Central Asian Republics

Among the Central Asian Republics (CAR), which comprises Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan, it is Tajikistan that has the highest tuberculosis (TB) incidence rate. According to the World Health Organization’s (WHO’s) Global TB Report 2009, Tajikistan has an estimated 231 cases per 100,000 population, and had the highest mortality rate of 46 per 100,000 population in 2007. Although there have been impressive gains in TB control and prevention, much remains to be done to reduce the threat of this serious infectious disease in the region.

Between 1991 and 2001, the number of reported TB cases in the region increased drastically, especially in prison populations. Since 2001, reported cases have declined in Kyrgyzstan and Kazakhstan but have continued to increase, along with DOTS (the internationally recommended strategy for TB control) expansion, in Tajikistan, Turkmenistan, and Uzbekistan. Multidrug-resistant (MDR) TB has become a serious problem. Tajikistan had the third highest proportion of MDR-TB globally (16.3 percent of newly diagnosed cases). Uzbekistan, Kazakhstan, and Kyrgyzstan had the fifth, sixth, and seventh highest proportions, respectively, ranging from 14.8 to 13.4 percent. HIV prevalence among TB patients remains limited, ranging from 2.0 and 4.0 percent in all countries.¹

TB trends and indicators in the CAR reflect the deterioration of health care systems and increased poverty since the breakup of the Soviet Union in the early 1990s. This breakup facilitated the spread of infectious diseases, including TB and MDR-TB, in many former Soviet republics. The newly independent CAR were unable to sustain the previous TB infrastructure and are in need of new solutions to combat the growing TB problem. Labor migration from Kyrgyzstan, Tajikistan, and Uzbekistan to Kazakhstan and Russia is possibly fueling the epidemics, but real prevalence among this risk group is unknown. Other system challenges include poor TB infection control; weak integration between civic and prison systems, ambulatory and inpatient services, and TB-HIV services; as well as a lack of social support for TB patients. Case detection has steadily improved under DOTS in all countries except for Kazakhstan, where estimated incidence is also declining, but only Turkmenistan has met the WHO target of 70 percent. In Tajikistan, case detection has reached only 30 percent. In recent years, Turkmenistan, Kyrgyzstan, and Tajikistan met the target for DOTS treatment success rate (85 percent), although they have all declined slightly in 2007. Uzbekistan’s treatment success rate has remained around 81 percent over the past four years, while Kazakhstan has seen declines in treatment success since 2002. Kazakhstan has the highest failure rate among new sputum smear positive (SS+) cases in the 2006 cohort, at 16 percent, while Uzbekistan has the highest default rate, especially among SS+ retreatment cases in the 2006 cohort, at 13 percent. According to Default from Tuberculosis Treatment in Tashkent, Uzbekistan, a published study conducted by Project HOPE in Uzbekistan, the defaulter rate among all SS+ and SS negative cases in the 2005 cohort in Tashkent was 21 percent.

USAID Approach and Key Activities

Since 1998, USAID has supported the fight against TB in the CAR by helping the governments of these countries implement DOTS. USAID activities for TB control and prevention in the CAR now cover more than 50 percent of the total population. USAID has launched a five-year, $15 million TB control program to strengthen surveillance, laboratory quality, and rational drug management in the region’s reforming health care systems. USAID has worked regionally to facilitate the creation of multisectoral high-level working groups that coordinate TB control activities in a range of priority areas, including DOTS expansion, drug management, prison health systems, management of TB-HIV/AIDS co-infection, and MDR-TB. In fiscal year 2008, USAID funding for TB programming in the CAR totaled was almost $4.0 million for the five countries. USAID assistance includes support for the following activities:

• Supporting development of TB infection control strategies in all five countries in the Region
  
• Strengthening National TB Control Program (NTCP) management in all countries
• Increasing the human resources capacity to respond to the TB epidemic in Central Asia
• Building capacity to address MDR-TB and TB-HIV/AIDS co-infection
• Advocating for government support for the inclusion of TB in national health budgets, including funding for capacity building of the NTCP
• Building better information and logistics systems
• Improving laboratory networks through external quality assurance systems
• Supporting community advocacy and mobilization, including developing national behavior change communication strategies for the general population and risk groups
• Developing approaches to bring DOTS to special populations (e.g., prisoners) and strengthening civilian sector linkages for TB control

USAID Program Achievements

USAID support has improved the capacity to implement DOTS region-wide. Achievements include:

• Improved political support to the NTCPs in the region
• Assisted in developing proposals for grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria
• Implemented an electronic surveillance and case management system in all countries and trained specialists on the system
• Introduced laboratory quality assurance system for smear microscopy
• Improved the logistics management information system for drug management in all republics of the region.
• Provided technical assistance to countries in their applications to the Global TB Drug Facility, which enabled pediatric anti-TB drugs to become available to all countries in the region – with the exception of Uzbekistan – for the first time
• Implemented a small grants program in Tajikistan, Kazakhstan, and Kyrgyzstan to build capacities of civil societies to control TB and to expand the reach of information throughout the countries, resulting in more than 10,000 schoolchildren in Kyrgyzstan being reached with TB prevention education
• Improved the integration of TB control activities into primary health care (PHC) and updated a six-month PHC retraining curriculum with essential TB-DOTS topics
• Supported training region-wide since 1997, in collaboration with the Global Fund, for 5,080 TB specialists, 6,957 PHC staff, 1,151 laboratory staff, and 6,251 other health staff
• Equipped the TB laboratory and trained medical specialists in one district in Turkmenistan and provided educational materials and equipment for a new national training center
• Equipped the national laboratories in Tajikistan and Turkmenistan and a laboratory in Karaganda, Kazakhstan
• Improved management of TB-HIV/AIDS co-infection through collaboration of services in four countries
• Developed a successful model for case management of MDR-TB in Almaty City, Kazakhstan, which facilitated development of 12 standard protocols on various components of MDR-TB management, including diagnosis, treatment, and direct observation of drug use protocols, which are now institutionalized for nationwide use and will be used as a best practice example for regional scale-up

Partnerships

USAID is the leading donor supporting DOTS implementation in the CAR. USAID’s partners include CAR national governments, the Project HOPE Consortium (Project HOPE, the Johns Hopkins University’s Center for Communication Programs, the New Jersey Medical School Global Tuberculosis Institute, and John Snow, Inc.), WHO, the U.S. CDC, Abt Associates, Management Sciences for Health, the Gorgas TB Initiative, the KNCV Tuberculosis Foundation, and Catholic Charities. The Global TB Drug Facility has provided first-line drugs to Tajikistan and Uzbekistan. The Global Fund provided Round 6 grants to Kyrgyzstan for $4.2 million and to Tajikistan for $6.5 million to enhance DOTS implementation and strengthen the NTCPs. For Round 8, only Uzbekistan, Kazakhstan, and Tajikistan have been approved for $55.5 million, $77.5 million, and $12 million, respectively, for the next five-year program (2009–2014), which will mostly address MDR-TB.

1 Data for Turkmenistan not available

June 2009

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Related Links

• Information on USAID's Programs in the Central Asian Republics