When TB drugs fail, we pay a heavy price

Stephen Otieno is a stressed man. The Siaya resident has been unwell for a month now. He has not taken his TB drugs for two months.
Otieno was diagnosed with active TB in 2016. He had been religiously taking his drugs until June, when he went to the hospital and was told to take a Covid-19 test.

Being a different hospital from the one where he usually collects his drugs, the health workers insisted on a Covid-19 certificate. “I had gone to the hospital where I used to pick my drugs from, but they were out of stock,” he explains.

“I had a continuous dry cough and when I went to the hospital, I was told that I had to be tested for the coronavirus. I was required to pay Sh5,000 for the test, an amount I did not have. Even after telling them that I had gone to collect my TB drugs, they said they would only attend to me after the test,” he tells HealthyNation.

Otieno has since decided to stop his TB drugs because he cannot afford to test for Covid-19.

Test walk-ins

Testing for Covid-19 is free in public hospitals, while it costs from Sh5,000 in private facilities. However, the test is only conducted in select public hospitals, which most Kenyans are not aware of.

And to make matters worse, most public testing facilities, including Kenya Medical Research Institute and the National Influenza lab, do not test walk-ins. Their focus is samples from various institutions.

Otieno is faced with a tough choice: To either look for money to test for Covid-19 before he collects his drugs or do without the life-saving medication. He is now in danger of developing drug resistance, which can lead to MDR-TB when he gets back on his medication after nearly two months of defaulting.

“It is not that I do not want to go and refill my drugs. I have tried getting drugs in two facilities and whenever I go, I am asked to do a Covid-19 test because I present with one of the symptoms,” said Otieno.

The nightmare is just getting started if such cases are anything to go by. Kenya seems to be hurtling down the dangerous path of multi-drug resistant (MDR) TB.

TB patients have been missing clinics and skipping crucial medication. Without adherence to drugs, TB treatment becomes ineffective. Things can take a turn for the worse for such defaulters when they develop resistance to drugs.

Whopping Sh1.3m

MDR-TB is caused by bacteria that are resistant to at least one first-line drug. The treatment takes longer than that of normal TB. MDR-TB occurs when patients develop resistance to Rifampicin and Isoniazid, the two most powerful drugs.

When a patient gets MDR-TB, the cost of treatment soars and it takes longer to cure it. The result is likely more deaths, where drugs are not available. Considering TB treatment is free in public hospitals, this means a greater burden for the government.

A full dose of drugs for second-line TB treatment costs the government a whopping Sh1.3 million per patient. The patient receives drugs and an injection every day at the facility and the treatment goes on for 18 months, with extensions for the harder-to-cure cases. Patients with MDR-TB also receive a Sh6,000 monthly stipend for food and treatment.

Last year, a survey released by the national TB programme revealed that patients with drug resistance spend an average of Sh145,000 seeking treatment  over a 20-month period.

These costs include direct medical costs (consultation fees and diagnostic fees), non-medical costs (transport, accommodation and food) and indirect costs (productivity hours lost). The high costs plunge many into poverty. The costs make patients less likely to present themselves to hospitals for treatment, complete TB testing and initiate and adhere to treatment.

Even more dangerous is that TB is very infectious and patients with MDR will spread it as easily as those without. In rare cases, this kind of TB can progress to extensively drug-resistant TB (XDR), which is even harder to treat.

GeneXpert machines

The interruptions in treatment have been blamed on Covid-19. Because TB patients exhibit symptoms similar to those of Covid-19, they choose to stay away from hospitals due to the stigma they face.

Diversion of resources to Covid-19 has also been blamed for inadequate care. In March, the Health ministry announced that it would repurpose the TB-testing GeneXpert machines to Covid-19. Reports showed that the reassignment of the machines to Covid-19 would reduce the chances of TB diagnosis by 70 per cent.

This is despite the fact that already, not very many TB patients are diagnosed and treated, with some going unnoticed.

A National Tuberculosis, Leprosy and Lung Disease Program report showed that an estimated 147,000 people fell ill with TB in 2019, yet only 86,385 people were diagnosed, treated and notified to the program.

The country misses nearly half of the people with TB. This translates to a treatment coverage of 59 per cent, down from 63 per cent in 2018. Men remain the most affected, contributing to 65 per cent of all notified cases.

Health Cabinet Secretary Mutahi Kagwe expressed concern that fewer people have been visiting hospitals for fear of contracting the coronavirus.

Restrictions in movement, while meant to protect people from Covid-19, have now turned against patients and TB treatment seems to be suffering the greatest assault.

TB is the fifth biggest killer in Kenya. A 2016 survey revealed the burden of TB in Kenya was 426 cases per 100,000 people. This means that 52 people are dying daily from TB, according to the World Health Organization figures.

The disease kills 1.5 million people per year worldwide, making it the top infectious disease killer.

Avoid hospitals

Dr Laureen Nyaboka, Chief of Party of the TB Accelerated Response and Care Program, says since the start of Covid-19 , many patients who present with respiratory symptoms similar to the coronavirus keep off hospitals.

“We have noted a decline in the number of cases from what we would expect particularly because Kenya is a high TB burden country. We would normally expect a certain number of patients to be diagnosed, but the cases have been declining,” says Dr Nyaboka.

The decline is not good news, she says. It is an indication that patients are not going to the hospital. “When you have respiratory symptoms, healthcare workers would want to test you because they are highly sensitised to Covid-19 and many patients are anxious about isolation,” Dr Nyaboka tells HealthyNation.

She says they are more concerned about the progression of the disease. Failure to take drugs also presents another problem as it might lead to the transmission of the disease within families and the community.

“In addition, with drug resistance, the bacteria that causes TB stops being responsive to the normal anti-TB drugs and this would mean that the patient requires a larger regimen of more toxic drugs, which one would have to take for a longer time,” she says.

High-burden countries

She emphasizes on the need for patients with respiratory symptoms to visit a health facility. However, she encourages health workers to be on the lookout for other diseases, such as TB, so that they do not insist on a Covid-19 test when it is unnecessary.

“When you get to a facility, explain your condition to the health worker and they would be able to tell whether your symptoms during screening are Covid-19 related or not. People are not going to the hospital because of the mandatory testing even when the symptoms are obviously not related to Covid-19,” she says.

Kenya has been listed as an MDR-TB high-burden country, together with eight other nations grappling with the deadly disease globally. Kenya features in all three high-burden country lists under the categories of TB, MDR-TB and TB/HIV.

From the 2019 report, an estimated 2,170 patients got MDR-TB and only 692 drug-resistant TB cases were notified to the government, translating to a treatment coverage of 32 per cent.

“With the Ministry of Health implementing interventions geared towards strengthening access to drug susceptibility testing (DST), Kenya’s burden remained low at 31 per cent among new TB patients in 2019,” says Dr Elizabeth Onyango, the head of the Division of National Tuberculosis, Leprosy and Lung Disease Program.

A data quality assessment conducted in 25 counties showed that the highest number of drug-resistant TB cases were reported in Nairobi County, accounting for 14 per cent, followed by Mombasa (seven per cent), Turkana (six per cent), Nakuru (five per cent) and Meru at four per cent.

Hearing loss

Samburu and Tana River counties notified the least number of patients, with only two cases each.

Among the drug-resistant patients notified in 2019, 516 (75 per cent) had Rifampicin resistance and 172 (25 per cent) were mono-resistant.

Improved access to second-line DST has seen Kenya diagnose XDR TB patients since 2017, with at least one case notified annually except in 2017 when there were two patients.

Only 30 per cent of patients with drug-resistant TB completed their treatment in 2016, according to the Health ministry. Another 19 per cent often succumb to the disease.

WHO requires that MDR-TB patients be supervised directly in order to increase adherence to medication. Many patients fail to complete their drug courses because they take medication for a longer time and it has many more side effects.

However, the cost burden for patients could be something of the past after the government in collaboration with partners, embarked on a journey towards the adoption of WHO recommendations on injection free treatment guidelines for MDR-TB patients.

With this, patients with drug-resistance will no longer receive injectable medicine, but instead oral regimens that will last for 18 months.
The new, more effective medicine replaces painful, daily shots and drugs, which have risks of permanent hearing loss.