Three years ago Kenyatta National Hospital, East Africa’s largest referral hospital, diagnosed and reported, for the first time, three cases of a new strain of Tuberculosis: Extensive drug-resistant tuberculosis (XDR-TB) — a type of TB that is resistant to first and second-line drugs.
Although two of the patients died a year later, one patient, a female, has lived under the care of Kenyatta National Hospital (KNH) and is expected to be XDR-TB free this year after completing her medication in April.
This is a success story for KNH in partnership with the government, in its efforts to manage drug-resistant TB.
XDR-TB patients are said to be resistant to two more multi-drug resistant TB drugs administered to patients to treat multi-drug-resistant tuberculosis.
The female patient arrived at KNH on May 2011 and was diagnosed with multi-drug-resistant tuberculosis (MDR-TB) and put on treatment but after a month she was not improving.
“At KNH we carry out a monthly TB laboratory test to confirm if the patients are improving as soon as they start medication and check if they still have active bacteria that causes TB,” said TB specialist at KNH Eunice Wahome. “Once the patient is put on medication we expect the TB bacteria to reduce and by the third month the patient should have negative TB bacteria.”
In the just released Global TB 2013 report, XDR-TB was reported in 92 countries at the end of 2012.
The new World Health Organisation report however indicates that none of the East African countries are among the countries that reported new cases of XDR-TB although the countries are still faced with the burden of MDR-TB.
MDR-TB is a lethal infectious strain which is resistant to two common or first-line drugs for treating TB — isoniazid (INH) and rifampicin (RMP).
“New cases of MDR-TB are still being recorded but are under control because TB services in Kenya are standardised and free in all public hospitals,” said Dr Wahome. “We have similar testing procedures and treatment as required by the government.”
However she says that poor treatment, misdiagnosis, poverty, poor ventilation and the use of counterfeit drugs are common triggers of MDR-TB.
Although the new cases of MDR-TB are reducing in the region, over time Kenya still has the highest burden in East Africa.
In 2012, Kenya recorded 225 newly confirmed cases of MDR-TB, followed by Uganda which recorded 89 new cases; Rwanda 58; Tanzania 42 and Burundi confirmed 24 cases, the least in the region.
However, only Kenya and Uganda recorded an increase in new MDR-TB cases since 2011 while in Rwanda and Tanzania, new cases reduced in the one year period.
According to Shahnaz Sharif, Kenya’s director of Public Health, the Ministry of Health has taken actions to ensure that TB is managed and controlled; ensuring earlier detection of MDR-TB and enrolment of patients on second-line treatment; strengthening patient support to improve adherence to treatment (especially among the most socially and economically disadvantaged patients).
“The introduction of a patient-based monitoring system for those with MDR/XDR-TB and patients co-infected with HIV in the near future will also help to improve the quality of care and treatment outcomes,” said Dr Shahnaz.
The WHO advocates directly observed therapy (DOTS) under the supervision of health care workers to reduce the emergence of drug resistance.
Tanzania started diagnosing and treating MDR-TB in 2008 while Uganda started offering the same treatment last year.
According to the report, South Africa accounted for most of the global cases of MDR-TB and XDR-TB, as well as the highest proportion observed in Africa. Globally 450,000 new cases of MDR-TB were reported worldwide in 2012. This total includes cases of primary and acquired MDR-TB.
“In high MDR-TB burdened countries, increased capacity to diagnose it must be matched with supplies of quality drugs and capacity to deliver effective treatment and care,” said the report.
This, the report says, will require high-level political will and leadership; more collaboration among partners, including drug regulatory authorities, donor and technical agencies, civil society and the pharmaceutical industry.
Just over 77,000 people with MDR-TB were started on second-line treatment in 2012, equivalent to 82 per cent of the 94,000 newly detected cases that were eligible for treatment globally.
Treatment coverage gaps for detected cases were much larger in some countries, especially in Africa and widened in China, Pakistan and South Africa.
Generally, WHO estimates that one-third of the world’s population is infected with TB, with the largest number of new cases occurring in 2008, and over 350 per population of 100,000 reported in sub-Saharan Africa.
Experts indicate that of the $78 billion per year required in low and middle-income countries in 2014 and 2015, about two thirds is needed for the detection and treatment of drugs susceptible TB; 20 per cent for treatment of MDR-TB; 10 per cent for rapid diagnostic tests and associated laboratory strengthening, and five per cent for collaborative TB/HIV activities.
Global efforts are under way to ensure that TB rates are reduced.
Targets in the Global Plan to Stop TB 2011–2015 are that by 2015 all new cases of TB considered at high risk of MDR-TB, as well as all previously treated cases undergoing drug susceptibility testing for at least the first-line drugs rifampicin and isoniazid. Similarly, all patients with MDR-TB should be tested for XDR-TB.
“Progressing towards the target for treatment success requires the scale-up of treatment programmes globally; enhancing the effectiveness of drug regimens; supporting patients to avoid treatment interruption and improved data collection,” said WHO.