Somalia has some of the worst health indicators in the world and tuberculosis is not an exception
Interview with Luis Neira, MSF medical coordinator for Somalia, about the new tuberculosis (TB) services the organisation has started providing in two rural areas of Middle Shabelle region, South Central Somalia.
Luis is part of the MSF team based in Nairobi supporting the organisation’s operations in South Central Somalia, where over 1,300 Somali staff are providing medical care in eight regions in the country. Luis is the medical reference person for the projects in Middle Shabelle and also in Mogadishu, the country’s capital.
In Middle Shabelle region, MSF provides basic medical care through a network of four health centres in urban and rural areas in several districts within the region and a maternity unit in Jowhar town. On 5 June, MSF teams were able to start providing tuberculosis diagnosis and treatment in the rural areas of Mahaday and Gololey.
What is the situation in this area with regards to tuberculosis? Are many cases reported? Do you already have suspected cases?
The situation with regards to tuberculosis in Middle Shabelle is not different from that in the rest of the country. Health indicators in Somalia have been known to be, for many years already, some of the worst in the world and tuberculosis is not an exception. Based on the statistics produced by the World Health Organisation (WHO), which have not been updated since 2007, this disease kills over 5,500 people every year. Through our health centres we have been able to identify a number of suspected TB cases, whose final diagnosis and treatment have been very difficult due to the shortage of programmes in the area. The situation is more pressing in the rural areas of Mahaday and Gololey, given that the nearest programme, which is the one in Jowhar, is located very faraway and this makes it difficult, when not impossible, for rural and nomadic populations in these areas to have access to treatment. This situation has prompted us to open a tuberculosis programme enabling us to assist sick people that did not have access to this type of care.
What do the services offered by MSF consist of?
Suspected cases are identified in the medical consultations we carry out in our primary healthcare centres in Mahaday and Gololey. Then patient samples are tested in a clinical laboratory equipped for the programme and the disease is thus diagnosed and treated. Furthermore, the patient is provided with clinical follow-up, counselling, a medical check-up is conducted to close contacts to detect whether they have TB or not, particularly children under five, and nutritional support is provided to patients who are malnourished due to the disease.
To treat tuberculosis, WHO recommends the so-called DOTS (Directly Observed Treatment Short-course) strategy, meaning that the patients take the medication under supervision from health staff in order to avoid the development of resistances to the antibiotics. How can this strategy be implemented in a country as unstable as Somalia?
WHO’s DOTS strategy will be used with the patients that are able to go to the health centre on a daily basis. A modified DOTS strategy will be implemented for those patients finding it difficult to go daily either because they live too faraway or because of other reasons, this modified strategy enables them to receive their first dose under supervision from health staff and then continue their treatment at home until their next scheduled appointment at the health centre. We ask that each patient has a “treatment assistant”, this can be a family member or a friend who will make sure that they take the medication as prescribed. This person is also responsible for informing health staff whether the patient is following the treatment or letting them know if they are suffering from any side effects from the medication. In this way, the burden of following the treatment regime is reduced for the patient. We also find that their adherence to the programme is enhanced as they do not need to go to the health centre daily, something difficult for rural populations, and they have someone to count on who will encourage them to take their medication on a daily basis.
Tuberculosis in southern and western African countries has recently been related to HIV/AIDS and outbreaks of resistant strains to the usual antibiotics have also been reported. Are these also concerns in Somalia?
Accurate data is very limited as very little work has been done regarding HIV/AIDS and drug resistant tuberculosis in Somalia. However, we assume that resistance may be a major problem in Somalia. In the few places that treatment is available it is very badly managed, and anti-TB drugs are often sold over the counter in private pharmacies, which means uncompleted, shorter treatments and dubious quality drugs. Another reason that the MSF programme is so important.
For the last two years MSF’s programmes in Somalia have been run by national staff, supported by management teams based in Nairobi, due to the ongoing insecurity. How have you trained the team in TB diagnosis and treatment?
For our tuberculosis team we have selected health staff that were already working in our project in Jowhar, people that have experience and medical skills who have been joined by a new laboratory technician who has a great deal of experience in MSF TB programmes. We have also hired a medical officer specialised in respiratory diseases, who has been working in MSF’s TB programmes in Kenya. She will provide technical support to the team from her base in Nairobi and will visit the field whenever possible. This team have received four months of training in tuberculosis management and in the overall programme. The training has included a theoretical as well as a practical component in the TB programmes that MSF has conducted in Kenya and other regions of Somalia.
MSF IN South Central Somalia.
MSF has been working in South Central Somalia continuously since 1991. Currently, the organisation is present in eight regions of South Central Somalia: Banadir, Bay, Hiraan, Galgaduud, Middle Juba, Middle Shabelle, Lower Shabelle and Mudug. MSF does not accept institutional funds for its projects in South Central Somalia. Its entire funding comes from private donors.
TB: diagnosis and treatment
Tuberculosis is a contagious disease transmitted by the air. In its pulmonary form, is characterised by a persistent cough, shortness of breath and chest pain. In addition to the lungs, the infection can also affect almost any part of the body, such as the lymph nodes, the spine or bones. One-third of the world’s population is currently infected with the TB bacilli. Every year, nine million people develop active TB and close to two million die from it.
The most widely used technique for diagnosing TB in developing countries is examining a suspected patient’s sputum sample under a microscope; a method was developed well over a century ago and detects less than half of cases of TB. Currently, the best alternative is a culture which consists of incubating a sputum sample to see whether it contains live TB mycobacteria. This technique is more accurate, but must be done in a laboratory with trained personnel and may take up to eight weeks.
Drugs used to treat TB were developed in the 1950s and a course for uncomplicated TB takes six months. Poor management of or lack of adherence to treatment has led to new strains of bacilla that are resistant to one or more anti-tuberculosis drugs. Multi-drug-resistant TB (MDR-TB) is the most serious form of this, identified when patients are resistant to the two most powerful first-line antibiotics. MDR-TB is not impossible to treat, but the required regimen causes many side effects and takes up to two years. A newer strain, extensively drug resistant tuberculosis (XDR-TB), is identified when resistance to second-line drugs develops on top of MDR-TB, making the treatment even more complicated.