Uganda's Health Ministry has begun rolling out its first treatment programme for multidrug-resistant TB (MDR-TB) and expects to treat some 250 confirmed cases of the disease.
The acting programme manager of the National TB and Leprosy Programme (NTLP) at the Ministry of Health, Dr Frank Mugabe Rwabinumi, says the treatment will be carried out in phases to accommodate an inadequate number of isolation wards and a shortage of health workers - just over half of the health worker positions in Uganda's public sector are filled.
"These patients need to be followed and monitored closely. When… [treatment has] started, it requires serious monitoring every month for the next eight months," he told IRIN/PlusNews. "The treatment is complicated. It needs trained dedicated health workers, isolation wards, feeding... You need to test culture and drug acceptability. If you don't manage, your patients will die."
Drug-resistant TB develops when patients do not complete the full six-month course of treatment when they are first diagnosed with active TB. They then require treatment lasting around 18 months with second-line drugs, which are much more expensive.
Uganda is ranked at 15 on the UN World Health Organization's list of 22 countries with the highest TB burden in the world. It has about 250 confirmed cases of MDR-TB, but health officials estimate the total number - including those so far undiagnosed - to be closer to 800.
"According to a national mini-survey we carried out in 2011, the MDR cases among new [TB] cases were at 1.3 percent, and 12.1 percent of those who are on treatment," said Dr Samuel Kasozi, MDR-TB coordinator at the Ministry of Health.
The treatment of five patients in the northern Ugandan district of Kitgum has already started, and five more are on the waiting list. In the capital, Kampala, the Mulago National Referral hospital will treat 100 cases, starting with a group of 30-40 patients. Five selected regional hospitals - Fort Portal, Mbale, Gulu, Arua and Mbarara - will each admit around 10 patients, depending on the available space.
A programme run by the NTLP at Mulago Hospital has already trained at least 25 doctors and nurses in MDR-TB treatment initiation and care. The health workers received a three-week intensive, case-based course in the theory, management and treatment of MDR-TB.
"We are going to admit and manage the patients for at least three months in the hospitals," the NTLP's Rwabinumi said. "Afterwards, they will be discharged and monitored by the nearby health centres. We shall have people to support them at the health facilities, and the village health team to do follow-ups, give daily injections and medicine."
"When we are treating, special priority will be given to the patients with MDR and HIV. We have to integrate MDR and HIV treatment because it's a matter of life and death," he noted.
About 53 percent of TB patients in Uganda are also HIV-positive, according to government statistics.
Rwabinumi stressed the importance of adherence to the medication if the treatment is to work. "We must not compromise with the MDR treatment," he said.
Dr Christine Ondoa, Uganda's Minister of Health, said the government had procured second-line TB drugs to treat the patients, who had all become resistant to first-line drugs. "This is the first time we are procuring these kinds of drugs," she said.
Henry Nsobya, a TB officer at MildMay Uganda, which provides outpatient care for people living with HIV, said, "The government should know that MDR-TB is a reality. It must ensure there is continuous supply of drugs and no stock-outs to avoid these [resistant] cases occurring."
Care in the community?
MildMay recently published a study on the successful treatment of MDR-TB in HIV-positive patients, using home-based care.
In a special report on drug-resistant TB in Uganda in April 2012, the NGO Médecins Sans Frontières (MSF), suggested that community-based care would be more effective in treating MDR-TB patients than a centralized approach .
"Many patients and their caregivers from rural districts will find it impossible to manage a lengthy stay [in a hospital] in the capital, and default rates [from taking the medication] are likely to skyrocket. Community-based care has been shown to be safe, practical and extremely effective for drug-resistant TB, leading to high adherence, close follow-up, and encouraging outcomes," the report noted.
"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 authors pointed out.
Since 2009, MSF has run a community-based TB programme in Kitgum, where some patients with drug-resistant TB have been treated. The organization reports that there have been no defaulters, no treatment failures, and no deaths.
However, MDR-TB coodinator Kasozi said, "We don't have the staff to monitor the patients at their homes. We shall emphasize admission of the patients at our public health facilities."
The NTLP's Rwabinumi stressed the need for prevention of TB and effective treatment of the disease in order to prevent the development of MDR-TB.
"It's important to note that TB is curable if medicines are swallowed well as recommended," he said. "For the health workers - identify suspected TB pateints, diagnose them, educate them, give them treatment, record them in registers, follow them up periodically and inform them on the progress of their disease."
He added that the programme would require ongoing investment to achieve its goals. "MDR treatment requires support and commitment from everybody - government, development partners and donors. It's very expensive and needs resources to manage."