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Tuberculosis in Kenya

Kenya has a large and rising TB disease burden and is ranked among the twenty-two countries that collectively contribute about 80% of the world's TB cases. The TB case notification rate (CNR) rose from 51 to 326 per 100,000 population between 1987 and 2009. As in the rest of Sub-Saharan Africa this large increase in TB is attributed primarily to the Human Immunodeficiency Virus (HIV). Other factors that may be contributing to the spiralling TB disease burden in Kenya include the high poverty levels with consequent socio-economic deprivation. This is most evident in urban areas where there has been a phenomenal growth of slums and a slum population. The large urban slum population has been followed closely by an increase in the proportion of TB cases notified to the DLTLD from urban areas. For example in 2005 over 35% of all notified TB cases in Kenya were from five largest urban areas of Nairobi , Mombasa , Kisumu, Nakuru and Eldoret, reinforcing the known fact that poverty and TB are closely interrelated. The implication of this observation is that a general improvement in socioeconomic conditions may be the answer to TB control in the long term. However case finding and specific chemotherapy are the only methods that are known to have an important and immediate impact on the transmission of TB. The finding of TB cases and the provision of efficacious chemotherapy is the major preoccupation of the DLTLD.

TB Case Finding Trends in Kenya

The DLTLD adopted the Directly Observed Therapy Short Course (DOTS) strategy for the control of TB in 1993 and achieved countrywide geographic DOTS coverage by in 1997. In 1993 the World Health Assembly set up global TB control targets which were to detect (find) 70% of infectious cases and successfully treat 85% of the detected cases by 2005. The TB control targets for the Millennium Development Goals are to have halved the mortality due to TB by 2010 and to halt and begin to reverse the incidence of TB by 2015. Despite nearly a decade of countrywide implementation of DOTS Kenya is yet to achieve the internationally agreed 70/85 TB control targets. The WHO estimates that the Case Detection Rate (CDR) for 2004 was around 47% while the treatment success rate has been a steadily increase with 85.43 % in the year 2009. It is for this reason that the DLTLD, in line with international trends, launched several new approaches to increase access to DOTS and truly expand population DOTS coverage. These approaches include community based DOTS (CB-DOTS), Public-Private Mix for DOTS (PPMDOTS), collaboration between TB and HIV control programs and the development of an elaborate advocacy, communication and social mobilization strategy aimed at influencing communities to seek care early when TB symptoms occur and to remain on treatment until this is completed when treatment is initiated.

Tuberculosis remains a major cause of morbidity and mortality in Kenya. It affects all age groups, but has its greatest toll in the most productive age group of 15 to 44 years. The major factor responsible for the large TB disease burden in Kenya is the concurrent HIV epidemic. Other factors that have contributed to this large TB disease burden include poverty and social deprivation that has led to a mushrooming of peri-urban slums, congestion in prisons and limited access to general health care services. In the last decade TB case notification has been increasing at an average of 16% annually. Within the same time period the DLTLD has been confronted with the challenge of providing integrated TB and HIV services in addition to other interventions without a commensurate increase in the human resource available for TB control. Additionally there have been increasing concerns about the emergence of drug resistant TB, a threat that would pose major challenges in the fight against TB in this resource limited country.

In order to address the new challenges posed by the tuberculosis epidemic in the face of the HIV epidemic and the socio-economic environment, the ministry of health through DLTLD has identified the following areas for increased support: Strengthening of the human resource capacity at all levels of the DLTLD for effective coordination of TB control activities, decentralisation of TB control services down to the community level to increase access to these services, a stronger collaboration between TB and HIV control programmes in order to promote delivery of integrated TB/HIV services, private –public partnerships to increase the number of private providers integrated into the TB service provider network and a sustained public education campaign coupled with health care worker training and support to promote early care seeking and adherence to treatment at community level and better TB case management by health care providers. In the last few years great strides have been made in all these areas thanks to the many stakeholders dedicated to making a difference.

The Division of Leprosy, Tuberculosis and Lung (DLTLD) is implementing initiatives towards achieving internationally agreed TB control targets including the TB relevant Millennium Development Goals (MDGs). The immediate short term goal is to sustain the gains already achieved the 70/85 targets – that is to detect 70 % of infectious TB and cure 85% of the detected cases and then sustain this effort over a long time to achieve the MDGs. The TB MDGs are, to have halted and begin to reverse the incidence and mortality due to TB by 2015.