A Consequence of Conflict: The Spread of Multidrug-Resistant Tuberculosis

For more than 20 years, Kenya has been providing asylum to people fleeing civil war and conflict from Somalia. Many first reach Dadaab refugee camp, located in Garissa County, Kenya, about 50 miles from the Somali border where the United Nations High Commissioner for Refugees (UNHCR) and partners provide humanitarian relief and protection assistance. In recent years, Dadaab has experienced a new arrival trend – in addition to those fleeing insecurity, persons with a diagnosis of multidrug-resistant tuberculosis (MDR TB) have crossed the border to seek treatment.

A drug resistance survey conducted in 2011 in Somalia showed that the country had the highest rate of MDR TB infection on the African continent. MDR TB develops when a patient receives ineffective treatment or treatment is interrupted, a common occurrence when people are subjected to violence and insecurity. The TB bacteria still present in the patient’s body develops resistance to drugs commonly used to treat it, including isoniazid and rifampin.

With more than 400,000 Somalis residing in refugee camps in Kenya and still more moving to other areas of Kenya like Eastleigh, a suburb in Kenya’s capital of Nairobi, and to Ethiopia, addressing MDR TB has become a regional public health concern. Led by Dr. Nina Marano, the CDC Kenya Refugee Health Program has worked in Dadaab refugee camp for 8 years, collaborating with government of Kenya, the International Organization for Migration (IOM) and UNHCR to address a range of health concerns within the camp, including TB.

“As the tuberculosis bacteria know no political boundaries, it’s important that MDR TB is addressed from a regional and multi-agency perspective in East Africa. CDC and its partners recognize that supporting efforts to rapidly identify and fully supervise the effective treatment of MDR TB cases in Somalia is critical to stopping transmission,” said Dr. Marano.

CDC also collaborates with the Kenya Medical Research Institute (KEMRI) and other U.S. government partners like the National Institutes of Health (NIH) and the U.S. Agency for International Development (USAID) to conduct research to improve and simplify diagnostic tools, case detection procedures, and treatment regimens.

TB is difficult to treat. Patients with drug-susceptible TB must take treatment drugs for 6-8 months, while MDR TB treatment can take 2 years. Without treatment many MDR TB patients will die within 1-2 years, and their families and members of their communities become vulnerable to TB infection.

CDC Kenya and its partners recognize the need for improved health systems within Somalia. Even when patients actively seek treatment for diseases like TB, they face significant hurdles when health facilities, staff, and resources like necessary drugs and supplies are not consistently available, leading to more severe consequences, including drug resistance.

However, the current capacity to prevent, diagnose, and treat infectious disease in Somalia is limited. While donors have provided TB diagnostic machines to Somalia and the Global Fund to Fight AIDS, Tuberculosis, and Malaria is scaling up MDR TB treatment, capacity is not yet available to diagnose and treat the large number of patients who require it.

Several strategies have been proposed to address the problem in Somalia and the region

• First is the need to ensure that all patients with MDR TB receive treatment wherever they seek it, regardless of their country of origin.
• Second, efforts are needed to expand the capacity to diagnose and treat TB and drug-resistant TB in the region. CDC supports this urgent need by working with countries to increase their capacity to conduct disease surveillance and research improved case detection and diagnosis.
• Third, long-term solutions are essential to ensuring all countries can effectively prevent, detect, and treat MDR TB.

The situation in Somalia and Dadaab illustrates the need to ensure health systems can respond to public health challenges like TB and implement programs to support early diagnosis and effective, uninterrupted treatment, reducing poor health outcomes in vulnerable populations.

Reference: Cain KP, Marano N, Kameme M, Sitienei J, Mukherjee S, Galev A, et al. The movement of multidrug-resistant tuberculosis across borders in East Africa needs a regional and global solution. PLoS Med. 2015;12(2):e1001791.

Activities to support the East Africa region to address MDR TB are in line with the international Global Health Security Agenda (GHSA), which seeks to accelerate progress among all countries in having the capacity to prevent, detect, and respond to a variety of infectious diseases.

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