Posted by Duncan Maru
Peptic ulcer disease, a condition in which the lining of the stomach is damaged, is commonplace throughout the world. If left untreated, peptic ulcer disease can lead to severe disability and, if an ulcer ruptures, death. Helicobacter pylori is the bacterial cause of this condition. H. pylori is also a definitive cause of stomach cancer and is classified as a group I carcinogen by the International Agency for Research on Cancer. Infection is related to sanitary conditions, with infection rates several times higher in developing countries than in developed ones. Over half of the world’s population is infected.
A public health strategy of testing and treatment can effectively prevent most of the damage that the microbe causes. A two-week course of antibiotics and antacids can be as high as 90% effective in curing h. pylori infection. Nyaya has just initiated a helicobacter pylori control program that involves screening of patients who present to the clinic with gastric complaints for infection and then treating those who test positive. As with all of our programs, we focus on simple-to-use clinical forms integrated with our electronic patient database. We use this for program monitoring and evaluation. The English-language form is available at this link:
Our screening protocol is available at this link: http://nyayahealth.org/Library/nyaya_protocol_gerd_dyspepsia
For testing for infection, we are using Quidel corporation’s rapid serum test kit. This tests for previous infection by assessing the presence of antibodies that the body has produced to fight the infection. This technology is not available in Nepal, and we are relying upon Quidel’s genereous donation of 1800 kits, which should be sufficient for the first year of our program. At the end of treatment, we ask patients about their symptoms to assess cure, since presently we do not have access to the test-of-cure technology. This technology is based on detecting antigens, or components of the h. pylori itself rather than the body’s response to infection. We hope to add this test on once resources become available.
This program is part of Nyaya’s overall “diagonal” strategy of building a comprehensive primary care system by adding on disease-specific programs to our general healthcare infrastructure. The problem with exclusively “vertical” programs, where disease-specific programs for TB, HIV, maternal care, and vaccinations run largely independent of each other, is that they fail to build an integrated health system capable of meeting a population’s evolving health problems. The benefit of such programs, however, is that they have well-defined budgets and public health outcomes. Fully “horizontal” programs, on the other hand, where a generalist primary care team is expected to address whatever comes through the door, are plagued by wasteful expenditures on conditions that are not necessarily public health priorities.
H. pylori is an excellent test case for our model, since h. pylori is a readily testable and treatable condition and it is associated with a very common symptom– dyspepsia. In the first several months of our clinic’s operations, dyspepsia was an exceedingly common condition for which we spent large amounts of money– 20,000 nepali rupees (about $260) on antacids in the month of august alone. The bulk of these prescriptions, while providing some symptomatic relief, would not alter the course of patients’ underlying conditions or achieve any public health benefit. As a free clinic, this did not make economic sense. After reviewing our pharmaceutical expenditures, we decided to stop the practice of dispensing these medicines. But this strategy left many of our our group, interested as we are in healthcare justice and equity and wanting to provide meaningful clinical care to our patients, frustrated that we could not be providing effective treatment to at least some of the patients who were presenting with dyspepsia. Now that we have started to screen and treat for h. pylori, we can now provide meaningful, disease-modifying care to these patients.