Author: duncanmatheka

Part 1: Combating Rheumatic Heart Disease in Kenya

Prevention and Control of Rheumatic Heart Disease in Kenya: Issues and Barriers

Rheumatic heart disease (RHD) is the most common acquired heart disease in children (common age group is 5 to 15 year olds) in developing countries. Over 15 million people suffer from the condition, resulting in about 233 000 deaths annually. RHD is a chronic heart condition caused by rheumatic fever – whose main symptoms include fever, muscle aches, swollen and painful joints, and in some cases, a red rash. Rheumatic fever is as a result of an untreated strep throat that is caused by bacteria called group A streptococcal (strep) infection. Overcrowding, poor housing conditions, undernutrition and lack of access to healthcare play a role in the persistence of this disease in developing countries.

According to the World Heart Federation (WHF), the “primary prevention of acute rheumatic fever (the prevention of initial attack) is achieved by treatment of acute throat infections caused by group A streptococcus. This is achieved by up to 10 days of an oral antibiotic (usually penicillin) or a single intramuscular penicillin injection.” Moreover, regular antibiotics (usually monthly injections) can prevent patients with rheumatic fever from contracting further strep infections and causing progression of valve damage. The decline of rheumatic fever in developed countries is believed to be the result of improved living conditions and availability of antibiotics for treatment of group A streptococcal infection.

Although Rheumatic Heart Disease (RHD) has been eradicated in the developed world (Carapetis 2007), it still imparts significant health and economic burdens in developing countries worldwide (Ozer et al. 2005, Nitin et al. 2013). The irony is that the disease is completely preventable. A study performed in western Kenya showed that 9 out of the 526 enrolled patients exhibited echocardiographic evidence of RHD (Holland 2012). The transthoracic echocardiograms were performed on randomly selected hospitalized patients, aged 5-35, who were not previously diagnosed with RHD, on the surgical wards.

 

The Issues and Barriers to RHD Control

RHD is a neglected ‘preventable’ chronic disease that requires continuous and expensive medical follow-up if not prevented or treated effectively as early as possible. RHD is closely associated with poverty and poor quality medical services, so most RHD patients are not able to access medical services in a timely or effective manner (Okello et al. 2012). After initiating treatment, most patients are lost to follow up. As a result, the disease often progresses to advanced stages with complicating comorbid conditions, in which treatment is rarely successful. This contributes to the high morbidity and mortality rates observed in patients diagnosed with RHD in Kenya.

Kenya’s health system is inappropriately designed and inadequately financed to prevent and to manage RHD – with poorly equipped hospitals, a low doctor to patient ratio, and unaffordable drugs such as penicillin. The issue is exacerbated by a flawed national health insurance plan through which patients are still unable to afford medical services (Kimani et al. 2012, Stone et al. 2014).

RHD requires specialized care, only accessible in Nairobi and a few urban centers across Kenya (Jowi 2012). Even in such places, availability of services at public hospitals is limited due to inadequate numbers of cardiologists or lack of necessary diagnostic and treatment facilities. “We need to treat approximately 500 patients with RHD, but we can only handle about 50 open heart surgeries locally due to resource constraints.” stated Prof Gerald Yonga, Chair Department of Medicine at the Aga Khan University Hospital, Kenya.

Widespread lack of awareness and accurate information about RHD in part explain why prevention is rare and many RHD cases are diagnosed too late to treat effectively (Mondo et al. 2013). Furthermore, the presentation of RHD often mimics many other tropical fevers (malaria, typhoid), and thus also presents a challenge to early detection. At presentation, many healthcare workers misdiagnose, prescribe inappropriate treatment, and do not design adequate follow-up mechanisms for their patients, contributing to late presentation, complications, and meager patient follow-up.

 Action required to reduce barriers to RHD Prevention and Care

1.3RHD is preventable by detecting and treating streptococcal sore throats early, ensuring access to penicillin as well as by streamlining the healthcare infrastructure. There is thus a role for urgent multi-sectoral promotion of holistic healthcare in Kenya to ensure early diagnosis and affordable access to health services for those at risk, so as to alleviate this preventable burden.

Part 2 of this blog highlights some multisectoral actions in place in Kenya to combat RHD.

 

References

  1. Carapetis, Jonathan R. 2007. “Rheumatic      Heart Disease in Developing Countries.” New England Journal of Medicine      357 (5): 439–41. doi:10.1056/NEJMp078039.
  2. Holland, Thomas. 2012. “The Prevalence of      Rheumatic Heart Disease in Western Kenya: An Echocardiographic Study”.      Duke University. http://dukespace.lib.duke.edu/dspace/handle/10161/6204.
  3. Joseph Nitin, Deepak Madi, Ganesh S Kumar,      Maria Nelliyanil, Vittal Saralaya, and Sharada Rai. 2013. “Clinical      Spectrum of Rheumatic Fever and Rheumatic Heart Disease: A 10 Year      Experience in an Urban Area of South India.” North American Journal of      Medical Sciences 5 (11): 647–52. doi:10.4103/1947-2714.122307.
  4. Kimani James, Remare Ettarh, Catherine      Kyobutungi, Blessing Mberu, and Kanyiva Muindi. 2012. “Determinants for      Participation in a Public Health Insurance Program among Residents of      Urban Slums in Nairobi, Kenya: Results from a Cross-Sectional Survey.” BMC      Health Services Research 12 (March): 66. doi:10.1186/1472-6963-12-66.
  5. Mondo Charles, Charles Musoke, James Kayima,      Jurgen Freers, Wanzhu Zhang, Emmy Okello, Barbara Kakande, and Wilson      Nyakoojo. 2013. “Presenting Features of Newly Diagnosed Rheumatic Heart      Disease Patients in Mulago Hospital: A Pilot Study.” Cardiovascular      Journal of Africa 24 (2): 28–33. doi:10.5830/CVJA-2012-076.
  6. Okello Emmy, Barbara Kakande, Elias Sebatta,      James Kayima, Monica Kuteesa, Boniface Mutatina, Wilson Nyakoojo, et al.      2012. “Socioeconomic and Environmental Risk Factors among Rheumatic Heart      Disease Patients in Uganda.” PLoS ONE 7 (8).      doi:10.1371/journal.pone.0043917.      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3428272/.
  7. Ozer Sema, Olgu Hallioğlu, Süheyla Ozkutlu,      Alpay Celiker, Dursun Alehan, and Tevfik Karagöz. 2005. “Childhood Acute      Rheumatic Fever in Ankara, Turkey.” The Turkish Journal of Pediatrics 47      (2): 120–24.
  8. Stone GS, Titus Tarus, Mainard Shikanga,      Benson Biwott, Thomas Ngetich, Thomas Andale, Betsy Cheriro, and Wilson      Aruasa. 2014. “The Association between Insurance Status and in-Hospital      Mortality on the Public Medical Wards of a Kenyan Referral Hospital.”      Global Health Action 7 (February). doi:10.3402/gha.v7.23137.      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925809/.
  9. Jowi Christine Awuor. 2012. “African      Experiences of Humanitarian Cardiovascular Medicine: A Kenyan      Perspective.” Cardiovascular Diagnosis and Therapy 2 (3): 231–39.      doi:10.3978/j.issn.2223-3652.2012.07.04.

Authors

Dr. Duncan M. Matheka is a Kenyan Medical Doctor and Public Health Researcher. He is a member of Young Professionals Chronic Disease Network (YPCDN) and is the Nairobi RHD Patient Club Coordinator. Twitter @duncoh1

Dr. Laura Musambayi is a Kenyan Medical Doctor and the Nairobi RHD Club Assistant Coordinator.

Mohamed A. Omar is a fourth year medical student at the University of Nairobi, Kenya.

Dr Kate Armstrong is the Founder and President of CLAN (Caring & Living As Neighbours) and the Executive Secretary of NCD Child (a global coalition committed to integrating children and adolescents within the global NCD, health and development discourse). Twitter @ncdchild

 

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Tackling Cancer in Kenya

This week on PLOS blog Translational Global Health, two emerging health leaders from Kenya lend their voices on the topic of cancer control and care. 

Meet Mary, a 43 year-old mother of 5 children and a poor peasant farmer from rural Kenya, who has been battling breast cancer for 7 years. In denial of her condition, Mary has held the firm belief that her breast lump is a result of witchcraft against her. She received her initial diagnosis at a rural health facility 7 years ago, but declined the advised mastectomy.

After her diagnosis, Mary went 5 years without any medical follow-up until she finally visited the health facility again. At this time her breast was ulcerated and oozing, but she still did not agree to a mastectomy. Earlier this year, Mary was sent to Kenya’s main public referral hospital in Nairobi, Kenyatta National Hospital, where specialists found that her breast cancer had metastasized to her spinal cord. An aggressive treatment regimen was initiated, but radiotherapy could not reverse the complications. Unfortunately, the only remaining option is to manage her pain, although her breast cancer could have been manageable had it been detected sooner. Sadly, Mary is a prime example of the many people struggling with cancer in Kenya.

medical camps

The issues and barriers to cancer control

Cancer accounts for approximately 18,000 deaths annually in Kenya, with up to 60% of fatalities occurring among people who are in the most productive years of their life [1, 2]. Men are most commonly diagnosed with prostate or esophageal cancer, and women are most frequently affected by breast and cervical cancer [3].

A huge disparity exists in patient outcomes between low-income countries like Kenya and high-income countries like Canada. Take cervical cancer as an example: due to pap testing, cervical cancer is rare in Canada or the US; however, it is the number one cause of cancer deaths in Kenyan women [4]. Prevention and screening has just not been available or accessible to most people in Kenya. Most cases are often undiagnosed or misdiagnosed, which is partly due to inadequate healthcare infrastructure.

The issue is exacerbated further by a faulty national health insurance plan that doesn’t allow patients to afford medical services [4]. The health system is inadequately designed and resourced – particularly for people with cancer – with poorly equipped hospitals, a low doctor to patient ratio, and a lack of access to affordable drugs. These factors lead to late presentation, complications and meager patient follow-up [4].

Widespread lack of awareness and accurate information about cancer is another reason why screening is rare and many cancers are detected when it is too late to treat effectively. Several cultural myths exist regarding cancer, which are critical obstacles to expanded cancer control and care in Kenya, especially when it comes to early detection [4]. One popular myth, as demonstrated by Mary’s case, is that cancer is caused by curses from ancestors and elders. In such cases, people even believe that you can ‘catch’ the disease from those who have it.

Although developing countries bear 80% of the cancer burden, only about 5% of global resources devoted to cancer are found in these countries [5]. Most cancer care services in Kenya are concentrated within a 5 km radius of each other in Nairobi, making it difficult for most Kenyans to access necessary care. The public national hospital hosts most of Kenya’s oncology expertise and technology. About 78% of Kenyans live in rural areas, which mean that many patients requiring care may travel up to 600 km to access cancer services [3]. The wait time for treatment at Kenyatta National Hospital is extremely long, and this is a problem, as there is a narrow window of opportunity to treat cancer effectively.

The other option of private cancer care, is not actually an option for the majority of Kenyans, as treatment costs in these hospitals are so astronomical that many patients travel to India for cancer treatment instead. More effort and resources are needed to make treatment more widely available and accessible.

Kenya_rural

Action required to reduce barriers to cancer prevention and care

Prevention efforts, both on a personal and policy level, must be scaled up for cancers that are amenable to prevention such as cervical cancer.

Non-communicable diseases (NCDs), which include cancer and other chronic conditions, share common behavioural risk factors that must be reduced to facilitate disease prevention: physical inactivity, tobacco use, harmful use of alcohol, and unhealthy diet [1, 2]. Smoking and alcohol abuse are on the rise in Kenya, air pollution is potent in urban areas, schools do not prioritize physical activity, obesity is on the rise, and the list goes on [3].

Reduction of these NCD risk factors is not addressed sufficiently by the Ministry of Health and other policymakers. Only 5% of the Kenyan budget is spent on health – instead of the recommended 15%, and much of the cost is on treatment rather than prevention [4]. Robust prevention policies will result not only in lives saved in the long term, but also in long-term economic gains.

Some community awareness campaigns are happening at the grassroots level, but these must be scaled up nationally to affect sustainable change. Additionally, the many people currently struggling with cancer, and those to be diagnosed with the disease in the coming years, should not be deprived of cancer care due to their geography or inability to pay. These patients have a right to receive treatment, and it is time that this right is recognized with investment in better cancer care in Kenya.

Kenya 2

Progress is on the horizon

In 2012, Kenya established a National Cancer Prevention and Control Act, making it one of the few countries in Africa with legislation for cancer [6]. The Act, which stipulates the establishment of a National Cancer Institute among other important advances to counter this disease in Kenya, has yet to be operationalized [6].

During a launch of 2013 breast cancer awareness and screening month (October), the Kenyan Ministry of Health called for revenue allocation for cancer control in the government budget. The presence of the First Lady, Margaret Kenyatta, and other government officials at the cancer-screening launch ignited hope for high-level commitment in reducing the cancer burden. The First Lady declared that she and President Uhuru Kenyatta had been screened for cancer, encouraging the public to follow suit – potentially lifting some of the public’s stigmatization of cancer.

DSC_0215-2Kenya is currently undergoing decentralization of government functions, including healthcare, which means that there is a renewed opportunity to integrate cancer care into other regions of the country and build an overall healthier Kenya. As 47 counties of Kenya absorb the healthcare mandate, it is expected that greater community involvement will result in tailored healthcare for each region. Devolution will facilitate more straightforward avenues for advocacy on NCDs at the county-level, as the decision-makers in government will be more localized and have so far demonstrated themselves as easier to communicate with. County health policymakers are usually also native to the communities that they serve and have a more vested interest in improved health outcomes in their designated regions, than the previous national level decision-makers.

For both healthcare devolution and expanded care for cancer, there is a push to build private-public partnerships. Both public and private healthcare providers must have a seat at the policy table and work together, as multi-sectoral action will have the biggest impact within communities. Yet, the need to safeguard public health must be emphasized and the terms of such partnerships critically evaluated and monitored.

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References

  1. World Health Organisation. Non Communicable Diseases: An overview of Africa’s New Silent Killers. Available from: http://www.afro.who.int/en/kenya/kenya-publications/1236-non-communicable-diseases-an-overview-of-africas-new-silent-killers.html [Accessed 9 Nov 2013].
  2. Baldwin W, Amato L. Fact Sheet: Global Burden of Non-communicable Diseases. Available from: http://www.prb.org/Publications/Datasheets/2012/world-population-data-sheet/fact-sheet-ncds.aspx [Accessed 9 Nov 2013].
  3. Yonga G. Case Kenya Study: NCD Situation http://iom.edu/~/media/Files/Activity%20Files/Global/ControlChronicDiseases/Sess2Sp2Yonga.pdf [Accessed 9 Oct 2013]
  4. The Conversation. Shining a Light on world’s biggest killer: non-communicable diseases. March 2013. Available from: http://theconversation.com/shining-a-light-on-developing-worlds-biggest-killer-non-communicable-diseases-12925 [Accessed 9 Nov 2013].
  5. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095128.
  6. Kenya National Cancer Prevention and Control Act http://www.ipcrc.net/pdfs/Kenya-National-Cancer-Control-strategy.pdf [Accessed 1 Dec 2013]

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Jordan Jarvis, is a Global Public Health Researcher based in Kenya’s office of African Medical and Research Foundation (AMREF), and a member of the Young Professionals Chronic Disease Network in Kenya.

Duncan M. Matheka, is a Kenyan Medical Doctor and Public Health Researcher, and the African Representative of Young Professionals Chronic Disease Network

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