Kazakhstan and the United States Tackle Drug-resistant TB
Dr. Adenov Malik Moldabekovich is the Director of Kazakhstan’s National TB Program. Since graduating from the Almaty Medical University in 1994, he has dedicated his career to Kazakhstan’s fight against TB.
Kazakhstan’s TB Epidemic
According to the World Health Organization (WHO), TB is endemic in a country when the prevalence is more than 50 per 100,000 people. “Over the past few decades, the TB epidemic in Kazakhstan has been on a steady decline. Due to the successful implementation of WHO recommendations, Kazakhstan’s peak TB infection rate of 162.5 per 100,000 of the population in 2002 is down to 49.2 per 100,000 in 2020,” says Dr. Adenov.
Since the early 2000s, Kazakhstan’s TB incidence rate has fallen by an average of 8-10 percent per year. In 2020, there was a 24.6 percent decline from the previous year, however, this is not due to program success. “We suspect that the drop was due to the COVID-19 pandemic; patients were isolated, they were staying at home, they couldn’t visit health facilities, and consequently case findings went down. That explains the dramatic drop,” says Dr. Adenov.
TB Detection
In 1999, USAID began a pilot program to implement the WHO-recommended Directly Observed Treatment Short (DOTS) Strategy in Kazakhstan. Over the next decade, USAID helped scale the strategy nation-wide.
“DOTS improved overall diagnostics, registration, recording, and reporting of TB. Before DOTS, the prevalence was around 70 per 100,000 of the population in 1999. The spike to 162.5 per 100,000 in 2002 was due to improved detection of the number of patients,” says Dr. Adenov. “USAID helped institutionalize the guidelines and policies to roll out the DOTS strategy and trained TB specialists and medical workers on WHO-recommended detection and treatment regimes, building the country’s human capital to fight TB,” adds Dr. Adenov.
A drop in TB mortality rates is a significant benchmark in the fight against TB. “In 1999, the mortality rate was 39.8 per 100,000 of the population. In 2020, it was 1.9 per 100,000,” says Dr. Adenov.
Rise of Drug-Resistance
Unfortunately, Kazakhstan is among the 30 countries in the world with the highest burden of multidrug-resistant tuberculosis (MDR TB). Drug-resistant TB occurs when bacteria become resistant to first-line TB treatment drugs. Extensively drug-resistant TB (XDR TB) is a rare type of MDR TB that is resistant to two of the most effective first-line drugs and at least two second-line anti-TB drugs.
Dr. Adenov lists the factors that led to the rise in drug-resistant TB in Kazakhstan. “First, after the fall of the Soviet Union, only one or two of the four WHO-recommended TB drug and treatment regimens were available. Not all drugs for proper treatment were available in the country.”
“Second, poor treatment adherence by patients. Since there was no national system to track treatment, some patients would stop treatment when they felt better instead of completing their full course.”
“Third, weak laboratory testing. Drug susceptibility testing methods were outdated and time-consuming, taking an average up to 70 days to detect drug-resistance. As a result, sometimes treatment would begin with standard TB treatment and later switch to appropriate treatment once drug-resistance was detected. Late diagnosis of drug resistance led to a phenomenon called amplification, when resistance is developed to additional drugs, not just to drugs resistant at the beginning of the treatment.”
“And finally, lack of public awareness. Not recognizing the early signs, patients would only seek treatment once TB was extremely severe, having spread throughout the lungs and other organs, making it hard to cure.”
U.S. Interventions
USAID has been a steadfast partner with the National TB Program since 1999 with the introduction of the Directly Observed Treatment Short (DOTS) Strategy.
In 2007, through the U.S.-supported Global Fund, Kazakhstan received Becton Dickinson MGIT-960 machines, enabling liquid culture drug susceptibility testing, bringing down drug resistant TB detection from 70 to 40 days and later, on average to a month. However, even a month’s wait for a diagnosis is too long. “During this one month, drug-resistant TB patients would receive inappropriate treatment compounding amplification,” says Dr. Adenov.
From 2008-2013, USAID helped introduce a national registration system that recorded culture tests in an electronic database, enabling centralized monitoring, quicker, appropriate treatment, and tracking of results.
In 2008, with USAID assistance, Kazakhstan introduced MDR TB treatments which over time showed encouraging results. However, it also led to a rise in XDR TB. Annually, there were around 800-900 XDR TB patients, of which approximately 40 percent were being cured, a low success rate.
In 2012, USAID introduced GeneXpert machines, that detect drug-resistance within hours rather than weeks, enabling patients to get on the right treatment immediately. In 2018, USAID donated 50 GeneXpert machines through the USAID Global Accelerator to End TB to Kazakhstan, resulting in universal access across the country. “GeneXpert machines were even installed in rural areas. By 2019, the entire country could benefit from rapid drug susceptibility testing,” adds Dr. Adenov.
In 2016, through a pilot program, USAID introduced Bedaquiline, a new drug-resistant TB treatment in Kazakhstan. Thanks to an 80 percent treatment success rate, Bedaquiline was made available across the country. Consequently, XDR TB is on the decline. Kazakhstan currently has a total of 285 XDR TB patients.
With the introduction of new TB drugs, XDR treatment time has reduced from up to 32 to 36 months to 18 months, and MDR treatment time is down from 24 to 9 months.
Funding Kazakhstan’s TB Program
The Ministry of Health funds 95 percent of the country’s TB program. International donors including USAID, account for 5 percent of the budget. “But this 5 percent is very critical. It supports research and innovation and the introduction of new pilot programs. After USAID introduces a new pilot and has promising results, it presents the proof of concept to the Ministry of Health, which then provides funding to roll out the program nation-wide,” says Dr. Adenov. “USAID plays a vital role in introducing scientific innovation and cutting-edge technologies to Kazakhstan’s National TB Program. I hope for this reason, USAID will continue to partner with us in the fight against TB.”
Eliminating TB
Dr. Adenov is hopeful that one day Kazakhstan will eliminate TB from the country. “But it’s a daunting task because of the prevalence of latent TB which is hard to detect. Perhaps by 2030, we will be close to achieving this vision.”
Kazakhstan has made great strides to defeat TB and yet there’s more to be done. The desire to end this epidemic keeps Dr. Adenov motivated. “This is my country. I feel responsible for its future. Throughout my career I’ve seen that TB can be controlled and cured. I believe we will one day finally beat TB,” says Dr. Adenov.
ABOUT THIS STORY:
In 2021, the United States is celebrating 30 years of diplomatic relations with Kazakhstan. The American people, through USAID, have invested more than $700 million in Kazakhstan since 1992. This story highlights U.S.-Kazakhstan decades' long partnership in the fight against TB. #USKZ30 #KZUS30
Narrative: Hazel Correa, Sr. Regional Development Outreach and Communications Coordinator, USAID Central Asia
Виктор Магдеев для USAID