Trans R Soc Trop Med Hyg 2014; 108: 4–5 doi:10.1093/trstmh/trt107 Advance Access publication 3 December 2013
COMMENTARY
Reaching out to take on TB in Somalia David AJ Moorea,* and Simo M Granatb,1 a
1
London School of Hygiene and Tropical Medicine TB Centre, London, WC1E 7HT, UK; bProgramme Director, PSR-Finland TB Programme for Somalia, Finland
Present address: Hietaniemenkatu Service Centre for Homeless, Department of Social Services and Health Care, Helsinki, Finland *Corresponding author: Tel: +44 (0) 207 927 2142; E-mail: [email protected]
Received 8 November 2013; accepted 10 November 2013 Among the many challenges facing populations disrupted by complex emergencies, personal security and food security rank much higher than access to healthcare. However, over time health needs assume increasing importance. Many complex crises occur in settings where the background incidence of TB is already high; social and economic conditions in crises are then highly conducive to amplification of the existing TB problem. Innovative approaches to delivery of diagnostic and treatment services, transition planning and integration with other healthcare providers and services are vital. In the extremely challenging environment of Somalia, multiple partners are making headway though collaboration and innovation. Keywords: Emergency, Somalia, TB, Tuberculosis,
Healthcare is one of the many casualties in complex emergencies. Within the health sphere, initial attention is focussed on prevention and control of catastrophic outbreaks of acute infectious diseases, such as cholera and measles. Chronic disease management (diabetes, hypertension, HIV) is disrupted and not prioritised because more immediate threats to security and survival understandably dominate. As such emergencies enter a more chronic phase and systems become more established the spectrum of healthcare delivery needs to widen. Later still, a transition from emergency relief response to sustainable healthcare programme delivery needs to take place with handover to national Ministries of Health. TB control is an interesting lens through which to examine this challenging process.1 Affected populations often hail from settings where the background incidence of TB is high.2 Most low and middle-income countries organise TB control through National Tuberculosis Control Programmes operating through the Ministry of Health, following (albeit to varying degrees) WHO guidelines and framework for TB prevention, diagnosis and treatment. Though a significant proportion of TB management is undertaken by the private sector in some countries, such a contribution is rarely apparent in complex emergencies. What is apparent is that non-governmental relief organisations (NGOs) usually take up the baton and step into the healthcare void created when large populations find themselves suddenly and/or chronically without their pre-existing health system. As Liddle and colleagues from the Me´decins Sans Frontie`res (MSF) describe in
the November issue of Transactions of the Royal Society of Tropical Medicine & Hygiene, there are unique challenges to delivering TB care in settings where security is unreliable.3 As clinicians we need to constantly remind ourselves that health is simply not the number one priority for most people, anywhere. In settings where their day to day existence is dominated by concerns about food security and violence and the psychological trauma of displacement and uncertainty this is particularly true. In post-conflict Somaliland, which neighbours the regions of Puntland and South Central Somalia where MSF were working, only 2% of respondents in a 2012 community survey identified access to healthcare as their greatest ongoing need.4 So although communities are not specifically demanding TB control capacity it is evidently needed, although perhaps as part of a wider package during the complex emergency phase. Extraordinary conditions demand innovative solutions, and the use of directly observed treatment (DOT) ‘corners’ to enhance accessibility, as previously described in Bangladesh, and the provision of ‘escape drugs packages’ are two good examples implemented in Somalia by MSF. Getting to treatment default rates below 10% is an astonishing accomplishment in this environment and testimony to what can be achieved. However, diagnostic capacity is, inevitably, constrained and leads to much empiric treatment that may partly explain the association of death with a lack of microbiologically confirmed TB (patients dying of something else). Similarly, the reported poorer treatment outcome rate for paediatric TB should be considered rather as the outcome of TB
# The Author 2013. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
4
Transactions of the Royal Society of Tropical Medicine and Hygiene
treatment for presumed childhood TB, which is clearly a different thing. An alternative and immediately more alarming explanation of TB-associated mortality may be failure to diagnose and treat multidrug resistant (MDR) TB. A 2010–2011 drug resistance survey in Somalia found that 5.2% of new cases and 40.8% of retreatment cases had MDR-TB.5 Current diagnostic capacity across the region is currently woefully inadequate to identify these patients, although MDR treatment, which MSF pioneered in Puntland in early 2013, has recently been initiated in the Somaliland National Tuberculosis Programme (NTP), and in-country phenotypic (MODS) and genotypic (Xpert MTB/RIF) drug susceptibility testing capacity is now being implemented. Diagnosis and treatment of MDR should not be regarded as a luxury but rather as an emergency: failure to act now creates a time bomb that will go on ticking for generations. Yet once again the crisis setting complicates matters: treatment interruptions can be particularly disastrous for patients with MDR-TB. Given how hard it is to complete lengthy MDR treatment (conventionally .18 months) under normal circumstances it may be that the advantages of shorter regimens recently showing considerable promise could be particularly useful here.6 MSF made the enormously difficult decision to withdraw from Somalia in August of this year but took care through contingency planning to leave behind complete treatment courses for those MDR patients already on treatment.7 The importance of quality assurance is even greater in complex settings and is feasible with imaginative use of available resources. In our TB REACH supported roll-out of LED fluorescence microscopy in Somaliland, real-time remote external quality assurance was achieved by requiring microscopy centres to text message to the central laboratory their reading of a slide from a blinded panel prior to reading the routine work: significant variance immediately highlighted deficiencies in staining or reading and prompted corrective action. Ultimately the goal is for TB services to eventually come under the auspices of organised government although realistically this can take a considerable time, particularly where there is heavy reliance on external support. There are complexities in securing and maintaining external donor financing in the absence of clear government structures, and linkage of statistics from multiple providers (let alone the private sector) and coordination of multi-partner efforts to maximise impact benefits greatly from consolidation by a credible overseeing agency. Currently in Somalia, World Vision International is the principal recipient of Global Fund support and, through collaboration with the NTPs of Somaliland, Puntland and South Central Somalia and multiple
sub-recipient NGOs, navigates a complicated political and demographic landscape. In recent years, support from the STOP TB Partnership TB REACH programme to World Vision (Wave 1) and a London School of Hygiene and Tropical Medicine/PSR Finland/Somaliland NTP consortium (Wave 2) has financed activities that effectively complement Global Fund supported work. While populations such as these await emergence from the complex emergencies in which they have become unwillingly immersed, dependence on non-governmental agencies working effectively together will continue.
Authors’ contributions: DM conceived the paper; DM and SG wrote the first draft and critically revised the manuscript for intellectual content. All authors read and approved the final manuscript. DM is guarantor of the paper. Funding: None. Competing interests: None declared. Ethical approval: Not required.
References 1 Kimbrough W, Saliba V, Dahab M et al. The burden of tuberculosis in crisis-affected populations: a systematic review. Lancet Infect Dis 2012;12:950–65. 2 Coninx R. Tuberculosis in complex emergencies. Bull World Health Organ 2007; 85:637–40. 3 Liddle KF, Elema R, Thi SS et al. TB treatment in a chronic complex emergency: treatment outcomes and experiences in Somalia. Trans R Soc Trop Med Hyg 2013;107:690–8. 4 IRI. Survey of Somaliland public opinion. RI Survey 2011. International Republican Institute;2011. 5 Sindani I, Fitzpatrick C, Falzon D et al. Multidrug-resistant tuberculosis, Somalia, 2010–2011. Emerg Infect Dis 2013;19:478–80. 6 Van Deun A, Maug AK, Salim MA et al. Short, highly effective, and inexpensive standardized treatment of multidrug-resistant tuberculosis. Am J Respir Crit Care Med 2010;182:684–92. 7 Karunakara and Dolle´. Blog: The limits of humanitarian aid—MSF and TB in Somalia. BMJ 2013. http://blogs.bmj.com/bmj/2013/10/23/unnikarunakara-and-jean-christophe-dolle-the-limits-of-humanitarian-aidmsf-and-tb-in-somalia/ [accessed 11 November 2013].
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COMMENTARY
Reaching out to take on TB in Somalia David AJ Moorea,* and Simo M Granatb,1 a
1
London School of Hygiene and Tropical Medicine TB Centre, London, WC1E 7HT, UK; bProgramme Director, PSR-Finland TB Programme for Somalia, Finland
Present address: Hietaniemenkatu Service Centre for Homeless, Department of Social Services and Health Care, Helsinki, Finland *Corresponding author: Tel: +44 (0) 207 927 2142; E-mail: [email protected]
Received 8 November 2013; accepted 10 November 2013 Among the many challenges facing populations disrupted by complex emergencies, personal security and food security rank much higher than access to healthcare. However, over time health needs assume increasing importance. Many complex crises occur in settings where the background incidence of TB is already high; social and economic conditions in crises are then highly conducive to amplification of the existing TB problem. Innovative approaches to delivery of diagnostic and treatment services, transition planning and integration with other healthcare providers and services are vital. In the extremely challenging environment of Somalia, multiple partners are making headway though collaboration and innovation. Keywords: Emergency, Somalia, TB, Tuberculosis,
Healthcare is one of the many casualties in complex emergencies. Within the health sphere, initial attention is focussed on prevention and control of catastrophic outbreaks of acute infectious diseases, such as cholera and measles. Chronic disease management (diabetes, hypertension, HIV) is disrupted and not prioritised because more immediate threats to security and survival understandably dominate. As such emergencies enter a more chronic phase and systems become more established the spectrum of healthcare delivery needs to widen. Later still, a transition from emergency relief response to sustainable healthcare programme delivery needs to take place with handover to national Ministries of Health. TB control is an interesting lens through which to examine this challenging process.1 Affected populations often hail from settings where the background incidence of TB is high.2 Most low and middle-income countries organise TB control through National Tuberculosis Control Programmes operating through the Ministry of Health, following (albeit to varying degrees) WHO guidelines and framework for TB prevention, diagnosis and treatment. Though a significant proportion of TB management is undertaken by the private sector in some countries, such a contribution is rarely apparent in complex emergencies. What is apparent is that non-governmental relief organisations (NGOs) usually take up the baton and step into the healthcare void created when large populations find themselves suddenly and/or chronically without their pre-existing health system. As Liddle and colleagues from the Me´decins Sans Frontie`res (MSF) describe in
the November issue of Transactions of the Royal Society of Tropical Medicine & Hygiene, there are unique challenges to delivering TB care in settings where security is unreliable.3 As clinicians we need to constantly remind ourselves that health is simply not the number one priority for most people, anywhere. In settings where their day to day existence is dominated by concerns about food security and violence and the psychological trauma of displacement and uncertainty this is particularly true. In post-conflict Somaliland, which neighbours the regions of Puntland and South Central Somalia where MSF were working, only 2% of respondents in a 2012 community survey identified access to healthcare as their greatest ongoing need.4 So although communities are not specifically demanding TB control capacity it is evidently needed, although perhaps as part of a wider package during the complex emergency phase. Extraordinary conditions demand innovative solutions, and the use of directly observed treatment (DOT) ‘corners’ to enhance accessibility, as previously described in Bangladesh, and the provision of ‘escape drugs packages’ are two good examples implemented in Somalia by MSF. Getting to treatment default rates below 10% is an astonishing accomplishment in this environment and testimony to what can be achieved. However, diagnostic capacity is, inevitably, constrained and leads to much empiric treatment that may partly explain the association of death with a lack of microbiologically confirmed TB (patients dying of something else). Similarly, the reported poorer treatment outcome rate for paediatric TB should be considered rather as the outcome of TB
# The Author 2013. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: [email protected].
4
Transactions of the Royal Society of Tropical Medicine and Hygiene
treatment for presumed childhood TB, which is clearly a different thing. An alternative and immediately more alarming explanation of TB-associated mortality may be failure to diagnose and treat multidrug resistant (MDR) TB. A 2010–2011 drug resistance survey in Somalia found that 5.2% of new cases and 40.8% of retreatment cases had MDR-TB.5 Current diagnostic capacity across the region is currently woefully inadequate to identify these patients, although MDR treatment, which MSF pioneered in Puntland in early 2013, has recently been initiated in the Somaliland National Tuberculosis Programme (NTP), and in-country phenotypic (MODS) and genotypic (Xpert MTB/RIF) drug susceptibility testing capacity is now being implemented. Diagnosis and treatment of MDR should not be regarded as a luxury but rather as an emergency: failure to act now creates a time bomb that will go on ticking for generations. Yet once again the crisis setting complicates matters: treatment interruptions can be particularly disastrous for patients with MDR-TB. Given how hard it is to complete lengthy MDR treatment (conventionally .18 months) under normal circumstances it may be that the advantages of shorter regimens recently showing considerable promise could be particularly useful here.6 MSF made the enormously difficult decision to withdraw from Somalia in August of this year but took care through contingency planning to leave behind complete treatment courses for those MDR patients already on treatment.7 The importance of quality assurance is even greater in complex settings and is feasible with imaginative use of available resources. In our TB REACH supported roll-out of LED fluorescence microscopy in Somaliland, real-time remote external quality assurance was achieved by requiring microscopy centres to text message to the central laboratory their reading of a slide from a blinded panel prior to reading the routine work: significant variance immediately highlighted deficiencies in staining or reading and prompted corrective action. Ultimately the goal is for TB services to eventually come under the auspices of organised government although realistically this can take a considerable time, particularly where there is heavy reliance on external support. There are complexities in securing and maintaining external donor financing in the absence of clear government structures, and linkage of statistics from multiple providers (let alone the private sector) and coordination of multi-partner efforts to maximise impact benefits greatly from consolidation by a credible overseeing agency. Currently in Somalia, World Vision International is the principal recipient of Global Fund support and, through collaboration with the NTPs of Somaliland, Puntland and South Central Somalia and multiple
sub-recipient NGOs, navigates a complicated political and demographic landscape. In recent years, support from the STOP TB Partnership TB REACH programme to World Vision (Wave 1) and a London School of Hygiene and Tropical Medicine/PSR Finland/Somaliland NTP consortium (Wave 2) has financed activities that effectively complement Global Fund supported work. While populations such as these await emergence from the complex emergencies in which they have become unwillingly immersed, dependence on non-governmental agencies working effectively together will continue.
Authors’ contributions: DM conceived the paper; DM and SG wrote the first draft and critically revised the manuscript for intellectual content. All authors read and approved the final manuscript. DM is guarantor of the paper. Funding: None. Competing interests: None declared. Ethical approval: Not required.
References 1 Kimbrough W, Saliba V, Dahab M et al. The burden of tuberculosis in crisis-affected populations: a systematic review. Lancet Infect Dis 2012;12:950–65. 2 Coninx R. Tuberculosis in complex emergencies. Bull World Health Organ 2007; 85:637–40. 3 Liddle KF, Elema R, Thi SS et al. TB treatment in a chronic complex emergency: treatment outcomes and experiences in Somalia. Trans R Soc Trop Med Hyg 2013;107:690–8. 4 IRI. Survey of Somaliland public opinion. RI Survey 2011. International Republican Institute;2011. 5 Sindani I, Fitzpatrick C, Falzon D et al. Multidrug-resistant tuberculosis, Somalia, 2010–2011. Emerg Infect Dis 2013;19:478–80. 6 Van Deun A, Maug AK, Salim MA et al. Short, highly effective, and inexpensive standardized treatment of multidrug-resistant tuberculosis. Am J Respir Crit Care Med 2010;182:684–92. 7 Karunakara and Dolle´. Blog: The limits of humanitarian aid—MSF and TB in Somalia. BMJ 2013. http://blogs.bmj.com/bmj/2013/10/23/unnikarunakara-and-jean-christophe-dolle-the-limits-of-humanitarian-aidmsf-and-tb-in-somalia/ [accessed 11 November 2013].
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