Archive for the ‘Clinical’ Category

TB drug shortage redux

March 17, 2009

I wrote about the TB drug back in December:

I wish I could report the situation was improving. In fact, it has worsened. Yesterday, one of the doctors mentioned at a research meeting that the drugs were out in the National TB/Leprosy Control Programme (NTLP). Some of our doctors have dual roles in our research center and at the NTLP. Our research participants have access to medications. However, most TB patients are not enrolled in studies.

I’ll briefly explain the regimens and then the shortages.

TB medications: S=streptomycin; E=ethambutol; H=INH; R=rifampin; Z=pyrazinamide

New TB patients get either: (1) 2 months E+H+R+Z then 4 months H+R; or (2) 2 E+H+R+Z then 6 months H+E.

Retreatment TB cases typically get: 2 months S+E+H+R+Z then 1 month E+H+R+Z then 5 months E+H+R.

Mulago Hospital TB Wards 5&6/NTLP Clinic see about 25% of the nation’s TB burden and about 200-250 TB patients per month. The shortage is especially worse in Kampala then in some rural areas. (We’re ranked 16th in the world for TB burden in the 202/212 countries that report TB cases.)

As of this morning we had:

(1) NO R+H+E formulation for pediatric TB patients.

(2) 2-month initial phase of E+H+R+Z for only 12 patients.

(3) Only 15 one-month boxes of E+H+R for the retreatment TB cases.

(4) Hundreds of H+E but…..they were all expired.

(5) 1300 vials of streptomycin. However, given that it would have to be taken with E+H+R+Z (see #2 above) in the retreatment regimen, the surplus is of practically no use.

Later in the day, I found out that the Daily Monitor had a blame-game story on this:

I’m not in the position or have the knowledge to offer more on who is at fault than the story does, but off the record I have some hunches. Anyhow, the focus needs to be on the solution and future prevention of shortages as numbers of patients continue to suffer.

I emailed two human rights organizations after my tour of the NTLP pharmacy with one of the doctors and the pharmacist there. Tomorrow morning I am going to the NTLP clinic to see what it is going to be like to tell patients they have TB but that we can’t give them the medications. Tomorrow afternoon I am talking with a reporter and on Thursday there will be a press conference on drug shortages in general. I’ll post how these all go. Click on the comments below for an update.


Alex’s Father

September 28, 2008

Last Friday, September 19, Alex came back, but this time with his father. Dad had a CD4+ T-cell lymphocyte count of 28 on August 9. To say that 28 is low is an understatement. A normal CD4+ count in a healthy individual ranges between 500-1500. We addressed his medications, but father looked quite ill. This boy has really captivated the nurses and physicians. I think embedded in our concern for Alex, lies not only the human draw to preserving childhood innocence, but also some elements of hope and fear surrounding the outcome. Alex’s father’s death would leave him an orphan. But from what I can tell and in light of my previous posts, he will not be stranded.

HIV/AIDS, tuberculosis, and KS Part 2 – her health story

September 18, 2008

This week has been my first “normal” week since I have been here in the sense that my weekly schedule is starting to solidify. Shortly, I will post what I now do through the program. Among those activities, I will have clinical time three times a week at this point.


On Wednesdays, I will be seeing patients with Dr. Henry Luzze, one of the researcher co-investigators and physicians here at Mulago. He staffs the tuberculosis clinic at Mulago hospital in Wards 5 and 6, which are pictured elsewhere on my blog already. We had one woman in particular whose condition particularly struck me this past Wednesday, as do many.


She came in for her “check-up.” A tough woman in her 40s (but looking as in her 60s), she was taking second-line anti-retroviral therapy (medication for HIV/AIDS), presumably because of a resistant strain. She had miliary tuberculosis (more advanced form of the disease), cervical cancer (status unknown by this staff but status post two radiation therapy courses I was told), and disseminated KS (Kaposi’s sarcoma) lesions. I wrote about KS lesions in an earlier post. This lady had the distinctive KS lesions on her arms, legs, and in her mouth scattered around her oral palate. Relatively emaciated – relative, that is, to other patients seen here – she was still strong and kept going.


We knew a little less about her because she is enrolled in a clinical research trial through the IDI (Infectious Disease Institute: at Mulago, a well-funded research institute here on campus. Dr. Luzze commented on her grave condition. One Ugandan resident physician here who has rotated in the US talked about how different aggressive therapy approaches are in the US compared to here. He said in her case, “why would we continue when she is in the condition she is in?” looming on death’s doorstep. Part of his answer may have been cultural, but part of it has embedded in it in the resource constraints here, even despite decent medications available through the IDI research study. I listened but wanted to say that her life is worth it, and she keeps going; this is why she should continue therapy.


Physician Paul Farmer writes of tuberculosis as an imposition, a punishment in many ways. I will write more on his views and how I see them manifest after I have experienced more here. Suffice it to say, the illness-poverty link is unmistakably glaring and visible. I have studied and written about this link in the context of the USA through an opportunity as editor of an issue on the topic in Virtual Mentor: American Medical Association’s Journal of Ethics ( And while there are similarities, there are many differences structurally between access (or restrictions) to care in the US and here. More rumination on that topic throughout the year to come…