Friday, February 02, 2007

We are all infected, except perhaps you..." Tales of TB control in Sierra Leone by John Daniel Kelly

Dan Kelly accepts a traditional Sierra Leonean cloth in honor of NOW launch of their Kono Mobile Clinic.

“When drawing sputum samples, hand the patient a cup to spit into, stand upwind, and then tell the patients to cough,” said the Tuberculosis (TB) Lab Coordinator in a monotone voice. I briskly responded, “Don’t you wear masks?!” Slightly puzzled, he said, “No.” More puzzled than him, I asked, “Aren’t you worried about getting TB?” He responded, “No, I just focus on staying healthy.” Without understanding, I ignorantly rephrased my question, “But don’t you worry about becoming infected?” He responded soberly, “I am infected. [Pause] We are all infected, except perhaps you...”
Staring at the dirt road from the window of the staff bus, I allowed myself to be jostled into resignation of TB infection. After years of negative PPDs and a culture enforcing such a result, I was assured to return PPD positive and be required to take nine months of isoniazid (INH) therapy. How many times in my life would I take INH therapy? While other menial questions passed through mind, my pondering settled upon the remarkably growing awareness between TB control in the Bronx, New York, and Lakka, Sierra Leone. However, my imagination never could have prepared me for what I unfortunately have witnessed.
First, it is appropriate to describe the starting point of my imagination. If a patient is suspected to have TB in New York, the patient is immediately moved into an isolated room with negative pressure, a private bathroom, and television. Health workers are required to don masks at all times. A chest x-ray is taken by portable machine. Over three consecutive mornings, sputum samples are collected in sterile cups and sent to the laboratory for staining and culture. During these three days, the patient is not permitted to leave the room. Then, upon evaluation of the chest x-ray and sputum samples, a patient is determined to be negative or positive for TB. If the patient is TB negative, the patient is permitted to leave the isolation room and receive medical treatment with the other hospitalized patients. If the patient is TB positive, the patient is not permitted to leave the isolation room at least two months. During this time, empirical TB therapy is begun while the pending cultures determine the specific medications to be used. Infectious disease specialists monitor the treatment of each patient and use first-line or second-line medications accordingly.
Cries of injustice ring from many patients during this lengthy and commonly unexpected process. From a perspective based on the immediate surroundings, these cries may be validated. However, injustice appears different in Sierra Leone, a country that hears no cries from patients.
Infection control for airborne diseases in Sierra Leone is mostly outpatient therapy. If a patient is suspected to have TB, the patient is asked to give three separate sputum samples at a community clinic that is affiliated with the National TB program. A patient is found positive based upon sputum results without emphasis on completion of a chest x-ray. If the patient is TB positive, the patient is required to report to the clinic for directly observed therapy (DOT) on a daily basis. If the patient is TB positive and requires hospital admission, the patient is transported to the one control center called Lakka Chest Hospital.
In contrast to hospital admission in the USA, the therapy of a patient begins with a truck ride to Lakka, a village outside the capital city of Freetown. There at Lakka, the patient is placed in a bare two-bedded room where the windows are left open at all times. The patient begins receiving empirical first-line medications. In fact, all TB therapy is based on empirical methods since there are no facilities in the country to conduct sputum cultures. Most patients at Lakka have co-existing medical problems. While the TB medications are free by donation from a German-based non-governmental organization (NGO), no other medication is free nor is given to a patient until he or she pays for the medication. Most medications needed are not available at the makeshift pharmacy, so a relative or friend oftentimes must first buy the medications in Freetown and bring them to Lakka. Unfortunately, most patients are abandoned without money.
Most patients not only have a social plight, but they also come to Lakka in grave condition. If first-line TB medications fail, then they are given the same medications for a second time with streptomycin. No other second-line medications are available in the country. If a patient fails the second administration of medications and is still alive, he or she is sent from the hospital. Where that seldom patient goes remains a mystery. If the family of the patient has not abandoned their blood relative, the patient travels home with multi-drug resistant TB (MDR-TB) to infect the family.
Essentially, infection control fails to exist in Sierra Leone as we know it. However, after spending two weeks at Lakka in the TB/Leprosy Control Program, the glaring problem was not the failure called infection control, but the social injustices surrounding these displaced individuals.

Courtesy of John Daniel Kelly