Jacquie Oliwa successfully defends thesis about TB diagnosis in children in Kenya

On January 19, 2021, Jacquie Oliwa presented her thesis “Unmasking The Hidden Epidemic – The process of theory-guided intervention design to improve case detection of tuberculosis (TB) in hospitalized children in Kenya” on livestream from Kenya. Jacquie, who has visited Amsterdam every year during her PhD, was planning to travel with husband and child for her defense and graduation ceremony. Due to the COVID pandemic, celebrations in Amsterdam will have to wait.

Jacquie is a trained pediatrician who also holds a master in epidemiology from LSHTM. Following her studies, she joined the Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Program in 2011, as a researcher. Jacquie always knew that she would pursue a career in TB research. Previously, she worked as a pediatrician in a ward in rural Kenya where she witnessed the death of four children in one week due to the complications of TB. She realized that patients came to the ward at a very advanced stage of illness, making it virtually impossible to cure. Jacquie felt compelled to do something. When she was introduced to Prof. dr. M. Boele van Hensbroek through a colleague, she knew this would be the perfect opportunity for her to contribute to TB research. Her PhD research began in 2017, under supervision of Prof. dr. M. Boele van Hensbroek, Prof. dr. M. English, Dr A. van’t Hoog and Dr C. Jones.

A broad list of achievements

Jacquie’s PhD was the result of hard work and long hours, and in the end, she provided Kenya with their first estimates of the burden of TB amongst hospitalized children. Jacquie had a rough start to her PhD journey because of healthcare worker strikes in Kenya, where the contracted time loss would lead to running out of funding. There was no other choice than to adapt her thesis proposal towards a theory-based result rather than an implementation-oriented one. “A theory is a way of organizing ideas that can be made actionable and replicable. You need to understand the underlying mechanisms of action to make something work. This is what implementation science is and what I aim to do.” Kenya is one of the 30 high burden TB countries in the world, where the sum of all notified TB cases is high in comparison to other countries. Children are not prioritized in TB programs in Kenya and they are “falling through the cracks,” which, leads to a high number of TB-related child deaths. This too urged Jacquie to take action.

In order to begin her research, Jacquie obtained epidemiological data of child TB in Kenya. She detected a major diagnostic gap; “children are 8 times less likely to get reported for TB than adults do in Kenya”. Focusing on 13 hospitals in Kenya, she went on to describe what was happening in children, as nationwide prevalence survey had shown that approximately 75% of adult uptakes had TB symptoms but were left undiagnosed. Modeling estimates showed that in children too, reported TB cases are not representative for of all TB cases, a discrepancy that occurs even more in children. Jacquie interviewed healthcare professionals to understand the reasons behind such a low detection rate. She identified a knowledge gap in the differential diagnosis phase (where a doctor differentiates between two or more conditions that could be behind a person’s symptoms). Where children would come in with symptoms of TB, they would not actually get the TB diagnosis. In addition to the knowledge gap, Jacquie outlined many other factors that related to lower TB diagnosis rates: lack of skills, training and priority setting from busy healthcare workers, hospital leadership structure and care coordination. She highlights a few factors.

Diagnosing TB in children requires skills because the phlegm needed to identify the disease is often swallowed by children; specific methods are needed to collect the necessary samples. Decentralized care in hospitals constitute a barrier to diagnostics as patients are referred from doctor to doctor and eventually get lost in the cracks. Finally, there is the issue of stigma. TB is a disease that is not accepted by the community overall due to its associations with HIV, poverty, low social class. Throughout her PhD, Jacquie published one policy brief, six first authored articles and eight co-authored publications.

In addition to her research in Kenya, Jacquie supported Malawi National TB program in the development of a curriculum for advanced specimen collection in children. She delivered training and provided mentorship that resulted in increased bacteriological confirmation of TB in children. Something that was previously not being done. This 6-month project, funded by the Elizabeth Glaser fund, was a major achievement throughout her time as a PhD candidate.

Jacquie is thankful for the support she received from her supervisors, including her co-promotors Dr. C. Jones and mentor Dr. Anja van ‘t Hoog whom she met with on a weekly basis through Zoom. “They held my hand, right up to the finish line!” She is grateful for the collaboration with AIGHD and the interaction she had with employees during her time at the AIGHD office. She was delighted to see how many people in the AIGHD and Pharmaccess offices had partnerships and research project in Kenya.

What’s next?

“TB diagnosis in children is a hidden-endemic and from a human rights perspective, failure to diagnose this disease is a crime. In 2021, it is a crime to die from an infectious disease that has been around for 100 years. The world needs to pay attention and more funding needs to go towards TB vaccination.” Jacquie reminds us that her work is not done. As a global health community, we must continue to fight for funding and research that will contribute to the elimination of TB. As a member of the Union of Lung Health, Jacquie aims to raise TB awareness.

In October 2020, she started a post-doc project where she is researching essential critical care delivery in COVID-19 wards. She also plans to carry on teaching, another passion of hers. “Sometimes you need a mentor to prove it can be done, and I want to be that mentor.”