The toddler is barely 18 months old but she has come to dread the medicine. For the past six months, she has been forced to swallow a daily concoction of five-and-a-quarter tablets, crushed and mixed with water, forming a thick, reddish-brown fluid.
Ivy has tuberculosis (TB).
Her mother, Grace Wambui, has brought the little girl for her weekly appointment at the Ruiru Sub-District Hospital in central Kenya, 25km from Nairobi.
Kenya is one of 20 countries where TB is the most rampant, according to the World Health Organisation’s (WHO) 2016 World TB report, which was released in October.
Not everyone who has contracted the TB germ, a bacterium called Mycobacterium tuberculosis, develops TB disease. But the United States government’s Centers for Disease Control says infants like Ivy are far more likely to do so — and, when they do, they often develop life-threatening forms of TB disease such as TB of the brain, which can leave children with a permanent mental disability.
Child TB cases in Kenya make up more than one-tenth of all TB cases, the International Journal of Tuberculosis and Lung Diseases has found.
A bitter diagnosis
Wambui softly strokes her daughter’s back. “She really hates these drugs,” she says and takes a seat in the doctor’s room. “Sometimes she keeps it in her mouth for almost an hour, refusing to swallow.”
Ivy recoils at the sight of any similarly coloured liquid, even to taste juice of a similar hue. “Whenever she sees me opening the bag where I keep the drugs, she starts crying in fear,” her mother says. “Sometimes she almost vomits while swallowing the drugs.”
She and her mother are here to see Polycarp Kariuki, the head of the TB unit, who is preparing a dosage of the medicine. “It is indeed very bitter,” Kariuke confirms, pulling his face as he tastes it.
In 2015, Kenya reported nearly 7 000 cases of TB in infants and children, according to WHO figures.
Like Wambui, parents and carers of children with TB have to crush or cut adult pills and guess the correct dose every day of a treatment journey of at least six months. The WHO reports that this includes a two-month intensive phase, with the medicines isoniazid, rifampicin, pyrazinamide and sometimes ethambutol. A continuation phase with isoniazid and rafimapicin follows for at least four months.
Those with drug-resistant TB, which is far more difficult and expensive to treat, need 12 to 18 months of treatment.
According to the international advocacy organisation, TB Alliance, incorrect dosages have often led to treatment failure and death from TB in children.
“The TB regimen [for children] is complex to use for both health workers and caregivers,” says Jackson Kioko, Kenya’s director of medical service. “The tablets are big and difficult for children to swallow, hence [they] have to be crushed and sometimes mixed with food. This results in inaccurate dosing and poor adherence.”
The WHO report reveals alarming statistics: more people are dying from TB, a curable disease, than previously thought. Worldwide there was a 50% increase in deaths of children from TB from 2014 to 2015, with 210 000 reported to have died in 2015.
Kenya pioneers kinder, gentler treatment
Kenya is the first country to roll out the new three-in-one fixed dose combination treatment specially formulated for children. The tablets dissolve in water to make them easier to take (Cyrus Kinyungu)
Kenya has become the first country in the world where children are given appropriately dosed, child-friendly TB medicines, which are expected to help improve treatment outcomes and children’s chances of surviving TB.
These treatments are the first to meet WHO guidelines, according to the TB Alliance. The development of medicines was overseen by the organisation, and funded by the global health initiative Unitaid and other partners.
The new drug course consists of fewer pills and is easier to give to a child, says Immaculate Kathure, the programme officer for childhood TB at the National TB Programme in Kenya. “They also taste better and dissolve easier in water, and, because it is a fixed-dose [an all-in-one-pill], with the correct dosage of the multiple drugs, there is no more cutting, chopping or guessing,” Kathure says.
The new pills are fixed-dose combinations of the three most commonly used drugs — rifampicin, isoniazid, and pyrazinamide — to treat drug-sensitive TB. They are used for the initial two months of treatment, followed by four months of rifampicin plus isoniazid, according to the TB Alliance. The dosage required is calculated according to a child’s weight — the more a child weighs, the higher the number of fixed-dose pills. Only children who weigh 25kg or less qualify for the new treatment. The rest will use adult treatment.
TB Alliance says the right medicines in the right doses will improve adherence and save more lives.
All children in Kenya diagnosed with TB after October 1 will be treated with the new medicines, says Kathure.
“Those on the old medicines will continue and finish them. These are not new medicines, but improved versions of the current medicines. Therefore, in terms of efficacy and quality, it is comparable.”
According to TB Alliance, almost 30 countries have adopted the improved medicines in principle and about 230 000 treatment courses have been ordered — enough to meet the needs of more than half of the world’s children reported to have TB. Kenya is the first country to implement this strategy.
Phamacist Evelyne Siaiti shows off the new, flavoured tablets after they have been dissolved in water. (Cyrus Kinyungu)
Derick Ogonya (4) is one of the first patients to use the new pills. In late September, he was diagnosed with TB at the Kitengela Sub County Hospital, 35km from Nairobi.
“It is sweet, just like soda,” he declares with a broad smile after his mother, Maxmilla Wandai, gives him a spoonful of the medicine.
“He really loves the mixture and has been volunteering to take it,” says Wandai.
But Cherise Scott, director of paediatric programmes at the TB Alliance warns that the new treatments won’t have an effect until they reach the children that need them. “We are proud to partner with the government of Kenya, the first of many countries, as they work to translate the potential of these medicines into lives saved.”
For Ivy Wanjiku, her mother’s commitment to the gruelling six-month treatment paid off. She has been given a clean bill of health.
Grace Wambui hopes her daughter will soon forget her fear of dark liquids. When she leaves the clinic, she gently hugs her daughter and says: “If the new medicine spares other children some of the tears Ivy shed, I feel happy.”