Call for home-based care for drug-resistant TB

HARARE - Many children wail when they receive an injection, but Tanyaradzwa Mungare,3, is braving months of injections.

“Tanya”, as he is affectionately called, has to receive an injection at least six days every week.

On top of the daily jab, Tanyaradzwa has to swallow a combination of five drugs for treatment of drug-resistant tuberculosis (DR-TB drug).

For five months, Tanyaradzwa has been on treatment and he still has another 19 months to go.

Grateful for re-joining his age mates in kicking the ball after months of quarantine, the little boy savours going outside the house to play with his peers. He is like any other three-year-old.

He breaks his play to take pills from the hands of his paternal grandparents.

His mother cannot be there for him as she is fighting for her own life at her parents’ place, kilometres away.

“We had to build that shade over there for Tanya and his mother. Each time we went in there we would wear masks to avoid contracting the infection,” said his grandfather Elliot Chikore, 47, reciting infection prevention rules that the family had to follow.

Today, there is a special visitor at home. Tanya gives a hug to his nurse, Claison Nkomo (a Medicins San Frontiers (MSF) employee), which speaks volumes of extended periods the two have shared.

“Hey boy, I can see we are now friends,” Nkomo says as she hugs the boy.

His family initially thought he had kwashiorkor, until his mother fell sick and was diagnosed with DR-TB.

“Then they (MSF) came and tested every one of us. It is something new but they made us understand,” said the boy's grandfather.

Tanyaradzwa was diagnosed with DR-TB last December and was immediately initiated on treatment. He is among the 300 pioneer people diagnosed with DR-TB in the country.

DR-TB is a stronger strain of tuberculosis which does not respond to the traditional first-line TB drugs. It is detected by a GeneXpert machine.

Although notifications for ordinary TB are on the decline, according to the ministry of Health and Child Care, cases of DR-TB are on the rise, prompting stakeholders to push for adequate resources to kill the contagious killer strain in its infancy.

Adults with DR-TB are injected for eight months and placed on drugs for 16 months.

Treatment is available. DR-TB usually manifests in TB patients who default on their medication because of lengthy and arduous treatment regiments. Nkomo said the management of the disease is made difficult because its prevalence is high among poor communities, especially rural areas.

“For people with big houses, they can simply allocate a room for the sick member but here it is difficult,” Nkomo said.

It takes two years and at least $5 000 to cure DR-TB per individual.

Treatment is in phases. During phase one, or the intensive phase, patients are injected six days every week for eight months.

They are then put on the continuation phase, where they take a combination of about five tablets.

Many patients in rural areas, who are normally diagnosed when their health has already deteriorated, struggle to adhere to treatment owing to the difficult process to access health services.

Lorraine Zemba, cured of DR-TB patient in Buhera, said she hated having to wake-up at 4am to go and queue up for the drugs everyday.

“The treatment made me feel nauseated and even weaker," Zemba said. “I was not admitted and I hated the long walk to and from hospital every morning. I thought it was not worth the trouble. Fortunately, MSF started injecting me from home. I became more determined and I am now well.”

While Zemba worried about her access and body reaction to treatment, her husband Isaac Makaripe bemoaned the limited knowledge on DR-TB in Zimbabwe, which is promoting stigma and discrimination.

“When I heard the diagnosis, I said ‘What is that?’ I was told it is ‘TB nhinhi.’ Relatives started advising me to marry another wife. I am glad that her mother stayed and stood by us. Immediately, I realised the burden was bearable.”

While ordinary TB cases dropped from 47 000 in 2010 to around 35 000 in 2013 —  those of DR-TB have nearly doubled in the last three years from 156 in 2011 to last year’s 300 cases recorded.

Shelton Kwiri, Buhera district medical officer in the ministry of Health and Child Care, said the country cannot let the disease grow.

“Numbers of DR-TB appear to be small but it is a problem,” said Kwiri. “If we leave them untreated, the disease will spread and very soon it will be an epidemic so we have to pour resources into managing those cases now.”

The World Health Organisation (WHO) estimates that the country has at least 1 000 DR-TB patients. But government insists the country has a third of WHO-estimated cases in its patients records.

With a history of defaulting patients, MSF believes resources and laws permitting, the treatment should be brought to the patient during the intensive phase.

“Normally these people have other conditions or ailments and may not be able to travel long bumpy distances for the injection,” said MSF Murambinda DR-TB and HIV focal person, Ye Htun Naing.

“We should always try to keep DR-TB patients on treatment until they are cured because it will become stronger and spread to others,” he said, advocating for the community-based approach as the best option for DR-TB management.

The disease manifests through persistent cough with sputum which sometimes contains blood. HIV positive people are more prone to TB infection.

Zimbabwe has 1,2 million people living with HIV and a TB incidence rate of 547 per 100 000 people.

“Patients are normally moved from the intensive phase with less sputum review test results,” Naing said. “We need more so the management becomes more effective.”

Richard Muchemwa,36, a DR-TB survivor said with the right attitude, adequate medicine and mutual support, DR-TB can be beaten.

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