Tuberculosis in complex emergencies
In 2004 there were 9 million new cases and approximately 2 million deaths from tuberculosis (TB). Control programmes are difficult at the best of times, but the direct and indirect health and health-system effects of complex emergencies complicate these programmes to such an extent that many organizations choose not to implement them. However, as TB is recognized as a major cause of mortality in long-term complex emergencies, several agencies have taken up the challenge of establishing control programmes in these circumstances. They have met the WHO targets for successful programmes (to detect at least 70% of estimated new smear-positive cases and successfully treat at least 85% of all detected smear-positive cases) without increasing the rates of multidrug-resistant TB (MDR-TB).
This paper describes the key factors and the remaining challenges for successful tuberculosis control programmes in complex emergencies. A complex emergency is defined as “a humanitarian crisis in a country, region or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single agency and/or the ongoing United Nations country programme.”1 These emergencies are characterized by extensive violence and loss of life; massive population displacement; widespread damage to societies and economies; the need for large-scale, multifaceted humanitarian assistance; political and military constraints that hinder or prevent humanitarian assistance; and significant security risks for humanitarian relief workers in some areas.
Some 200 million people are believed to live in countries affected by complex emergencies. Almost all of these are developing countries which also bear the main burden of TB: approximately 80% of all TB patients live in sub-Saharan Africa and Asia.2 Humanitarian aid workers all over the world face the major challenge of controlling TB during complex emergencies that affect entire countries (e.g. Afghanistan, Democratic Republic of the Congo, Somalia, Timor-Leste) or parts of a country (e.g. Darfur, southern Sudan).
Situations that affect large civilian populations through war or civil unrest, food shortages and population displacement also result in excess mortality and morbidity. These are caused not only by violence, but also by preventable communicable diseases.3 Several of the direct and indirect effects4 of complex emergencies impact on TB control programmes: they interfere with the goals of identifying and curing TB patients, and may lead to the emergence of MDR-TB, thereby compromising – or at least complicating – future control programmes.
There are detailed descriptions of aid interventions during complex emergencies in many countries, including Afghanistan, the Democratic Republic of the Congo,5 Kosovo,6 Sudan,7 and Timor-Leste. However, TB control programmes are absent from most of these reports as humanitarian aid workers concentrate on the most obvious killers during the acute phase of a complex emergency: diarrhoeal diseases, measles, acute respiratory infections, malaria and other infectious diseases.8 As TB is not a visible killer in the acute phase it is rarely a priority in complex emergencies, and often is left for the rehabilitation phase.9 But complex emergencies include situations of chronic conflict and political instability, often covering entire countries for long periods, and health-care workers are forced to address issues beyond the immediate emergency. If TB is neglected it may quickly result in increased morbidity and mortality, as was demonstrated in Bosnia and Herzegovina10 and in Somalia.11 Health-care workers now recognize that TB (also HIV/AIDS) may be responsible for a relatively large proportion of deaths among both adults and children.12,13 TB is a major disease in complex emergencies14 and requires an appropriate public health response.15
By nature, TB programmes are multifaceted and complex. It is an additional challenge to implement these programmes in emergency situations that affect large numbers of a civilian population. Such situations produce constraints related to poor infrastructure, which is often destroyed; lack of human resources, often themselves affected by the emergency; and difficult logistics, sometimes complicated by security and/or ethnic issues. HIV/AIDS further complicates these programmes, as TB control generally is failing in high-HIV-prevalence settings.16 Failed treatments or, more frequently and worryingly, indigenous transmission have resulted in more people with MDR-TB. These patients require attention and resources that are rarely available in complex emergencies.
There are now well-established criteria for establishing TB control programmes in emergency situations.17 Yet often these programmes are postponed until after the acute phase, as it is considered impossible to follow the WHO-recommended DOTS treatment for the detection and cure of TB. This requires six months of treatment and the achievement of high cure rates. The difficult task of running a TB control programme is complicated when there is the chance of aggravating an already serious problem – by introducing or increasing the rates of MDR-TB. The Sphere Project, representing the opinion of many major aid agencies, produced a consensus document intending to set minimum standards.18 This document says that poorly implemented TB control programmes have the potential to do more harm than good, and warns programme managers about the public health risks of suboptimal programmes, i.e. programmes with < 85% cure rate and fewer than six months of treatment.19 Programme manuals for refugee situations describe minimal conditions and absolute contraindications for starting TB programmes20 in refugee settings. Often these are the hallmarks of a complex emergency, e.g. open warfare or a very unstable population, and also valid contraindications.
Public health workers who agree to the International Standards for Tuberculosis Care21 know the standards against which they will be held accountable. These may be difficult to achieve in situations affected by the constraints typical of complex emergencies. Confronted with requirements for high standards of care and bombarded with warnings about the risks of a suboptimal TB control programme, many aid agencies choose to wait until the situation has stabilized and to concentrate on more obvious and urgent health-care problems. But complex emergencies often last. Is it appropriate to delay when TB prevalence rates exceed 300 per 100 000 per year, and we know that absence of treatment, poor nutrition and general lack of services aggravate the situation?
In complex emergencies health-care workers are faced by TB patients and their problems on a daily basis, and these are difficult to ignore. The several organizations that have decided to take action against TB in such circumstances are reminiscent of the 1980s discussion about treating TB in refugee camps. Purists were alarmed that treating TB could be even contemplated in such inherently unstable situations. It took several bold individuals and several controlled trials to establish beyond doubt that TB could be treated in refugee settings,22,23 even in rather unstable conditions.24 These previously controversial practices are now accepted, and these experiences have led to official interagency guidelines.25
The refugee camp experience underpins the solutions for problems related to the lack of health-care services and the danger of interrupted treatments. Complex emergencies produce a major challenge to set up (or maintain) health-care structures in precarious conditions, often in situations with little or no effectual government. Often it is pointless to ask for political commitment as authorities not only have other priorities, especially in the initial phases of a conflict, but also may be unable to commit resources. Health infrastructures may have been destroyed, or those that remain may have staff with basic training only. TB control is complicated further by the concurrent epidemic of HIV/AIDS and the enforced movement of populations at short notice. Security problems hinder the logistics of supplying medicines and supplies on a regular basis, and make it extremely difficult to follow up patients regularly. Poor coordination between agencies with overlapping health programmes also may further complicate provision of health care.
The reconstruction of TB services has been described in the post-conflict phase as stressing coordination and collaboration9 or needing international support.26 Experiences from several ongoing complex emergencies (such as in Afghanistan or the Democratic Republic of the Congo) suggest that the major impediments to establishing national TB control programmes are: mobile populations; destroyed infrastructure; lack of coordination and/or interest in TB treatment; scarce and/or poorly qualified human resources; difficulties with communications and logistical support; and limited financial resources. However, these also suggest possible solutions.
DOTS is the cornerstone of the Stop TB Partnership.27 Can this five-point programme be applied in complex emergency situations? Certainly, there have been considerable advancements:Standardized short-course chemotherapy is now accepted universally. Case-management appears difficult but possible, while alternative treatment regimens are explored and evaluated.28 Progress has been made towards a regular uninterrupted supply of medicines, through increased funding and increased logistical capacities. Difficult-to-reach areas are much better served. Case detection through case-finding by sputum-smear microscopy examination of suspected cases has been carried out in complex emergencies. Innovative methods for programme supervision and evaluation have been developed. Government commitment, usually through a national TB programme, often is initially absent or impossible because of the nature of complex emergencies. Commitment from a lead agency may be a suitable replacement strategy. Health ministries need to be phased in as soon as possible; their absence in the initial phase of an emergency is no excuse for lack of participation at a later date. Community involvement strategies have proven their worth; most successful programmes cite the commitment of local communities as a key to success.Successful TB programmes have been reported from war-torn southern Sudan29 and during civil strife and post-conflict in Timor-Leste;30 programmes in Somalia also have reported important successes.31 The key factors for success in Somalia32 are remarkably similar to those described in the post-conflict situations:visible leadership by one agency effective partnerships and collaboration strong and flexible management that is adapted locally highly motivated individuals facilitating social network system and active community involvement.This evidence suggests that it is possible to implement successful TB control programmes in complex emergencies without compromising the success of programmes set up when the emergency phase is over and reconstruction begins. Success is dependent upon several basic principles being upheld and some innovative solutions being applied. There is evidence that success is possible even in the face of an HIV epidemic.33
Yet major challenges remain. It is still unclear how to run a successful TB control programme in a complex emergency in the presence of large numbers of HIV-positive patients, with the possible presence of large numbers of MDR-TB patients requiring treatment with second-line drugs (or continuation of pre-existing treatment as current TB programmes include the treatment of MDR-TB cases).
While there is no manual to cover complex emergencies, the interagency manual for TB control in refugee and displaced populations25 provides valuable guidance as the situations are often similar. These programmes contribute to the body of evidence needed to compile such a manual, and should ensure that the experiences of TB control in complex emergencies lead to the establishment of evidence-based programmes. ■
- OCHA orientation handbook on complex emergencies. New York: United Nations; 1999.
- Global tuberculosis control. Surveillance, planning, financing. Geneva: WHO; 2006.
- B Coghlan, BJ Brennan, P Ngoy, D Dofara, B Otto, M Clements, et al. Mortality in the Democratic Republic of Congo: a nationwide survey. Lancet 2006; 367: 44-51.
- A Zwi, A Ugalde. Towards an epidemiology of political violence in the third world. Soc Sci Med 1989; 28: 633-42.
- Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July 1994? Lancet 1995; 345: 339-44.
- PB Spiegel, P Salama. War and mortality in Kosovo, 1998-99: an epidemiological testimony. Lancet 2000; 355: 2204-9.
- E Depoortere, F Checci, F Broillet, S Gerstl, A Minetti, O Gayraud, et al. Violence and mortality in West Darfur, Sudan (2003-04): epidemiological evidence from four surveys. Lancet 2004; 364: 1315-20.
- MJ Toole, RJ Waldman. Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA 1990; 263: 3296-302.
- N Martins, PM Kelly, JA Grace, AB Zwi. Reconstructing tuberculosis services after major conflict: experiences and lessons learned in East Timor. PLoS Med 2006; 3: e383-.
- MJ Toole, S Galson, W Brady. Are war and public health compatible? Lancet 1993; 341: 1193-6.
- Sudre P. Tuberculosis control in Somalia. Geneva: WHO; 1993 (EM/TUB/180/E/R/5.93).
- S Accorsi, M Fabiani, B Nattabi, B Corrado, R Iriso, EO Ayella, et al. The disease profile of poverty: morbidity and mortality in northern Uganda in the context of war, population displacement and HIV/AIDS. Trans R Soc Trop Med Hyg 2005; 99: 226-33.
- P Salama, P Spiegel, L Talley, R Waldman. Lessons learned from complex emergencies over the past decade. Lancet 2004; 364: 1801-13.
- MA Connolly, M Gayer, MJ Ryan, P Salama, P Spiegel, DL Heymann. Communicable diseases in complex emergencies: impact and challenges. Lancet 2004; 364: 1974-83.
- FM Burkle. Lessons learnt and future expectations of complex emergencies. BMJ 1999; 319: 422-6.
- A Reid, F Scano, H Getahun, B Williams, C Dye, P Nunn, et al. Towards universal access to HIV prevention, treatment, care, and support: the role of tuberculosis/HIV collaboration. Lancet Infect Dis 2006; 6: 483-95.
- Connolly MA, editor. Communicable disease control in emergencies: a field manual. Geneva: WHO; 2005.
- The Sphere Project. Humanitarian charter and minimum standards in disaster response. Oxford: Oxfam Publishing; 2004.
- M Biot, D Chandramohan, JDH Porter. Tuberculosis treatment in complex emergencies: are risks outweighing benefits? Trop Med Int Health 2003; 8: 211-8.
- Médecins Sans Frontières. Refugee health: an approach to emergency situations. Oxford: MacMillan Education; 1997.
- International standards for tuberculosis care (ISTC). The Hague: Tuberculosis Coalition for Technical Assistance; 2006.
- SH Miles, RB Maat. A successful supervised outpatient short-course tuberculosis treatment program in an open refugee camp on the Thai-Cambodian border. Am Rev Respir Dis 1984; 130: 827-30.
- HL Rieder. Tuberculosis in an Indochinese refugee camp: epidemiology, management and therapeutic results. Tubercle 1985; 66: 179-86.
- T Mastro, R Coninx. The management of tuberculosis in refugees along the Thai-Kampuchean border. Tubercle 1988; 69: 95-103.
- Connolly MA, Gayer M, Ottmani S, editors. Tuberculosis care and control in refugee and displaced populations: an interagency field manual. Stop TB Department and Programme on Disease Control and Humanitarian Emergencies, WHO and UNHCR. Geneva: WHO; 2006 (WHO/TB/97.221).
- RF Doveren. Why tuberculosis control in an unstable country is essential: desperate TB patients embrace DOTS in Angola. Int J Tuberc Lung Dis 2001; 5: 486-8.
- Stop TB. Partnership. The global plan to stop TB 2006-2015. Geneva: WHO; 2006 (WHO/HTM/STB/2006.35).
- K Keus, S Houston, Y Melaku, S Burling. Treatment of a cohort of tuberculosis patients using the Manyatta regimen in a conflict zone in south Sudan. Trans R Soc Trop Med Hyg 2003; 97: 614-8.
- A Hehenkamp, S Hargreaves. Tuberculosis treatment in complex emergencies: South Sudan. Lancet 2003; 362: s30-1.
- N Martins, E Heldal, J Sarmento, RM Araujo, EB Rolandsen, PM Kelly. Tuberculosis control in conflict-affected East Timor, 1996-2004. Int J Tuberc Lung Dis 2006; 10: 975-81.
- WO Agutu. Short-course tuberculosis chemotherapy in rural Somalia. East Afr Med J 1997; 74: 348-52.
- Munim A. Summarised progress report on WHO-supported TB control programme in Somalia [internal document]. STB World Health Organization/Somalia; 2005.
- AJ Rodger, M Toole, B Lalnuntluangi, V Muana, P Deutschmann. DOTS-based tuberculosis treatment and control during civil war and an HIV epidemic, Churachandpur District, India. Bull World Health Organ 2002; 80: 451-6.
- International Committee of the Red Cross, 29 Layards Rd, Colombo 05, Sri Lanka.