Multi-drug resistant TB on the rise

Monicah Mwangi and Henry Kibira, Kenya 
(First published in The Star, Kenya on 3rd April 2013): When Jane Mwende noticed a swollen gland under the armpit of her 10-month-old baby, she never took it seriously. She thought it was a boil which would eventually clear.   “I took him for a check up and the doctor at a private hospital in Nairobi gave us some ointment to apply and said the infection should clear in a few days,” Mwende said.  This was however not to be. For about five months, Mwende moved from different hospitals trying to seek help for her son who was now beginning to lose weight. “I went to about six doctors and none of them seemed to get to the bottom of the problem.”  She visited a facility where she requested the doctor to conduct different check-ups on her son. The medic carried out multiple tests among them HIV, cancer, liver, kidney and chronic ailment examinations.  “That was a shocking moment for me.

While all the tests came out negative, TB read positive,” she says, adding that she could not believe it, since her son had been administered with the Bacille Calmette–Guérin (BCG) vaccine at birth. A Increasing cases of tuberculosis, especially multi-drug resistant ones continue to pose a challenge to the fight against the disease.  TB is an airborne disease that is transmitted among other modes, through sneezing, coughing and talking, and it is the number four highest killer in Kenya at six per cent of all deaths.

A total of 144 cases of MDR TB were recorded in 2011, up from the 58 in 2003, with most of the patients having difficulties accessing treatment.  Mwende recalls how paediatricians had earlier examined her boy and explained that it was a normal reaction which would subside with time.  However, the swelling continued and it burst open and pus started oozing from the wound. “This was the most devastating time of being a parent,” she recounts.  The doctor informed her that the TB was confined to the arm, but it was necessary for the baby to take drugs.

Mwende had no option but to start a six-month journey of administering the drugs.  The ministry of Public Health has now sent out an appeal to the public to be vigilant and watch out on resistance TB strands, as its drugs are expensive and not locally available.  The 2012 World Health Organisation TB Global Report estimates that Kenya, which is listed 13 out of the 22 countries that account for 80 per cent of total prevalence, has 3,400 cases.  “These figures are unacceptably high with major health implications,” Public Health PS Mark Bor says.

Bor appealed for more funding to enable the ministry tackle the disease.  He further called on patients who test positive to go for HIV/Aids testing, in addition to accessing medication, as the two diseases are interrelated.  With a strong message dubbed “Call for a tuberculosis-free Kenya,” and a slogan, “Adequate and Sustainable Financing to stop TB in my life”, Bor says the ministry requires over Sh1 billion to enable it roll out effective programmes that will bring TB infection rate to zero.  A cause for the increment in TB cases is attributed to the HIV/Aids pandemic.

Over 52 per cent of deaths from the viral disease reported have succumbed to TB complications.  Statistics reveal more males contract TB at 57 per cent, against females' 43 per cent, while majority of the cases go unreported.  Mwende's baby is half way through the long medication journey, but she still ponders how a vaccine she had pegged her hope on for prevention had backfired.

According to Dr Steve Graham from the Department of Lung Health and Non-Communicable Diseases in Australia, the reason that can lead to a child contracting TB after receiving the BCG jab could be due to immuno- suppression of its body.  He is calling on health experts to be more alert and to carry out vigorous investigations on children. “Better diagnostics are needed especially against forms of TB Like that of lymph nodes,” he says.  Graham further says a TB vaccine research is ongoing, but notes that nothing better than BCG has been developed.

To fight back the challenge, Bor says measures have been put in place to install 440 genexpert machines countrywide by 2016, which are expected to hasten the testing process.  He says the initiative will increase the number of MDR TB cases that will be diagnosed. Currently, there are a paltry 24 such machines, which have been hailed for reducing TB prevalence by two per cent.  Though now under control, TB had earlier been increasing at an annual rate of 12-16 per cent between 1990-2007, where it stagnated at more than 116,000 cases.  In 2012, a whopping 102,009 cases were notified to the ministry, though WHO thinks the figure only represents 85 per cent of the reality.

“Fifteen per cent of all TB were not detected and continue to infect more people, apart from causing useless suffering and death,” Bor says.  Graham says TB vaccine is still very relevant and it helps protect against severe and fatal forms of other diseases such as meningitis and leprosy.  He notes that in rare cases where a child is diagnosed with TB, even after receiving the jab, it could be due to the young one's low immunity that could be caused by it having HIV or chronic ailments.  He reiterated the importance of completing treatment. “Children tolerate TB drugs very well - better than adults and have low risk of toxicity. It is important that the treatment is completed even when the child seems better.”

Generally, BCG provides protection only against miliary TB and TB meningitis; the two severe forms of TB, common in children but not against pulmonary TB.  It is not safe for children with HIV, and it does not work against pulmonary tuberculosis – the most common and most infectious form of the disease. It also has no protective value in adults with TB.

Various controlled trials conducted over the years have revealed that the average protective efficacy of BCG in adults reaches 50 per cent and with an efficacy range from zero to 80 per cent protection.  The government has put up an isolation facility at Kenyatta National Hospital, which Bor hails. He says the initiative will enable caregivers reach out to more patients.

“This is a major milestone, since we now have a facility for handling cases that need to be treated in a hospital setup.”  He has called on well-wishers to partner with the government in erecting simple and easily affordable isolation facilities at county level, to ease the disease burden.   Proper ventilation and open space is vital in management and treatment of TB, which is rampant among the poor.

Monicah Mwangi and Henry Kibira, Kenya 
Citizen News Service - CNS
(First published in The Star, Kenya on 3rd April 2013)