterly TB Newsletter has been started by WHO in 1999, to act as a feed back & advocacy tool. 3 issues have been published & distributed till now.

Remarkable progress has been made in a short span, with conversion rates of 92% and cure/success rates of 88/90%.

Human Resources and training.

All centres have national staff supervising TB activities. Each centre has a laboratory technician and other paramedical staff. Five national doctors were provided with WHO fellowships to attend the IUATLD TB training course in Iran in 1997 and 4 doctors attended the same course in Arusha Tanzania, in ’98 & ‘99. In service training is provided by the WHO TB Coordinator & national coordinators.

The WHO/UNV laboratory supervisor has provided training and conducted quality control checks mainly in the NE and NW regions.

Private sector

TB drugs are freely available all over Somalia from drug retailers. TB patients who can not receive treatment at TB centres continues to access the private sector for medication. Inaccurate treatment and prescriptions are common.

Constraints

1.  Expansion of DOTS projects is dependent on the frequently changing security situation in the country.

2.  TB projects are often stopped due to discontinuation of donor support.

3.  Since there is no central government, there is no control over private practitioners and phamarcies. As a result TB treatment in the private sector is haphazard and indiscriminate. This may lead to dangerous increase in multi-drug resistance.

4.  Shortage of funds to procure an adequate and uninterrupted supply of TB drugs.

Conclusion

TB control in Somalia is challenging in the complex circumstances of political instability and insecurity. However, analysis of the DOTS outcome data collaborated by field supervisory visits suggests that DOTS is applied correctly at most centres and demonstrates that DOTS works as effectively in complex emergency countries such as Somalia.

Improving access, training the private sector, strengthening the capacity of national staff and advocacy for resource mobilization are of paramount importance to expand coverage and sustain the gains made already under TB control in Somalia.

DOTS works as effectively in complex emergency countries such as Somalia.

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