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High treatment cost keeping many TB patients in Uganda away from help

TB patients in agony of taking tablets to battle the drug resistant disease. (FILE PHOTO)

KAMPALA – When Mr Rashid Okiring, a local farmer from Kachumbara was diagnosed with Multi-Drug Resistance Tuberculosis in October 2016, he least expected his treatment would affect the family daily bread.

But just a year down the road, Okiring has sold his only cow that brought milk to the family, sold his land leaving the family clinging on only an acre of land in his village.

Okiring is not alone, many Ugandans who have developed Multi-Resistance Drug Tuberculosis [MDR-TB] and have had to change their drug line, have spent a lot of money and have been impoverished by TB treatment.

According to Dr Jonathan Wangisi, the Mbale District Health Officer, most TB patients become multi drug resistant after abandoning treatment on first line drugs and that they find it difficult to afford the second line drugs.

“Most of the patients abandon their drugs when they feel better after they have taken some TB drugs, at times patients take under doses and at times the patients can’t easily access the hospital for the drugs,” said Dr Jonathan Wangisi, a former project director for operational research at Taso.

According to Dr Wangisi the patients incur larger costs related to illness and disability and that the high costs of seeking treatment create barriers to access and adherence to medication thereby increasing the risk of disease transmission.

Reports indicate that TB is a bacterial disease that can be treated with a combination of antibiotic drugs, however, as a result of use and misuse of antibiotics (such as using the wrong drug, or not completing the full course of treatment) bacteria can develop drug resistance.

Dr Ruth Aceng the minister of health says Ugandans are paying a very high price for MDR-TB drugs, meaning that sometimes patients have to forgo treatment because they can’t afford it.

She revealed that an average Ugandan tuberculosis (TB) patient spends between Sh26,000 and Sh145,000 on food, travel and accommodation while seeking treatment for the infectious disease, plunging many patients into poverty.

The cost of treating Tuberculosis
A programme review report conducted in 2013 indicates that less than $30,000 (about Shs85m) was allocated by the government to NTLP and about $2m (Shs5b) to the National Medical Stores (NMS) for TB drugs.

And in the 2018/19 budget of Sh2,308b allocated to ministry of health, only Sh15m is allocated to TB treatment and control programmes across the country.

These allocations according to ministry of health exclude funds for TB reagents and a laboratory supply which resonates with limited funding at a time when the country gets about 1900 multi-drug resistant Tuberculosis (MDR) patients annually.

According to Dr Stavia Turyahabwe, MDR-TB coordinator at the ministry of health headquarters and researcher at the Centre for TB Control, it costs about $3,000 (about Shs11.2m) to treat one patient of multi-drug resistant TB for a period of 24 months and $1000 (Shs380,000) per patient with drug susceptible TB whose treatment duration is six months.

Dr Turyahabwe argues that for TB to be controlled, it has to be looked at as a national epidemic which is in line with the Maputo Declaration of 2005 where African countries were advised to do so.

“Every year, we need medicines and laboratory supplies of not less than Shs9b for TB patients and operational funds of not less than Shs2b at a national level if we are to do what we need to do as a programme,” Dr Turyahabwe notes.

She also adds that each district needs about Shs6m dedicated to TB control if Uganda is to successfully fight TB.

Dr Aceng while addressing the 2018 TB Conference at Imperial Royale Hotel August 14 admitted there was lack of adequate funds and added that there are also challenges with laboratory reagents but was quick to say it about budgetary issues which government is addressing with the Finance ministry.

The International medical humanitarian organisation Médecins Sans Frontières (MSF) is concerned at the high price announced for the new tuberculosis (TB) drug; Delamanid used to treat multidrug-resistant and extensively drug-resistant TB.

According to MSF, a Japanese pharmaceutical company Otsuka, Delamanid is available to some developing countries at a price of $1,700 (Shs5, 734,100) per treatment course.

“It is one of only two new drugs to treat TB to become available in the last half a century, and is effective against the deadliest strains of tuberculosis, including multidrug-resistant and extensively drug-resistant TB,” a statement by MSF stated.

Dr Frank Mugabi, the manager for National TB and Leprosy Programme at the Ministry of Health, said: “Its price should be reduced to allow use.”

He, however, said the government has acquired a donation from the United States and plans to introduce Dedaquiline as part of combination therapy to treat adults with multi-drug resistant pulmonary tuberculosis (TB) when other alternatives are not available.

Inadequate data collected
Besides under-funding, controlling TB in Uganda has been difficult due to the lack of accurate and reliable TB data or information to inform policy, support effective planning and control plus coming up with strategy.

However, Makerere University School of Public Health, on behalf of the Ministry of Health conducted the first nationwide population based TB prevalence survey with financial funding from Global Fund.

The project that started in September 2015 was targeting a sample size of 40,180 respondents from 57 districts in Uganda. The survey was completed in July, 2016.

The World Health Organisation country representative, Dr Yonas Tegegn said the Global fund is committed to helping Uganda fight the burden of TB across the country and asked government to also domestically find funds to treat and control the TB epidemic,

He said Uganda is among the 22 high burden countries of the world; countries with the highest number of TB cases and that Uganda has a high number of TB/HIV co-infected persons with about 50 per cent of the patients co-infected with HIV/Aids.

“You need local data to assess our performance progress as opposed to estimates,” says Dr Tegegn..

THE BACKGROUND
Uganda accounts for 1 per cent of the TB global burden and ranks 20th among the 22 high burden countries.

While better access to treatment programmes will reduce rates of drug-resistant tuberculosis in countries with a high burden, they will not eradicate the problem alone, and current efforts may not be enough to reverse the epidemic.

As a result, research into additional control measures will be needed to prevent drug-resistant tuberculosis spreading between people.

Dr Aceng says that to reduce the burden of drug-resistant disease, the researchers recommend that treatment be coupled with ways to prevent spread of the disease, such as early detection, reducing the number of patients who do not complete treatment, and providing tailored treatment depending on which drugs the strain is susceptible to.

Latest figures from the ministry of health indicate that the TB prevalence rates now stands at 253/100,000 compared to 159 per 100,000 in 2015 according to recent population TB survey.

The TB survey also explains that there are 89000 annual TB infections in the country and that the rate stands higher than that of HIV/Aids that stands at 60,000 annually.

Latest figures estimate that each year there are 10.4 million new cases of tuberculosis, leading to 1.8 million deaths globally and that nearly 40% of all drug-resistant tuberculosis cases occur in Russia, India, the Philippines, and South Africa — accounting for more than 230000 cases of drug-resistant disease in 2015.

Forms of drug resistance

There are two forms of drug-resistant tuberculosis important to public health — multidrug-resistant tuberculosis is resistant to more than one of the first-line drugs for the disease, whereas extensively drug-resistant tuberculosis is additionally resistant to fluoroquinolones and at least one of the second-line injectable tuberculosis drugs.

Treating extensively drug-resistant tuberculosis takes up to 2 years with toxic drugs, including daily injections that can have severe long-term side effects (e.g. hearing loss, psychosis). Around 40% of people diagnosed with multidrug-resistant tuberculosis die of the disease, compared with 60% of those with extensively drug-resistant tuberculosis.

 

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