Justice late is justice denied but still it is better late than never

Shobha Shukla, Citizen News Service - CNS
Dr Enos Masini
In December 2015, at the 46th Union World Conference on Lung Health in Cape Town, the TB Alliance (Global Alliance for TB Drug Development) and its partners had announced the availability of first-ever child-friendly fixed dose combinations (FDC) for treatment of drug-sensitive pediatric TB.

These water dispersible FDCs are formulated in correct WHO recommended doses and have a fruity flavour. While, the hitherto available child unfriendly and inappropriate TB treatment has been blamed for poor adherence, poor treatment outcomes and increased risk of drug resistance, the uptake of the new FDCs has been rather slow.

One year down the line, even though a total of 230,000 treatment courses have been ordered by over 30 countries, Kenya is the only country that has been able to actually roll them out through its public health program. 1st October 2016 onward each of the roughly 800 children diagnosed with TB every year in Kenya will be put on these new FDCs. Compare this with India - a country with the highest TB burden in the world. As of to date it has procured a mere 2000 doses which will be given to only TB-HIV co-infected children enrolled from December 2016 onward in ART centers at only 5 states of the country. It will take at least another 18 months (if not more) to roll out these FDCs in the entire country, as informed by Dr Amar Shah, senior consultant for Revised National TB Control Programme (RNTCP), Ministry of Health and Family Welfare, Government of India, at a meeting during the recent 47th Union World Conference on Lung Health in Liverpool.

What can we learn from Kenya?

Well, what made Kenya achieve where others failed? How was it able to prepare itself well in time to seize the opportunity by its horn, so to say, and accelerate its response to controlling childhood TB? Shared Dr Immaculate Kathure, Child TB Services Coordinator of the Kenya National TB Programme: “For Kenya, the journey started way back in 2009 when childhood TB was made part of it's National TB Programme. In 2010, as per WHO’s revised childhood treatment guidelines, an additional pill was added to the childhood TB regimen. This meant an increase in costs for procurement and storage for us. So since 2011 we were waiting for better drugs that would make the treatment simpler and more appropriate for children. And when in 2013, there were the earliest indications of the possibility of new drugs to be out in the market, with the help of technical support from TB Alliance, we started preparing our system to be able to receive them whenever they came out in the market.”  

Dr Enos Masini, Head of the National Tuberculosis, Leprosy and Lung Disease Program at the Ministry of Health, Kenya, told CNS (Citizen News Service) that: “In December 2015, at the 46th Union World Conference on Lung Health in Cape Town, we (Kenya) had given the undertaking to roll out the new FDCs. Soon after, we formed a task force to develop an implementation plan for (i) procurement of drugs well in advance; (ii) changing of treatment guidelines; (iii) training of healthcare workers; and (iv) involving the media to create public awareness so that the community was prepared to receive the drugs when they came. It was about collaborating with everyone - civil society, technical partners, government agencies and the media - for the entire country to move forward in one direction as one group. We started quantification of the drugs we already had, to decide upon the earliest possible date for the roll out as 1st October 2016 (even though we had procured the new FDCs in June 2016), as we had calculated that by then we would exhaust the old drugs in our stock."

Dr Masini also confirmed that all private facilities will also be providing the new FDCs. “As close to 40% of our TB patients are diagnosed and treated in the private health sector, we have an agreement with all private hospitals in terms of giving them access to the GeneXperts in the government sector and providing them drugs - either free of cost or at highly subsidised rates”. Dr Masini shared that Kenya also plans to use this opportunity get more missed cases into the system. Children contacts of every adult coming for TB treatment are being put on isoniazid preventive therapy for 6 months. Also 500,000 PLHIV have already been put on IPT to prevent risk of TB and the number would increase to 1 million by next year. Kenya also plans to roll out the shorter MDR-TB regimens from early 2017.

Lessons learnt

According to Kathure, “Fighting TB cannot be a one person battle. Everyone has to come on board. Efficient health systems have to be in place to deliver to a community that has been sensitised. At the time of roll out we realised that the drugs did not come with a measuring cup in which to dissolve the pills in an appropriate volume of water. There was no time to ask the suppliers to provide this. So we procured and supplied  syringes with the medicine for caregivers to measure 20 ml of water and dissolve the pill in it in a cup. In Kenya, patients come to the health facility once every week in the intensive phase and once every two weeks in the continuation phase. On every such visit the syringes will be replaced. Then again, we used the existing maternal and child health programs/campaigns to advocate the use of safe drinking water for dissolving the pills”.

As informed by TB Alliance, additional similar child friendly products that are likely to hit the market by 2017 are ethambutol, isoniazid and pyrazinamide. But countries will have to be ready to take ownership and accelerate their roll out. They can certainly learn from Kenya’s experience and make adequate advance preparations in their local context so that they can efficiently deliver the new regimens without any unnecessary delays. In the words of Dr Masini: “We have to stand up for our children. TB is both preventable and curable. No child should suffer from it. We need to make full use of the opportunities we have to end TB. Let us also use the new pediatric TB drugs as an advocacy to find more children with TB and to improve treatment outcomes”.

Shobha Shukla, Citizen News Service - CNS
3 November 2016
(Shobha Shukla provided thematic coverage from the 47th Union World Conference on Lung Health, Liverpool, United Kingdom, with kind support from TB Alliance (Global Alliance for TB Drug Development). Follow her on Twitter @Shobha1Shukla)