Nairobi has been long grappling with tuberculosis even before the first cases of COVID-19 were confirmed in March, 2020. The pandemic has brought new challenges to a city ranked the highest TB burdened in the country.
According to National TB Program there was a reduction in TB case finding in Nairobi with only 300 cases being reported in April 2020, where over 1,000 cases were reported in previous months. Most facilities were closed temporarily after staff were diagnosed with COVID-19. TB staff were deployed to COVID-19 isolation facilities with 17 out of 23 sub-county TB coordinators being assigned the role of managing quarantine sites.
There was initial resistance in most facilities to handle coughers, due to lack of personal protective equipment for the laboratory team who refused to test sputum samples.
There was also a low turn-out of patients at facilities for fear of contracting COVID-19, where some patients did self-referral up-county while others became lost to follow up.
Just like the famous anecdote depicts, a leader is forged in times of crisis, Elizabeth Mueni, the County TB Coordinator knew it was time to act before they lost all they had gained in the fight against the disease. She called her team together; sub county TB Coordinators and TB implementing partners, among them USAID Tuberculosis Accelerated Response and Care II (TB ARC II), and they developed innovative ways of ensuring continuity of TB services amid the pandemic.
The team began by holding a TB data review meeting to help in decision making where they also shared best practices on case finding across the sub-counties. Dissemination of TB performance monitoring charts were immediately initiated across all the facilities to help in reporting.
Differentiated care with longer return dates was adopted. Drug susceptible TB patients on intensive phase were given an appointment after two weeks, while those on continuation phase were given monthly appointments but in-line with follow up smears. Appointment diaries were well documented on each visit. Facility based Drug Resistant TB treatment was converted to community directly observed therapy with the county engaging community health volunteers to provide medicines to the patients in their homes.
The team forged intense joint supervision in facilities with low case finding. Mapping of patient pathways to optimise TB screening in facilities with low outpatient workload was conducted and multi-disciplinary review of complicated clinical cases with partners onsite was initiated.
A targeted door-to-door community TB screening in hot spot areas was conducted yielding three drug resistant TB cases and 126 drug sensitive cases. Intense contact tracing from this cluster found 61 contacts who had TB.
An integration of TB screening in ongoing polio immunisation outreaches was done and, from this exercise, 14 children were diagnosed with TB. At the facility level, an integration of COVID and TB screening was also done.
They adopted the use of virtual platforms to review drug resistant patients through the programmatic drug resistant meetings. In situation where a case was found to be complicated, a home visit was done while adhering to COVID-19 precaution measures. The virtual platforms were also used to conduct TB continuous medical education targeting health workers in both private and public facilities as well as give TB updates.
The team engaged national and community radio stations to raise TB awareness, demand creation for TB services and treatment completion. Experts and TB champions were invited to interactive radio shows to discuss TB.
A TB call center was set up and members of the public were sensitised and urged to call in for free TB consultation. From this, 106 patients were diagnosed with TB through the call center.
Through these interventions, improved case finding has been reported in the county with data showing a positive trajectory trend from 300 cases in April 2020, a month after the first case of COVID-19 was reported in Kenya, to 999 cases in September 2021 after the adoption of the above innovations.
