Launching a South-to-South partnership from Cambodia to Ethiopia: Initiating Care for Drug-Resistant TB

Initiating DR-TB Care in Ethiopia in 2009/

How GHC Shattered Barriers with a South-to-South Approach:

When CHC first visited Ethiopia in 2008, treatment for the deadly drug resistant form of drug resistant TB (DR-TB)— also referred to as multi drug resistant-TB (MDR-TB)—was unavailable in Ethiopia, the second most populous country in Africa.

Seeking to share Cambodian Health Committee’s highly successful approaches to TB and HIV with programs in Africa, CHC in partnership with Angelina Jolie and the support of the Jolie-Pitt Foundation (JPF), decided to work with the Ethiopian Federal Ministry of Health (FMOH) to implement a program to address this humanitarian crisis.

It was estimated at the time that approximately 6,000 patients a year were sick from and spreading drug resistant TB (DR-TB) in the country due to lack of access to medications. Although the country of Ethiopia had gone through a lengthy and bureaucratic process with the Green Light Committee (GLC) of the World Health Organization (WHO), which was the gate-keeper of free DR-TB drugs at the time, it was promised the drugs — 5 drug cocktails for 2 years— to treat only 45 patients. However, these drugs did not arrive and would indeed be delayed further for almost another 2 years for unclear reasons.

At the time, while tuberculosis (TB) itself usually takes 6 months of an all-oral treatment to achieve a cure, at the time, cure of DR-TB required 18-24 months of 5 drugs including 6-8 months of a daily painful injection, which could cause hearing loss and kidney failure. It has been estimated that untreated a person suffering with DR-TB infects at least 10 other people. For details on the challenges GHC faced and how we formed a partnership with the Ethiopian Ministry of Health establishing a south-to-south effort to transfer knowledge from Cambodia to Ethiopia with other global partners to give Ethiopians access to DR-TB drugs and care, and the steps that were taken to stand up the program.

Challenges and GHC’s Responses:

Under the newly named international extension of CHC, the Global Health Committee or GHC, we sought to overcome the hurdles to starting DR-TB care in Ethiopia in partnership with the Ethiopian Ministry of Health and with the support of Dr. Tedros Adhanom who was the Minister of the Federal Ministry of Health (FMOH) of Ethiopia at the time. The flexible support of the JPF, with the generous donations of drugs from Eli Lilly &Co., Jacobus Pharmaceuticals, and the Chao Foundation and with other donors, DR-TB treatment was made possible in Ethiopia.

Challenge 1: Ethiopian DR-TB medical team needed training in clinical management of DR-TB.

Response: CHC organized a first week-long didactic session on DR-TB patient management in Addis Ababa in the fall of 2008 and in December 2008 a team of 10 Ethiopian doctors/nurses/TB managers who were the designated new Ethiopian DR-TB team came to Cambodia for a highly successful 2 week didactic and hands-on practical training experience in the management of DR-TB patients under the CHC team’s mentorship.

Challenge 2: Lack of a DR-TB treatment isolation ward: no isolation ward was available as renovations of an essential isolation ward for DR-TB at St Peters Hospital, the FMOH-designated hospital for treatment of DR-TB, were a year behind without an end date in sight.

Response: With Ethiopian Ministry of Health (MOH) support, GHC obtained permission to convert an empty ward that had been built and prepared as an isolation ward at St. Peters for a bird flu epidemic that never emerged in Ethiopia, into the first DR-TB Isolation Ward in Ethiopia This DR-TB ward went on to house the DR-TB program at St Peter’s for +2 years until the planned ward was built. And it continued for several more years to accommodate less acutely ill overflow DR-TB patients who were too numerous for the new DR-TB ward, yet who needed isolation.

Challenge 3: Lack of DR-TB drugs: in the country and no system for managing the second line DR-TB drugs was in place

Response: GHC approached Eli Lilly & Co for a donation of the most expensive drug of the 5 drug DR-TB cocktail at the time, capreomycine. Jacobus Pharamceuticals and Chao Foundations donated PASER and cycloserine respectively, with Lufthansa gifting GHC 6 free bags to be checked from the US to Addis Ababa with anyone traveling from Boston to Addis Ababa so the drugs could be hand carried. Other needed drugs were purchased by CHC in Cambodia from WHO-pre-qualified Indian companies and also hand-carried to Ethiopia. This was how the first 175 Ethiopian patients were treated In Ethiopia. Furthermore, the CHC Pharmacist made several trips to Ethiopia to establish the second-line DR-TB Drug Pharmacy at St.

By 2012, GLC drugs and drugs purchased with grants to Ethiopia from for example the Global Fund for TB, Malaria, and AIDS and UNITAID supported drugs reached the DR-TB Program, while GHC continued to support ancillary medications necessary for successful treatment.

Challenge 4: Lack of DR-TB Treatment protocols, support for Lab tests, ancillary medications, food supplementation, and social support.

Response: Based on the successful strategies for DR-TB developed in Cambodia, GHC developed protocols to manage drug side effects and outpatient follow-up and home visits. Critical was the integration of food and social support into treatment and nutritional support once patients were discharged home on outpatient treatment. As a core member of the Ethiopian national technical working group, GHC shared these strategies with the national program and the GHC collaborative programs at St Peters and at Gondar University Hospital became major training sites for the emerging national program. Specifically, GHC developed protocols for DR-TB patient intake and general management, and DR-TB drug side-effect management as well as a mobile outpatient monitoring team based on protocols developed by CHC in Cambodia.

Challenge 5: Flexible Funding: Addressing Needs on the Ground

Flexible funding from the Jolie-Pitt Foundation allowed GHC to use funds as needed for strategic needs of the patients and programs such for lab reagents when there were stock-outs of reagents for DR-TB diagnosis and critical lab tests for side effect monitoring. Funds were also used for critical diagnostic and therapeutic procedures such as chest tube placement. As well, flexible funding allowed GHC to provide nutritious food for hospitalized DR-TB patients and food baskets for outpatients to take the multi-drug DR-TB regimens that often caused nausea and vomiting, and supported necessary transportation to the health facility or for rent for the most indigenous of the patients during their therapy.

Other very generous funders who were critical in this support through the years include the Lilly Foundation and MDR Partnership, Janssens Global Public Health, the Johnson&Johnson Foundation, Annenberg Foundation, Jeanne Sullivan, and Nancy and Steven Crown. Later, as the countrywide program developed, funds from the Global fund and other donors to the Ethiopian FMOH supported some of these needs that GHC filled, which have been incorporated into the national program directly through national FMOH mechanisms.