KENYAN GOVERNMENT POLICIES AND PROGRAMS TO ADDRESS TUBERCLOSIS

First we need to understand what tuberculosis means thus the question, what is tuberculosis?

Tuberculosis (TB) is an infectious disease caused by bacteria whose scientific name is Mycobacterium tuberculosis. It was first isolated in 1882 by a German physician named Robert Koch who received the Nobel Prize for this discovery. TB most commonly affects the lungs but also can involve almost any organ of the body. Many years ago, this disease was referred to as “consumption” because without effective treatment, these patients often would waste away. Today, of course, tuberculosis usually can be treated successfully with antibiotics.

A person can be infected with tuberculosis bacteria when he or she inhales minute particles of infected sputum from the air. The bacteria get into the air when someone who has a tuberculosis lung infection coughs, sneezes, shouts, or spits (which is common in some cultures). People who are nearby can then possibly breathe the bacteria into their lungs. You don’t get TB by just touching the clothes or shaking the hands of someone who is infected. Tuberculosis is spread primarily from person to person by breathing infected air during close contact.

There is a form of typical tuberculosis, however, that is transmitted by drinking unpasteurized milk. Related bacteria called Mycobacterium bovis, cause this form of TB. Previously, this type of bacteria was a major cause of TB in children, but it rarely causes TB now since most milk is pasteurized (undergoes a heating process that kills the bacteria)

Before the advent of the human immunodeficiency Virus (HIV) in 1990, notification rates of cases of tuberculosis (TB) in Kenya were falling steadily at about 4% per year. The HIV epidemic reversed this trend and by the middle of the 1990s the case notification rate was increasing at 15% per year. People who are at high risk include those with HIV infection; those who inject drugs; and those who have resided in; volunteered, or worked in high-risk congregate homes, hospitals, residential facilities for patients with AIDS or homeless shelters. In order to strengthen its national TB control programme (NTP), Kenya developed a national DOTS strategy that was finalized in 1991.

Short course chemotherapy was introduced in 1993, which aimed at reaching all districts by 1997. At least one diagnostic and treatment centre was set up in each district and sub-district hospitals. Some health services, while many more initiated DOTS treatment centers’. These were deemed inadequate, however, and in 2000 special steps were taken to increase the capacity of the programme. Between 1996 and 2006, the number of health units increased from 916 to 1796, the number of TB microscopy centers’ from 280 to 773 and the staff complement from 90 to 188 more or less doubling the overall capacity.

In 2005, Kenya adopted the policy recommended by the World Health Organization (WHO) of offering HIV testing and counseling to all TB patients. By the end of 2006, about 60% of TB patients had been counseled and tested for HIV. Those found to be HIV-positive were provided with co-trimoxazole preventive therapy (CPT) and referred to HIV care clinics for antiretroviral therapy (ART).

Approximately 25% were put on antiretroviral drugs. Other new initiatives that have been introduced since 1997 include: community TB care; engaging care providers, including public-private mix (PPM); infection control in congregate settings; strengthening the health –care delivery system through the provision of additional advocacy, communication and social mobilization activities. The resources available to the NTP have increased greatly since 2000 and have come from a range of sources including the Government of Kenya; the Global Fund to fight AIDs, Tuberculosis and Malaria (the Global Fund) as well as international technical partners and donors. The introduction of these initiatives and the consolidation of previous gains have served to increase TB case detection rates to be an estimated 71% in 2006. If the prevalence of HIV continues to fall, the increase of TB will probably fall with it.

An estimated 14 million people worldwide are infected with active tuberculosis (TB), which is a disease of poverty affecting mainly young adults in their most productive years. In 2009, there were 9.4 million new cases of TB and 1.7 million deaths, including 380,000 deaths from TB among people with HIV. The vast majority of deaths from TB are in the developing world. The latest data released by the World Health Organization (WHO) in November 2010 show that the number of new cases continues to fall globally and in five of the six WHO regions. The exception is Southern Asia, where incidence remains stable. In many countries TB prevalence is declining. Worldwide death from TB fell by 35 percent between 1990 and 2009.
Progress in tackling the global TB burden is associated with DOTS; the basic package that underpins the stop TB strategy, which was adopted by the WHO in 1993. The expansion of DOTS across the world since the mid-1990s is tracked through the proportion of estimated TB cases that are detected-or “notified”-and successfully treated under DOTS.

In 2009 5.8 million cases of all kinds of TB were notified globally, equivalent to a 63 percent case detection rate compared with 61 percent in 2008. Treatment success rates continue to be measured in terms of smear-positive pulmonary TB only. Of the 2.6 million cases notified in 2008, 86 percent were successfully treated against the new 90 percent target included in the 2011-2015 update of the global plan to stop TB. A total of 41 million TB patients were successfully treated in DOTS programs between 1995 and 2009.
The Global Fund has helped to accelerate case detection and successful treatment in recent years with 1.7 million additional cases of TB detected and treated by Global Fund-supported programs in 2010, compared with 1.4 million in 2009 and 1.3 million in 2008. Since the Global Fund’s inception in 2002, programs it has financed had supported DOTS for a total of 7.7 million people by December 2010.

TB epidemic in Kenya is primarily driven by HIV/AIDS. The burden of TB remains great with Kenya being ranked 15th among the 22 highest TB burden countries worldwide and 5th in Africa (WHO, 2011). Kenya still faces considerable challenges in its efforts to reduce the burden of TB, despite the excellent progress in meeting WHO targets over the last few years. Kenyan TB control is guided by the stop TB strategy and this is encapsulated in the division of Leprosy, tuberculosis and lung Diseases Strategic Plan 2011-2015. To facilitate TB prevention and control, Japan has been supporting both from policy level to grassroots level by employing different modalities such as technical cooperation, Grant Aid and volunteers. In order to prevent new HIV, TB and TB/HIV, the program is to provide technical assistance to policy formulation at the national level while supporting regional or grassroots activities with volunteers. With support of a JICA TB laboratory expert, the introduction of LED-based fluorescent microscopy and related training have been supported for improved diagnostic capacity and accuracy.

Multidrug-resistant TB is on the increase particularly in Eastern Europe and parts of Asia. Levels of case detection and successful treatment are far too low. Only 12 percent (30,000) of the estimated cases were notified in 2009 and less than 5 percent were properly treated. The Global Fund is the major donor for responses to multidrug-resistant TB. Programs it supports treated 14,000 cases in 2009, equivalent to nearly 60% of the 23,000 enrolled for treatment globally that year and an additional 13,000 with Global Fund support to 43,000 at December 2010.The HIV epidemic has fuelled the TB epidemic particularly in sub-Saharan Africa. Too little is done to prevent TB among people living with HIV who account for 13 percent of the new TB case in 2009. Less than 1 percent of the estimated number of people living with HIV worldwide received isoniazid preventive therapy in 2009 and only 26 percent of TB patients knew their HIV status. Service coverage for TB/HIV co-infectious remains very low. By December 2010, Global Fund-supported programs had provided a total of 2.4 million TB/HIV services.
As of 2010, WHO has discontinued the 70 percent target for case detection since there is major uncertainty about its true value in most countries.

Tuberculosis facts

• Tuberculosis (TB) is an infection, primarily in the lungs pneumonia), caused by bacteria called Mycobacterium tuberculosis. It is spread usually from person to person by breathing infected air during close contact.
• TB can remain in an inactive (dormant) state for years without causing symptoms or spreading to other people.
• When the immune system of a patient with dormant TB is weakened, the TB can become active (reactivate) and cause infection in the lungs or other parts of the body.
• The risk factors for acquiring TB include close-contact situations, alcohol and IV drug abuse, and certain diseases (for example, diabetes, cancer, and HIV and occupations (for example health workers).
• The most common symptoms and signs of TB are fatigue, fever, weight loss, coughing, and night sweats.
• The diagnosis of TB involves skin tests, chest X-rays, sputum analysis (smear and culture), and PCR tests to detect the genetic material of the causative bacteria.
• Inactive tuberculosis may be treated with an antibiotic, isoniazid (INH), to prevent the TB infection from becoming active.
• Active TB is treated, usually successfully, with INH in combination with one or more of several drugs, including rifampin (Rifadin), ethambutol (Myambuto), pyrazinamide, and streptomycin.
• Drug-resistant TB is a serious, as yet unsolved, public health problem, especially in Southern Asia, the countries of the former Soviet Union, Africa. And in prison populations. Poor patient compliance, lack of detection of resistant strains, and unavailable therapy are key reasons for the development of drug-resistant TB.
• The occurrence of HIV has been responsible for an increased frequency of tuberculosis. Control of HIV in the future, however, should substantially decrease the frequency of TB.