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Kenya Perspective: Tuberculosis

Background

Tuberculosis (TB) is a serious public health issue in Kenya. About 120,000 people a year develop TB (48,000 of them being HIV-positive) and 18,600 people die from it. It is the fourth largest cause of death, being responsible for about 6% of all deaths. Nearly two people an hour die from TB, despite effective treatments being available.

All this is despite considerable progress having been made. Kenya was the first African country to achieve World Health Organization (WHO) targets for detecting and treating cases. Numbers of cases reported has reduced, while mortality has hardly changed, although fewer deaths are from those also living with HIV (down from 15,000 in 2004 to 9,500 in 2013).

The current situation can be dramatically improved. The target proposed is a 90% reduction in TB deaths and an 80% reduction in new cases by 2030, while ensuring that no family is burdened with catastrophic expenses. In Kenya, that could be achieved by spending about 6.7 billion shillings ($71 million) a year to increase detection rates, strengthen primary health care provision and treat more patients.

This sounds a lot, but it would give each TB patient on average about another 31 years of life. Also, treating one patient should prevent at least one more case developing, so overall this annual investment would produce about 330,000 additional years of life for Kenyans.

Even valuing a year of life at just 95,000 shillings ($1,000), the low end of the range, means that each shilling spent gives benefits worth at least 5 shillings, as well as saving lives. If a year of life is valued at $5,000 (475,000 shillings) then the benefits are at least 26 shillings for each one invested.

People are first latently infected with TB.  5% going on to develop active TB within eighteen months and the same percentage at risk of developing TB later in life. The risk of developing active TB is significantly increased following HIV infection – and therefore TB is strongly associated with HIV.

Most cases are drug-sensitive and respond well to standard treatment with a combination of drugs, but failure to complete a proper course of treatment encourages the development of multi-drug resistant TB (MDR-TB), which is difficult and costly to treat and has poorer outcomes. Around 2.6% of all cases of TB in Kenya are multi-drug resistant.

But diagnosis is quite complex, since many symptoms are similar to those for other common diseases, and treatment takes several months. In the meantime, loss of earnings for the sufferer may drive families into poverty, multiplying the burden of the disease.

Diagnosis using a microscope to screen sputum samples is cheap and the most common method used. However, it may miss substantial numbers of sufferers and there are new tests (Xpert) that may can improve detection rates and find cases of drug-resistant infection. However, these tests are more expensive. Detection rate in Kenya is about 75%, which is good but must be improved further to meet the targets. Treatment of most cases takes six months and, in Kenya, the adherence rate is good, which contributes to the 86% cure rate.

HIV infection is a key driver of TB development and so a main focus of control efforts. About 1.6 million Kenyans are living with HIV, which increases the risk of developing and dying from TB. Over 93% of TB sufferers are tested for HIV and 83% given anti-retroviral treatment. HIV sufferers with latent TB can be given preventative therapy to avoid the disease developing, but by April 2014 only 6,000 out of half a million eligible people were receiving this treatment.

There are other aspects to an effective programme. Poverty can prevent people seeking treatment, since the overall cost of an episode of TB care, including lost earnings, is over 33,000 shillings on average. Poor nutrition can reduce chances of a cure. Both issues need to be addressed. Community healthcare provision also needs to be strengthened to improve counselling and increase adherence to treatment.

Overall, although TB control is not expensive in comparison to other healthcare investments and despite the clear economic justification for increased efforts, the National Leprosy, Tuberculosis and Lung Disease Programme estimates that only 40% of control needs are currently funded.