How to reach the missing three million
Ma Khine Khine Win receives TB advice from an outreach health worker.
By Naomi Mihara
Ma Khine Khine Win could easily have become one of the missing three million. Born and raised in a small village in Tharyarwati township, Bago District, Myanmar, she moved with her family to join other migrants seeking work in a village in Kyaikmayaw township, Mon state – over 300 km away. She knew she was suffering from poor health, but poverty prevented her from accessing health care.
“I had had a cough off and on since before leaving my home village, which never really went away. After arriving at [her new village] Taungkalay, I gradually began to lose weight, felt constantly fatigued from the hard work and had a prolonged fever. My cough became worse, even though I didn’t have a sore throat, and I noticed blood tinges in my sputum. But, without a penny, how could I get a consultation from a private clinic?”
Thankfully, her village was visited by trained health workers, who knew that migrants are especially vulnerable to TB and often lack access to diagnosis and treatment services. “My symptoms sounded similar to the ones I heard about in a health talk at the village and made me wonder if I was a suffering from TB”, Ma Khine explains. After contacting her village mobility working group – a health support group made up of other residents, community leaders and local employers – she was put in touch with an outreach health worker, who helped to test her sputum. “After the result came out positive, she told me not to worry and how to cope with the daily lifestyle and side effects of six months of drug taking.”
The World Health Organization estimates that a third of the nine million people who fall ill with TB each year miss out on diagnosis and treatment. The Asia-Pacific region, home to over 60 per cent of the world’s TB cases, is also known for high levels of cross-border and internal migration. Poverty, social stigma and lack of health system awareness all contribute to the fact that migrants are less likely to access testing services.
Sahadev in front of the GeneXpert Centre in Biratnagar, Nepal.
Another major reason why many TB cases end up being missed is the shortage of affordable, reliable diagnosis technology. “The best way to control TB is early detection,” explains IOM Thailand’s Chief Medical Officer, Dr. Olga Gorbacheva, who has worked on TB programmes across the region. Though cheap, the traditional method of detecting TB via microscopic analysis of sputum is prone to failure in developing countries with limited resources, as it has low sensitivity and requires skilled lab technicians to carry out properly.
Such was the case for 35 year old Sahadev Yadav, who lives with his wife and two children in Biratnagar, Nepal. He began to suffer from a sustained cough, diarrhea, abdominal pain, chest pain and fever. After numerous misdiagnoses, he heard on local radio about a new kind of testing. The equipment, known as GeneXpert, is highly sensitive and returns a result within two hours, as opposed to sputum microscopy which takes several days. Although microscopy indicated a negative result, the GeneXpert test confirmed that Sahadav indeed had TB and he was enrolled for treatment. After six months, all of his symptoms had disappeared.
The use of GeneXpert technology in Nepal is part of an ongoing project by IOM and the Stop TB Partnership to aid the country’s National Tuberculosis Programme (NTP) in improving TB diagnosis, focusing on impoverished, vulnerable and hard-to-reach populations. The technology can simultaneously diagnose both TB bacteria and rifampicin resistance (drug resistant TB). In addition to providing the new equipment, the project trains local health staff in the most up to date methods of laboratory detection. “When the programme winds down, the national TB programme benefits from highly trained specialists in diagnosis,” explains Bishwa Rai, Project Coordinator for IOM Nepal’s TB Reach project.
Globally, TB has been on the decline for the past two decades but several worrying trends threaten this progress. One is the proliferation of multidrug-resistant TB due to poor drug adherence – a significant problem amongst migrants – and another is the inroads the disease is making among mobile and hard-to-reach populations. The WHO estimates a current annual funding shortfall of $1.6 billion for low and middle income countries’ fight against TB. Combatting the disease depends on reaching the missing three million, and to do this, the gap in funding for technology, training of health workers and establishment of community support services must urgently be addressed.