Multi-drug resistant TB – the big challenge

Starting point

In total in Pakistan around 161 million people live in an area of 803,490 square kilometres.

Thanks to a close-knit leprosy control system the number of new cases totals around 500 per year. However, around 7,000 people are disabled due to leprosy.

Every year tuberculosis causes approximately 70,000 deaths, around 270,000 people per year fall sick of the disease. According to WHO the country is among the 27 most affected states, meanwhile this holds true for MDR-TB (see glossary “TB”), too.

Annually approximately 15,000 patients contract this severe form of tuberculosis, the standard antibiotics do not work anymore. The treatment of MDR-TB is lasting longer and is more expensive than the treatment of the common tuberculosis. Besides, it has severe side effects.

The project

In Pakistan DAHW has been cooperating since 1965 with the Rawalpindi Leprosy Hospital which is managed by Dr. Chris Schmotzer. The basic and referral centre for leprosy has a catchment area of around 90 million inhabitants. Since 2001 the hospital has also been used as a treatment centre within the scope of the national TB control programme.

General project aims

•  Leprosy: diagnosis, treatment, follow-up care and further training of medical staff
• Tuberculosis: health education, DOTS, treatment of MDR-TB cases
• General health services

Activities

Leprosy: here all patients suffering from a complicated form of leprosy will be relieved, even those with severe concomitant diseases or in need of surgery. During regular skin camps held in the catchment area patients with skin diseases or paraesthesia are examined, treated or referred to a clinic for further diagnosis. In this way between 10 and 15 per cent of all new leprosy cases are detected.

Tuberculosis: The hospital cares for patients who are not covered by the network of the governmental TB programme. The hospital admits, for example, malnourished, severely sick people and very poor patients, who cannot be cared for at home. Patients suffering from extra pulmonary TB, for example vertebral TB, will be helped here.

The treatment of MDR-TB is gaining more and more importance. Since, up to now, there has only been a government programme for MDR-TB in Lahore and Karachi, even the government hospitals of Northern Pakistan are referring these patients to Dr. Schmotzer, unfortunately often much too late.

Patients suffering from this highly infectious TB are treated in two small isolation wards with four to five beds each, in order to avoid infection of other patients. By now there is a waiting list for admission to this ward.

Prevention: The team in Rawalpindi especially emphasises the education of the public and the training of health staff. This is the reason why up to now no patients and co-workers have been infected by TB while staying at the hospital.

To change a life

Saima M., 22 years old and teacher for disabled children, felt pains on her right side. She came to Dr. Schmotzer and got the diagnosis: tuberculosis. Immediately she was admitted to the ward and treated with antibiotics.

Besides the drug therapy her lung had to be punctured several times because one of the typical complications of TB had developed – the accumulation of water between pleura and lung – which had to be removed. Thanks to these measures Saima could be completely cured.

What was achieved in 2009?

DAHW supported the Rawalpindi Leprosy Hospital for a sum of 186,456 Euros, approximately 40 percent of its annual budget.

In Rawalpindi 925 patients were treated, among them 82 newly detected leprosy patients (nine percent were children and 13 percent already had visible disabilities) and 264 TB patients. All patients were treated successfully with MDT.

32 new patients with MDR-TB were admitted, six could finish their treatment and were cured and released. They received regular checkups. Twelve patients were suffering from severe concomitant diseases like diabetes, asthma and severe malnutrition which had to be treated additionally. With two patients unfortunately XDR-TB (see glossary “TB”) had to be diagnosed. 60 patients with extra pulmonary TB were treated and got supportive measures like physiotherapy.

Almost 150,000 students and teachers were visited and informed about the disease, approximately 2,300 medical doctors, students of medicine, paramedics and nurses participated in training courses.

Plans for 2010

The Rawalpindi Leprosy Hospital will continue to take care of the education of patients and their families to get the increasing rate of MDR-TB under control.

It is planned to extend the hospital by a ward with 25 beds and a training hall in order to improve MDR-TB treatment.

Risks for the project

Despite the extension, the fast growing number of MDR-TB patients is causing capacity problems for the hospital. The laboratory is lacking equipment as well as qualified co-workers to detect the pathogen promptly and reliably in the sputum of a patient. Furthermore, there are too few health institutions which are able to detect TB definitely and to treat TB comprehensively. This makes the number of complicated cases of TB grow continuously.

Tuberculosis in figures

Number of TB cases worldwide in the year 2008*