Image: Stop TB Partnership

Uganda adopts tuberculosis community-based care

2 April, 2012, Esther Nakkazi

Gadi Eddy, 26, from Kitgum district, was the first person to be diagnosed with multidrug-resistant tuberculosis  (MDR-TB) in Uganda in 2008.

“I began treatment immediately but after some time we realised that this TB didn’t respond to any of the drugs. None of the other people in northern Uganda yet knew about MDR-TB. The lab assistant told me there were no more options.”

Gadi began getting treatment from an International medical and humanitarian relief organization, Médecins Sans Frontières (MSF) on 16 December 2009. The treatment started from home, and initially he was eager to take the drugs but after the first few weeks, he could not tolerate them. Three months later, he [frax09alpha]became critically ill, and was admitted to a hospital for two weeks.

The World Health Organization (WHO) reports of tuberculosis (TB) cases with severe patterns of drug resistance increasing while its treatment is even more complex, toxic, and prohibitively expensive. At least 40 percent of the patients who catch it die for inadequacy of the medicines, it says.

TB causes and problem

TB is transmitted through the air we breathe, its impact multiplying as it spreads. The average TB patient infects 10-15 others each year before he/she is cured. TB Alliance estimates that each person that develops TB will lose about 30 percent of their annual income.

Besides being infectious, it is also hard to diagnose—it commonly affects the lungs and other parts of the body. Infants and young children are at special risk of having severe, often fatal, forms of TB such as TB meningitis, which can leave them blind, deaf, paralyzed or mentally disabled.

Each year TB kills more adults worldwide than any disease but HIV. In children, it often goes undiagnosed from birth to 15 years of age; 200 children die from TB every day—more than 10 million children have been orphaned by the disease, yet it costs less than 3 cents a day to provide therapy that will prevent it.

Research by TB Alliance further says treating drug-resistant TB takes 6-24 months—3 or 4 times longer—while the long treatment times result in poor adherence, which drives the development of drug resistance, resulting to multidrug-resistant TB (MDR-TB), which is resistant to both of the main first line drugs, -isoniazid and rifampicin- and extensively drug-resistant TB (XDR-TB).

Tanzania, Kenya and Uganda are all in the world’s 22 high-burden countries for tuberculosis and rank 14th, 15th and 16th respectively according to the 2012 WHO rankings.

Uganda should adopt community-based care

Uganda particularly has increasing cases of MDR-TB, with 34 out of the 237 diagnosed cases treated spread across 40 districts. But the true figure is likely to be much higher says MSF. In Uganda, about 5,000 people die every year as a result of TB and it remains the leading cause of death among people who are HIV positive.

MSF has advised health authorities to urgently look into adopting a new treatment model that is based on home-based care for patients suffering from multi-drug resistant tuberculosis that has been successful in South Africa, Swaziland and Uganda. It argues that expansion of the decentralized and community-based approach is the most feasible method of averting an impending health crisis.

Samuel Kasozi, the MDR-TB coordinator at the Ministry of Health said they have a planned sequence of MDR-TB care. However, it does not necessarily focus on community-based care. It is more institutionalized—in a hospital setting.

Kasozi said they plan on constructing labs in four major towns of Arua, Mbale, Gulu and Mbarara. This will improve diagnosis as by 2010, only 20 out of 36 countries with a high burden of TB or MDR-TB had at least one laboratory capable of performing TB culture and DST per 5 million people says WHO.

MSF puts the success in a pilot MDR-TB programme in Kitgum down to the model of care they are using, which is comprehensive, decentralised, and community-based. In addition, to the conventional components of care, 3 constituents have played a vital part: the home-based care approach, food incentives, and the use of village health teams, who are trained, supervised and rewarded for their work.

“The treatment of multi-drug resistant TB can be very challenging,” said MSF Head of Mission Gabriele Ganci. “It takes not less than 24 months. As a result, many of them break off their treatment prematurely. This not only endangers their own lives, but also creates new forms of resistance against the known TB medicines.”

According to Okeny Richard Dick, a counselor with MSF, patients at home are a little bit relaxed in mind and although they too have the burden of many pills, they are not always being psychologically tortured, like all those patients in a hospital setting.

Indeed patients treated within their communities benefit from the practical and emotional support of friends and family in coping with the side effects of the drugs and adhering to their treatment, while increased understanding of TB within communities leads to higher detection rates and reduced stigma associated with the disease.

“The hardship I incurred from the hospital is that even the fellow patients and the caretakers are feeling bad because they have the fear that I can infect them with my disease, so they have no good times with me,” said a DR-TB patient.

“For the past 5 years I have been down, I have not done anything meaningful. But recently I began gaining some little energy, because I was getting more tolerant of the drugs and their side effects. Now I am working again, making shoes,” the patient said.

“Two years after starting, I’m the first man in Uganda to finish DR-TB treatment. I feel happy because I don’t have to take any more drugs and I have no side effects. I haven’t yet regained my full energy and full strength, and I still can’t play football like I used to. But I feel very, very good. Now I’ve finished my treatment, there’s not any bad thing disturbing me, I’m ok.”




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