Health is a major component in the socioeconomic development of any community. Indeed, it is not only a right but also a responsibility for all. The promotion of good health at different levels of society is the responsibility of all individuals, families, households, and communities. Kenya has embraced the community strategy to enable communities to improve and maintain a level of health that will enable them to participate fully in national development toward the realization of Vision 2030.

Respiratory diseases are responsible for a considerable burden of suffering and death in all age groups worldwide. The most frequently occurring respiratory diseases include pneumonia, acute respiratory infections (ARI), tuberculosis (TB), asthma, chronic obstructive pulmonary disease (COPD), and lung cancer.

Tuberculosis has existed for millennia and remains a major global health problem. It is an infectious disease caused by a bacillus belonging to a group of bacteria in the mycobacterium tuberculosis complex. Despite it being a preventable and curable disease, Tuberculosis is the leading cause of death due to a single infectious agent.

Tuberculosis (TB) remains a global threat to public health and is the leading cause of death by a single infectious agent with 1.4 million deaths in 2019. An estimated 10 million people developed TB disease but only 7.1 million (70%) were notified. The global TB targets aim at a 95% reduction in TB deaths, a 90% reduction in incidence compared to 2015, and 0% TB-affected families facing catastrophic costs due to TB by 2035.

Kenya is listed by the World Health Organization (WHO) among the 30 high-burden TB states. Despite the considerable investment done by the government and partners in TB care and prevention in the past 20 years, the disease is still the 4th leading cause of death.

In 2012, Kenya was one of the 22 high-priority countries selected by the WHO to undertake a national TB prevalence survey. The survey was eventually undertaken in 2016. The specific objectives of the nationwide tuberculosis prevalence survey were to determine the prevalence of bacteriologically confirmed pulmonary TB (PTB) among adults aged 15 years and above in Kenya and to assess the healthcare-seeking behavior of TB patients and those reporting TB symptoms.

The survey found that the TB incidence rate for Kenya is 348(213-516) compared to the WHO pre-survey estimate of 233 per 100,000 (95% CI 188-266) in 2015. Using the current incidence, about 169,000 (103,000- 250,000) people fell ill with TB in 2016, but only 46% (77,376) were diagnosed and put on treatment. Kenya is thus facing a high burden of TB and 54% of the people estimated to have TB remain unnotified.

According to WHO, Kenya is one of the 30 high-burden TB, TB/HIV, and MDR countries in the world. The 2015/2016 Kenya prevalence survey, found an overall national prevalence of 426/100,000 and demonstrated that Kenya misses approximately 40% of people with TB. It also found that screening for TB using a cough of more than two weeks would have missed 52% of the cases.

67% of the prevalent cases with at least one TB-related symptom had not sought any health care prior to the survey; the majority of whom were men. Among the prevalent cases who had sought prior care for their respiratory symptoms, 80% of them had not been diagnosed with TB before the survey. In 2019, Kenya reported 86,504 cases of all forms of TB with 9.7% of all cases notified being children below 15 years of age

ABOUT TUBERCULOSIS

TUBERCULOSIS (TB) is an airborne communicable disease caused by bacteria belonging to the Mycobacterium Tuberculosis Complex (MTBC). It typically affects the lungs (pulmonary TB) but can also affect other sites (extrapulmonary TB).

When people with lung TB cough, sneeze, or spit, they propel as many as 3000 infected droplets of TB germs into the air. A person needs to inhale only a few of these (less than 10 bacilli) to become infected. The germs can remain in the air for long periods of time, especially in dark enclosed spaces.

When a person inhales the germs, they can affect the lungs or other parts of the body. Most infections in humans result in an asymptomatic, latent TB infection, and about 1 in 10 latent infections eventually progress to active disease.

Microbiology of TB;

Mycobacteria are a group of bacteria that can cause a variety of diseases. Some mycobacteria are grouped as mycobacterium tuberculosis complex because they cause TB or diseases similar to TB. The following are the species of mycobacterium that cause tuberculosis:

• Mycobacterium tuberculosis – the most common cause of human tuberculosis.

• Mycobacterium bovis - acquired by drinking unpasteurized milk from an infected cow.

• Mycobacterium kasansii – an infection of the lung that causes a pulmonary disease similar to TB.

• Mycobacterium africanum – a species of mycobacterium found in West Africa that causes 40-50% of pulmonary TB.

• Mycobacterium leprae – this is the bacterium that causes leprosy.

• Mycobacterium avium intracellurae – a typical mycobacteria species commonly seen in people with advanced HIV/AIDS disease.

Predisposing Factors of Tuberculosis;

Predisposing factors are conditions that increase the likelihood of an individual acquiring tuberculosis or make an existing TB infection severe or difficult to manage. The following are the predisposing factors of TB.

Ignorance - Lack of awareness about the signs and symptoms of tuberculosis, modes of transmission, and prevention strategies increases the community's spread of the disease.

1. Misinformation - Myths and misconceptions about the disease by patients and healthcare service providers make it difficult to eradicate tuberculosis infections in the community.

2. Poor Hygiene and Sanitation - The prevalence of tuberculosis is high in the developing world, especially in slum areas, where poor sanitation, housing, and hygiene are common.

3. Poverty - Low socioeconomic status and lack of finances contribute to bad health-seeking behavior leading to delayed diagnosis and access to medication for tuberculosis or treatment failure.

4. Social Disruptions - War (internally displaced persons) and economic depression increase poor treatment compliance, and tuberculosis defaulter rates and also disrupt tuberculosis medication supply chains.

5. Immunosuppression - Reduced body defense mechanisms such as HIV/AIDS, cancer, chronic alcoholism, chemotherapy/radiotherapy, long-term use of steroids, diabetes, and chronic cigarette smoking are predisposing factors for developing TB because they lower the body’s immunity.

6. Overcrowding - Overcrowding in refugee camps, slum settlements, nursing homes, and prisons increases the transmission of TB.

Epidemiology of Tuberculosis

Epidemiology is the study of the distribution and determinants of health-related states in specific populations.

Tuberculosis (TB) is a communicable disease that is a major cause of ill health in the whole world. It is spread from person to person through the air. Humans may also be infected through the gastrointestinal tract following the ingestion of milk from tuberculous cows (now uncommon due to pasteurization) or, rarely, through an open wound

Globally, an estimated 10 million people fell ill with TB in 2019. Out of this number, 25% of them were in Africa. TB is one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent (ranking above HIV/AIDS).

Epidemiologic data indicate that large doses or prolonged exposure to smaller infecting doses are usually needed to initiate infection in humans. In some closed environments, such as crowded homes, a single open case of pulmonary tuberculosis can infect many non-immune individuals sharing sleeping accommodations.

In high-burden settings, TB has its high peak incidence in early adulthood, affecting the most economically productive age group. While in low-burden countries, TB is more common in elderly persons as well as among immigrants and people who are socially destitute.

According to the WHO Global TB (2020), there are more cases of TB among men than women. Men (aged ≥15 years) accounted for 56% of the people who developed TB in 2019; women accounted for 32% and children (aged <15 years) for 12%. Among all those affected, 8.2% were people living with HIV.

Infection with TB bacteria does not always lead to the development of the disease as the immune system of healthy people is able to contain the infection. Thus the bacilli remain dormant. People infected with TB bacteria have a 5–15% lifetime risk of falling ill with TB.

However, diseases such as HIV infection increase the chances of an individual developing active TB following exposure. Also, as immune suppression due to HIV advances, the reactivation of latent TB disease can occur.

Young children are less infectious. However, data on TB disease among children has not been collected in a systematic way due to the difficulty of confirming TB in this age group. Thus, many children are treated without notification. Apart from contributing to pneumonia deaths, TB is an underlying cause of a substantial number of children dying of meningitis, HIV, or severe malnutrition.

Smoking, diabetes, and other co-morbidities increase the susceptibility to activate TB. Individuals with diabetes have a 2-3 times higher risk of developing active TB. Around 10% of TB cases globally are now linked to diabetes.

Drug-resistant TB continues to be a public health threat. According to the WHO Global TB Report (2019), close to half a million people in the world developed rifampicin-resistant TB (RR-TB), of which 78% had multidrug-resistant TB (MDR-TB). Multidrug-resistant (MDR-TB) is defined as resistance to at least rifampicin and isoniazid – the two most powerful first-line TB drugs. Treatment for MDR-TB is longer and requires more expensive, more toxic drugs.

Extensively drug-resistant TB (XDR-TB) is defined as MDR plus additional resistance to any fluoroquinolone and at least one of the injectable agents (amikacin, capreomycin, or kanamycin). Infection with XDR-TB further decreases the chances of treatment success and survival.

TB Management Guidelines

TB management guidelines have been developed in order to provide a public health approach to the management of TB. These guidelines are designed to give healthcare workers (HCWs) and TB Champions guidance on the diagnosis, treatment, prevention, and rehabilitation of patients with TB.

The guidelines are organized into the following sections:

• Practical Approach to Lung Health: This section discusses the syndromic approach to the management of patients attending primary health care services with respiratory symptoms in order to improve early diagnosis of tuberculosis. It also includes the diagnosis and treatment of all forms of tuberculosis in children, adults, and other special populations.

• Nutrition: This section highlights the relationship between nutrition and TB.

• Advocacy, Communication and Community Engagement in Relation to Tuberculosis.

• Infection prevention and control of tuberculosis.

• Commodity management and management of adverse drug reactions (pharmacovigilance).

• Monitoring and Evaluation: This highlights the processes and tools involved in the accurate recording and reporting of TB activities and interventions within the program.

For more information look at the community health strategy for care and prevention.

Community Health Strategy for Care and Prevention

The community health strategy is a community-based approach through which households and communities take an active role in managing their health.

The goal of the community health strategy in Kenya is to:

1. Enhance community access to health care by providing health care services for all socio-economic groups at household and community levels;

2. Build the capacity of community health extension workers (CHEWs) and champions to provide community-level services;

3. Strengthen health facility-community linkages; and raise the community's awareness of their rights to health services.

The community health strategy looks at the community as a unit that is able to share its resources and challenges. The community unit (CU) has three types of actors with different roles.TB Champions - These are volunteer workers who provide services and support community initiatives to improve their health status.

Community Health Committee (CHC) - The governance body for CU consists of representatives from different groups and villages who provide leadership for managing level 1 service and activities in CU and build partnerships with stakeholders.

Community Health Extension Worker (CHEW) - Health or development workers support TB Champions and CHC technically through supervision and mentoring and strengthen the linkage between CU and higher health systems.

The Goals of Community Health Strategy.

TB champions are individuals who work as volunteers in their community to end TB. They complement the services offered by healthcare workers. TB champions are powerful advocates who defend the rights of TB patients by engaging with health institutions and other stakeholders in the community to ensure that TB patients receive person-centered services.  

TB Champions also play a key role in the fight against TB through

1. Awareness creation: They create awareness about TB in communities and help in accelerating notification in vulnerable areas as well reduce stigma.

2. Sensitization: They serve as a reliable conduit for providing TB information on causes, symptoms, treatment, and prevention to the community.

3. Home visits: They visit homes to give advice on treatment adherence, and nutrition, and identify and refer new cases as well as those cases with adverse reactions to treatment. They also link people at risk of TB infection with healthcare facilities in the community.

TB Champions facilitate people’s change so that they can achieve their dreams of living a healthy life. TB Champions build relationships through visits and also by listening and appreciating people. The trust that they build with people in the community determines how open they are to receiving the health information that TB Champions have to share.

The following are some of the activities that are undertaken by TB Champions  under the community health strategy:

• Door-to-door campaigns: To create awareness, detect, screen, and refer cases.  

• Home visits: To determine the health situation and initiate dialogue with household members to undertake the necessary action for improvement.

• Sensitization: Providing first-hand and reliable information about healthy practices and guiding the community on how to improve health and prevent illness.

• Follow up on cases in the community to promote care-seeking and compliance with treatment and advice.

• Referral of cases to the health facility.

Types Of TB

There are three types of TB, namely: Active, Latent, and Milliary TB.

Active TB - This is a state where a person who is infected with M. tuberculosis bacilli develops signs and symptoms of TB disease. In this case, there is active multiplication of the bacilli inside the body. The risk of developing TB disease following infection with the tubercle bacillus is very high in people who have a weakened immune system.

Latent TB - This is a state where a person is infected with M. tuberculosis but does not develop any symptoms of the disease.  Their immune system is able to fight TB and so they can remain healthy for years or even for life.  When cases of latent TB are tested, there is a positive reaction to the tuberculin skin test/blood test. However, they cannot spread TB to other people.

Miliary TB - This is a rare form of active disease that occurs when TB bacteria finds its way into the bloodstream and spreads throughout the body.

Diagnosis of TB

TB disease is diagnosed by taking the medical history of the patient and carrying out a physical examination, chest x-ray, and other laboratory tests.

1. Sputum Test 

This is a test done to find germs such as the TB bacteria that can cause an infection. A sample of the sputum is added to a substance that helps to promote the growth of bacteria.

          2. Chest X-ray

This is a rapid imaging technique that allows any abnormality in the lung to be identified. Its main use is to diagnose the condition of the thoracic cavity, airways, ribs, lungs, heart, and diaphragm.

          3. Culture

This test is used to confirm if the bacteria is present. It involves growing the bacteria on different substances. The substances are either solid substances on culture plates or bottles of liquid known as culture broth.  The substances make it as easy for the bacteria to grow.

         4. Gene Expert

This is a molecular test for TB that can find out if a person is infected and also whether the bacterium of the person has any resistance to TB medication.

         5.Mantoux Tuberculin Skin Test (TST)

This is a skin test that is used to determine whether a person is infected with M. tuberculosis.

TB Treatment Regimen.

The aims of TB treatment are to Cure the patient and hence stop suffering and death from TB, prevent long-term complications of TB such as loss of lung tissue, prevent reoccurrence of the disease, prevent the spread of the disease to the community and household member, and prevent the development of drug-resistant TB.

The basic principles of TB treatment include observing drug intake to ensure adherence and compliance to treatment, ensuring completion of treatment, never using one drug to treat TB as this would lead to resistance, always using drugs in combination to improve adherence – Fixed Dose Combinations (FDCs), and always basing the dose on the patient’s weight to avoid overdose or underdose.

The treatment of TB benefits the person who has TB, the immediate family, and the community at large. It helps the patient because it prevents disability and death and restores health. It benefits the immediate family and community because it prevents the further transmission of TB. 

TB disease must be treated for at least 6 months and in some cases even longer. Most of the bacteria are killed during the first 8 weeks of treatment; however, there are persistent organisms that require longer treatment. If treatment is not continued for a desired duration, the surviving bacteria may cause the patient to become ill and infectious again, potentially with drug-resistant disease.

The regimens for the treatment of TB disease contain multiple drugs to which the bacteria are susceptible. The standard of care for initiating treatment of TB disease is four-drug therapy.  Treatment with a single drug can lead to the development of a bacterial population resistant to that drug. Likewise, the addition of a single drug to a failing anti-TB regimen can lead to additional resistance. When two or more drugs are given together, each helps prevent the emergence of tubercle bacilli resistant in the others.

The treatment regimen for TB disease is divided into the following two phases:

1. The initial phase (2 months):  The aim of this phase is to rapidly shorten the duration of infectiousness by killing the actively growing and semi-dormant bacilli. The treatment uses a four-drug regimen, namely:  R-R-Rifampicin, H- Isoniazid, Z- pyrazinamide, and E- ethambutol.

2. Continuation phase (4-6 months): The treatment regimen during this phase aims at reducing failures and relapses by eliminating the remaining bacilli and stopping the emergence of drug resistance. A regimen of 2 drugs is used. These are:  R-rifampicin and  H-Isoniazid.

It is very important to provide the patients with information about their treatment and the consequences of not taking their medicines correctly.  You should also clearly inform them about the adverse reactions or side effects of the medication they are taking and when to seek medical assistance

Nutrition in the Context of TB

Nutrition refers to “the sum of all the processes that are involved in taking in nutrients and their assimilation and uses for proper body functioning and maintenance of health.  The successive stages include; ingestion, digestion, absorption, assimilation, and excretion  (NTLD-P, 2021).

A person with TB does not need special food; all they need is a balanced diet. Good nutrition means giving your body all the necessary nutrients, vitamins, and minerals it needs to work its best.