HISTORY OF TUBERCULOSIS IN KENYA: A STORY RETOLD 55 YEARS ON
The background of Tuberculosis in Kenya is of some interest, particularly to the writer. Its history is not very clear, but earlier medical workers did show that infection with TB has been prevalent along the Kenya coastline due to early contact with Europeans, Indians and Arab traders. It took some time for tuberculosis to spread in the hinterland, with the earliest records coming from post-mortem records in the late 1920s; even then, it was thought that TB was uncommon in Kenyan Africans.
My first contact with a Tb patient was in childhood, when one of my many aunts suffered and succumbed to the disease in 1951. I remember clearly the withering process she went through and the coughing up of blood.
From a clinical point of view, I encountered TB in my second year at university during clinical ward rounds and when I had a chance for vocational employment in 1964 at the Nyanza General Hospital in Kisumu. Interestingly enough, my father was working at Nyanza Hospital. He was in charge of TB services in the Central Nyanza District at the time. I travelled with him for field work and was able to observe TB screening services, which were carried out under tree shades using mobile X-ray vans that were taking mass miniature radiography (MMR) for screening for pulmonary TB. The team would also undertake ZN stain of sputum and examine it with a light microscope in the field.
My major encounter with TB patients was in 1971, when I was posted to the Infectious Diseases Hospital (IDH) in Nairobi as a medical officer (M.O). These were interesting days, with many advanced TB cases with extensive cavitation in the lungs and often with massive empyema. One would detect the smell of the TB patients as you approached the gate of IDH in Nairobi.
The treatment was for 18–24 months, and the pill burden was heavy, usually 1–2 months of daily streptomycin injections as an inpatient followed by oral tablets that included Isoniazid three tablets and para-aminosalicylic acid (PAS) six (6) tablets, ethionamide later thioacetazone, taken once a day for up to 2 years. The introduction of streptomycin for one month, often as an outpatient, and Thiazine as one tablet for 12-18 months improved the treatment regimen.
I proceeded to the United Kingdom (UK) for specialization, first at the Brompton Hospital Institute of Chest Diseases, then on to Edinburgh, City Hospital under the renowned TB specialist Prof. John Crofton. In 1975, I returned to Kenya as consultant in charge of IDH Nairobi and chest consultant in charge of the Kenyatta National Hospital’s chest clinic. Just before I left the UK, the World Health Organization (WHO) had initiated a pilot program for the National TB Control Program in Kenya (NTP). There were two districts selected, Machakos and Muranga, for the pilot projects, which proved successful, and when I came back, the late Dr. Koinange, who was my great mentor had established the department of Communicable Diseases Control under which the NTP was housed. I was nominated to be in charge of NTP as well as be the deputy director of communicable diseases.
Apart from two doctors seconded from the Netherlands, there were only two other doctors in full-time TB services, one at Port Reitz Hospital Mombasa and one at the Institute of Infectious Diseases in Nairobi. This shortage of healthcare workers in TB prompted me to work out alternative. I drafted a curriculum for clinical officers to be trained on TB and take charge of TB services at the district level. I designed a nine-month training course at the Medical Training College (MTC) which fortunately and happily adopted the programme. After discussion with the Directorate of Personal Management, it was agreed that this cadre, which I named COTULEP, short for Clinical Officers for Tuberculosis and Leprosy Services, would be considered for appropriate remuneration upon qualification.
Apart from lecturing at the university, I was also in charge of the COTULEP training program at the MTC. At the same time, I was deputy director of communicable diseases at the newly occupied Afya House (1976), national coordinator for the National TB Control Program, and a consultant at the IDH and at the Kenyatta National Hospital (KNH). Don’t ask me how I managed, but I did.
In the 1970s, TB services in Kenya were greatly augmented by the TB epidemiological and chemotherapy research activities coordinated by the British Medical Research Council, TB and Chest Diseases Unit at the Brampton Hospital (MRC/TCDU), London. TB surveys done in Kenya are on record; but what stands out most internationally are the short-course chemotherapy studies for pulmonary tuberculosis that were spearheaded by the Tuberculosis Centre (EATIC) in Nairobi, which later became KETIC, where I was director for 10 years after the break of the East Africa Community, and the Respiratory Disease Research Unit of KEMRI.
The short-course chemotherapy regimen developed in East Africa; Kenya, Uganda, Tanzania and Zambia namely 2SHRZ and later 2EHRZ—remains the standard TB chemotherapy forty years down the line with little if any modification. I had the opportunity to be the first to try directly observing short course chemotherapy, currently DOTS, With the help of an Italian social worker, Analine Toneli (who was brutally murdered in Somalia). We established a TB Manyatta in Wajir, where the diagnosed sputum positive clients were kept for six months with directly observed TB treatment. It was difficult to follow up on the Somali patients due to their nomadic nature. TB patients were frequent. We kept TB patients in the Manyatta for six months, the duration of short course treatment,
The Kenya Association for the Prevention of TB was established in 1968 and chaired by Dr. White, a Nairobi City Council employee. It was mainly dormant until 1976, when I returned from attending the International Union Against TB, Africa Region Conference in Tunisia, where Kenya was nominated to host the next conference in 1978. I was President-Elect for Africa at the time. A successful conference was held in Nairobi in June 1978 under my presidency.
The face of tuberculosis in Kenya took a serious turn in May 1984, when the first case of HIV was diagnosed. Subsequently, HIV cases kept rolling in and infectious diseases hospital in Nairobi became the isolation center for all HIV patients. This was understandable given that TB was present in more than 90% of HIV cases, particularly extrapulmonary TB (pleural effusion TB, adenopathy TB, and meningitis abdominal TB), which suddenly shot up and mycobacteria-negative PTB increased.
Severe Steven Johnson syndrome, which occurred in over 50% of the HIV TB cases presented to IDH at that time. This was, in fact, the most lethal, and it was later determined that this was due to an adverse drug reaction to Thioacetazone in Thiazina, which was then Kenya’s standard national regimen for Tb treatment. WHO recommended the withdrawal of Thioacetazone from anti-TB regimens.
In 1986, I retired from public service but continued to have an interest in TB services, particularly in the development of the TB society and participation in public-private partnerships in TB services.