The re-emergence of tuberculosis among the 
economically productive age group in Kenya: the 
case of Mombasa district 
JOELK. KIBOSS1 AND NICHOLAS K. KBBITOK2 
ABSTRACT 
In this investigation 43 cases of smear positive patients undergoing 
TB treatment at satellite treatment centres situated within 
Mombasa municipality were observed and interviewed 
retrospectively. The span of the study was five months commencing 
from April 1997. The study was carried out in collaboration with 
the National Leprosy and Tuberculosis Programme at Port Reitz, 
Coast General and Ganjoni centres of infectious and contagious 
diseases in Mombasa district. The data seem to indicate that the 
highest number (97%) of persons affected by TB come from the 
economically productive age (15-50 years). The possible cause of 
recurrence ofTB in Mombasa district is lifestyle. The majority of the 
people with sputum smear positive earn below the poverty line. 
They live in rented or overcrowded houses with inadequate 
ventilation, insufficient sanitary and transport facilities and poor 
health systems. In addition, there is a general lack of awareness of 
dangers of infection, spread and prevention ofTB. Areas 
warranting"closer attention by future research are highlighted in 
the study. 
KEYWORDS 
education, health, life style, poverty, Mombasa, TB 
1 Department of Curriculum and Instruction, Egerton University, 
Njoro, Kenya 
2 Department of Animal Science, Egerton University, Njoro, Kenya 
VOL 18 NO 2 JULY 2003 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 121
Introduction 
The re-emergence of infectious and communicable diseases such as 
tuberculosis in Africa has been blamed on various problems such as 
poor epidemic surveillance; lack of medicine and medical services; weak 
health systems and poor health conditions and hazards (Bobbin 1984, 
Pratt 1995). Tuberculosis (TB) is a disease caused by the Mycobacterium 
tuberculosis. It has been a misery of mankind for centuries, as accounts 
in the earliest surviving literature show (Barnes and Barrows 1993, Evans 
1994). A review of the literature shows that estimated cumulative 
tuberculosis deaths stood at 30 million during the period 1990-1999, of 
which about six million occurred in sub-Saharan Africa (Kochi, 1991). TB 
is perhaps the most important contagious disease in the world that 
causes millions of avoidable deaths worldwide (Pratt 1995, WHO/TB 
1997). 
A global survey reveals that generally, TB has affected about half of 
the world's population and kills seven million people per year (Evans 
1994, Kochi, 1991). This comprises 25 per cent of avoidable deaths 
occurring in developing countries and the highest percentage of TB 
cases (95%) and TB-related deaths (98%) occur in developing countries. 
Of those severely affected, 75% are in the economically productive age 
of 15-50 years old (WHO/TB 1997). In addition, the recent WHO 
estimation indicates that one-third of the world's population, over 1.72 
billion people, are currently infected by M. tuberculosis. 
According to the National Leprosy and Tuberculosis Programme 
(NLTP1996), there were then 43,860 TB cases in Kenya (with the patients' 
statuses categorized as either chronic, relapse, sputum smear positive 
or sputum smear negative and with Mombasa district alone having 
5,661 TB cases. The survey showed that the incidence of new patients 
with sputum smear positive tuberculosis (patients diagnosed as severely 
ill) in Kenya was about 18,909 cases. The leading district was Mombasa 
with approximately 2,459 (13%) of the TB cases reported nationally. Of 
all the 360 newly diagnosed TB cases reported (with all the four 
categories mentioned above) in Mombasa district, 52.4% (187) were 
sputum smear positive, 39% (141) were sputum smear negative and 
relapses and chronic cases were 8% and 0.6% respectively. This is an 
122 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 18 NO 2 JULY 2003
Kiboss/RE-EMERGENCE OF TB IN MOMBASA 
increase of 25.39 % compared with previous TB cases reported in 
Mombasa district. Considering this, Mombasa district appears to be a 
TB epidemic area in Kenya. 
Causes and spread of TB 
In essence, M. tuberculosis is transmitted from an infected person (a 
carrier) to a non-infected person (non-carrier) by means of the inhalation 
of the tubercle bacilli released from a carrier as droplet nuclei during 
coughing, sneezing and talking. In addition to the infectiousness of the 
source patient, the risk of infection is related to the closeness and 
intensity of exposure. In other words, anyone sharing the same air space 
for a prolonged period such as a family member, a fellow patient and a 
healthcare worker, is at more risk of contracting the infection than those 
individuals who are only briefly exposed to the source patient (such as 
one-time hospital visitors). Also, exposure of any length, especially in 
small, confined, poorly ventilated environments, is dangerous. This may 
include facilities in hospitals used for cough-inducing procedures such 
as physiotherapy, sputum induction and administration of aerosol 
therapy. The likelihood that an exposed person will become infected and 
develop TB is related to that person's susceptibility. 
Another factor that may increase an individual's susceptibility to 
primary infection is immunodeficiency, which includes immunodeficiency 
secondary to HIV/AIDS infection (Barnes et al. 1991). This poses a 
potential thread to susceptible non-carriers who can easily become 
infected when they breathe these droplet nuclei. The literature shows 
the following as the possible potential causes of the re-emergence of 
the TB epidemic: 
• Inappropriate diagnosis due to limited diagnostic knowledge and 
skill; 
• Improper treatment due to lack of sufficient diagnosis; 
• Negligence of private practitioners; 
• Lack of a guiding policy regarding the role of private practitioners 
on the eradication, prevention and control of TB; 
• A debilitating disease such as HIV or diabetes which reduces the 
patient's immune system; 
VOL 18 NO 2 JULY 2003 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 123
• Lack of community awareness of the dangers of TB and its spread 
(Bobbin 1984,EmokorandTukei 1982, Evans 1994,Pratt 1995, WHO/ 
TB 1997). 
Causes related to HIV/AIDS and diabetes 
Debilitating diseases-such as the HIV/AIDS and diabetes reduce the 
patient's immune system. Individuals infected with HIV/AIDS are at 
significantly greater risk of a progression to active disease than those 
who are not infected with HIV/AIDS. HIV-infected individuals who have 
not been infected with M. tuberculosis in the past commonly develop TB 
within a few months of exposure to a source patient (Barnes et al. 1991). 
Moreover, they are more likely to have a rapid and more severely 
progressive form of TB than non-HTWAIDS infected persons (Centre for 
Disease Control 1992). However, the M. bovis type of TB often reemerges 
in HIV/AIDS infected persons (Darbon and Grange 1993). 
TB is often the initial manifestation of the HIV/AIDS disease. This is 
often seen within the first six months following HIV/AIDS infection and 
may be the result of earlier infection by the tubercle bacilli or recent 
exposure (Festenstein and Grange 1991). In addition, extra-pulmonary 
tuberculosis is much' more common in individuals who are infected with 
HIV/AIDS. This is particularly because of the associative immunodeficiency 
which facilitates the blood-borne spread of tubercle bacilli 
from the primary site of infection in the lungs (Barnes and Barrows 1993). 
Although these indicators of crowded and unsanitary conditions 
have been reported to be prevalent in Kenya, especially among the 
economically-depressed population (Kibitok 1997), there is a need to 
ascertain whether or not there is a relationship between these prevalent 
conditions and the re-emergence of TB among the economically 
productive age group in Mombasa district. The purpose of this 
descriptive study, therefore, was to contribute in this regard. 
Data and methods 
Study design 
The paucity of literature on the re-emergence of TB, particularly in 
Kenya, has led to the selection of a descriptive research study in which 
124 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 18 NO 2 JULY 2003
Kiboss/RE-EMERGENCE OF TB IN MOMBASA 
the concepts and their interrelationships are used to describe the 
emerging social process or phenomenon in question (Diers 1979, Fawcett 
and Downs 1986, Glaser 1978). 
Sampling of cases 
The sampling technique used in this study is purposive sampling. 
Purposive sampling allows the collection of data from identified 
respondents (Glaser and Strauss 1967). This process was undertaken in 
the present study, based on the sampled cases from a list of in- and 
outpatients who reported to the centralized medical centre between 
April and June, 1997. The cases comprised ten new cases, ten relapses, 
ten in-patients, ten children aged between 0-14 and three defaulters 
and treatment failures. Consequently, a total of 43 cases who had been 
identified to receive treatment at satellite centres within Mombasa 
municipality participated in this study. However, the focus of the study 
was not limited to issues related to the cases sampled but included 
some professionals and laboratory personnel, namely, the NLTP coordinator, 
clinicians, radiographers and laboratory personnel. 
Instrumentation 
Three instruments were used collect data from the primary cases; an 
open-ended interview guide, a survey questionnaire and an observation 
form. The fourth instrument was an interview guide for professionals 
used to garner additional information from secondary sources (the NLTP 
co-ordinator, clinicians, radiographers and laboratory personnel). The 
interview guide for the cases focused on the following: 
• demographic data, 
• activities and factors that predispose them to TB infection, 
• their own awareness of TB infection and spread, 
• their knowledge of the government's free intensive treatment 
service and 
• their understanding of the importance of taking the full course of 
treatment. 
VOL 18 NO 2 JULY 2003 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 12S
Data collection procedure and analysis 
The data collected were both qualitative and quantitative. The qualitative 
data emerged from observation spanning five months. During this 
period, the cases, professionals and laboratory personnel were 
interviewed. Quantitative data were collected from all outpatients, 
including all defaulters or patients who had absconded and all cases of 
relapses and newly-diagnosed cases that had tested positive and were 
advised to go to the satellite treatment centres in their vicinity. 
The respondents included males and females ranging from 0 years to 
over 55 years of age. The target population included persons mainly 
working and living in Mombasa district who had visited any of the TB 
satellite centres for screening and treatment of TB between the months 
of April and August 1997. 
In this study, each incoming datum was analysed to understand the 
emerging theme. For instance, data on all new patients who reported to 
the centre for clinical screening appeared to support the notion that the 
highest number of persons severely infected by the TB disease came 
from the economically productive age group. Furthermore, problems of 
defaulters and relapse are common among persons age 20-50 years. 
The observational notes were analysed in conjunction with the data 
collected from interviews. The characteristics of interest noted during 
interviews included occupation, income, number of TB-infected persons 
in the family, nature of living conditions, culture and religious beliefs, 
type of socialization and access to primary TB-awareness campaigns. 
These empirical indicators of the possible causes of the re-emergence 
of the TB disease .were recorded and analysed to provide an insight 
into why this disease is endemic in Mombasa district. 
Results and discussion 
The purpose of the study was to ascertain the possible causes of the 
re-emergence of TB and to highlight indicators of possible TB infections 
in Mombasa district. In this study, all age groups of both male and 
female TB cases are included to help deduce any possible correlation in 
the mode of TB transmission. Table I gives a quarterly breakdown of all 
TB patients in accordance with their gender and age categories. An 
126 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 18 NO 2 JULY 2003
Klboss/RE-EMERGENCE OF TB IN MOMBASA 
Table I: A breakdown of a quarterly report of new TB cases 
in Mombasa 
Gender Age categories (pen:entacjes in brackets) 
Total 55+ 0-14 45-54 15-24 35-44 
Male 59 4 4 (16) 107 (30) 80 (22) 
10 Female 4 4 45 (13) 42 (12) 
(D 
(1) 
(D 254 (70) 
105(30) (3) (1) 
Taw. 359 (100) 8 69 (19) 8 151 (43) 123 (34) (2) (2) 
examination of Table I shows that the age group 0-14 years and 55+ 
years had an equal number of reported TB cases. In Kenya the 0-14 
years group are school-going children while the 55+ group are mostly 
retired persons and the elderly. This is perhaps the reason why there is 
a low number of new TB cases within this age group. 
One finding from the data is that the trend of reported TB cases from 
highest to least is in the following order: 1.35-44 (41%); 2.15-24(34%); 
3. 45-54 (19%), 4. 0-14 (%), and 5. 55+ (2%). Considering the 
economically productive age (15-50), acombination of the results of 1. 
2. and 3. gives a percentage of over 90 per cent of all TB reported cases, 
the majority (70%) being male. It is interesting to note that in Kenya TB 
is prevalent among adult men, unlike in Europe and America where it is 
more common in adult women (Pratt 1995). In America and Europe most 
adult women are employed. In Kenya most adult men are employed in 
urban areas and most of what they earn is not enough to maintain two 
homes. Consequently they are forced to share overcrowded, low-cost 
houses with friends and relatives while their wives, who are mostly 
farmworkers and homemakers, live with the children and older siblings 
in rural areas. Although there are no data to explain why TB is more 
common among adult men in Mombasa district, the same situation of 
overcrowded housing in urban settings is true for Mombasa town. This 
is supported by the data presented in Table II. 
Table II shows that at least one in every two male patients was 
engaged in one kind of business, and skilled/unskilled public or private 
work. The women patients constituted a smaller percentage (8%) of 
those working. Most are involved as food-vendors. This implies that a 
VOL 18 NO 2 JULY 2003 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 127
Number 
Men 
Category 
Occupation 
of cases (% in brackets) 
Total 
29 Working/employed 
Women 
(8) 
Farmer 3 
(38) 
(5) (0) 
Business/vendor 17 
Table II: Occupation and housing of cases oy gender 
24
3
6 
10 
(45) 
(5) 
(27) 
(23) 
(17) 
(8) 
0) 
(16) At school 15 
5
0 
11
5 
64 21 43 (100) (33) 
(2) 
(13) 
(15) 
(67) 
(8) 
(35) 
(27) 
5 
25 
22 
1
7
8 
4 
18 
14 
(10) 
(48) 
(42) 
Tow. 
Type of housing 
Permanent 
Semi-permanent 
Mud 
TOTOL 52 16 (30) (70) 36 (100) 
majority of women not only earn a very low monthly income but also 
work in less crowded places. Moreover, they live in rural areas (away 
from their husbands) and care for the children and older relatives in 
more spacious houses. Also, their husbands' visit is usually of short 
duration of one month's leave or short public holidays. Perhaps -the 
reason why more men .than women get TB is because they work and live 
in crowded and unsanitary conditions (Bobbin 1984). 
As Table III shows, most patients are aware that TB is a disease 
rather than an act of God or the result of witchcraft. A closer look at the 
data presented in Table II indicates that the majority of cases lived in 
poor conditions. For instance, 48 per cent and 42 per cent of the cases 
respectively lived in (rented) semi-permanent and mud houses compared 
with 10 per cent who lived in permanent houses. More often, water, 
housing and sanitation conditions in the areas where the cases lived 
are inadequate because repairs and maintenance depend largely on 
irresponsible landlords and the poor housing policies. These poor 
conditions tend to predispose the inhabitants to a high rate of TB 
128 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 18 NO 2 JULY 2003
Kiboss/RE-EMERGENCE OF TB IN MOMBASA 
Table III Percentage of categories of cultural practices and 
religious beliefs held by cases 
Percentage N of cases Category 
1. Cause of TB 
70
7 
16
7 
30
3
7
3 
TB germs (Viini vya Kifua Kikuu) 
act of God 
witchcraft 
it is inherited 
2. Acceptance of customs and cultural practices
8 18 
26 
28 
28 
11 
12 
12 
family sleeping in one room 
family eating together from one plate 
food remains go to children 
mother sleeps together with child 
infection (Bobbin 1984). The literature is replete with studies indicating 
that poverty, poor living conditions, overcrowding and lack of medical 
care leads to a high incidence and endemic pockets of TB. In other 
words, the re-emergence of TB is closely related to conditions that 
support the spread of TB from carrier patients to the non-carrier. 
In tropical Africa conditions that help the spread of TB have been 
identified as: a rapid population growth rate; limited housing and 
recreation facilities and inadequate transport facilities (Holmes 1964, 
Hughes and Marshall 1974). The high incidence of TB among the 
economically-productive age group in Mombasa district is not unrelated 
to the poverty of the victims, that is, those who live below the poverty 
line and are subjected to overcrowding, malnourishment, poor living 
conditions and lack of adequate medical care (Evans 1994,Pratt 1995). 
The results shown in Table IV suggest that most of the patients are 
not fully aware of the dangers of the spread of TB and the free services 
offered by the National Leprosy and Tuberculosis Programme. For 
instance the data in this table show that most of the cases (62 per cent) 
sought treatment in private health institutions compared to 38 per cent 
who went to public health institutions. But it is worth noting that most 
private practitioners referred them to the appropriate treatment centres. 
VOL 18 NO 2 JULY 2003 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 129
Table IV: The cases' awareness of TB treatment centres and 
medical services 
Percentage 
62 
12 
47 
19 
14 
Category N of cases 
27 
1. Did you seek help in private institutions? 
Yes 
2. How did you learn about Port Reitz/ 
Coast General/Ganjoni treatment centres? 
through the NLTP campaign 
from a private practitioner 
from a friend 
from a TB patient attending treatment 
from a leaflet 
5 
20
8
6
4 8 
The results show that the NLTP awareness campaigns have been less 
effective, although studies indicate that the successful prevention of 
the recurrence and control of TB is related to effective awareness 
campaigns aimed at educating the public on the prevention of the spread 
of TB. This finding corroborates the NLTP co-ordinator's concern that 
their TB campaign effort through a community-based primary health 
education was, in fact, inadequate in that they only managed to reach a 
small population of primary and secondary school children and hold 
local meetings where leaflets about TB were distributed. Unless the 
NLTP makes a more concerted effort to reach more people with 
community-based primary health education, the re-emergence of TB 
among the economically depressed people in Kenya might escalate 
rather than decline. 
Conclusion 
For a number of reasons this study was restricted to the re-emergence 
of TB among the economically productive age-group in Mombasa. The 
quarterly report of TB infections in Kenya showed that the disease in 
this age bracket is rampant (Kibitok 1997) and mobility and social 
interaction is greater among persons aged 15-50 years who must work 
to earn the income necessary to support and care for the family (Kibitok 
130 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 18 NO 2 JULY 2003
Kiboss/RE-EMERGENCE OF TB IN MOMBASA 
1997). The possibility of infected people transmitting the disease to 
other members of the family and fellow workmates is very high. This is 
another potential danger that might exacerbate the re-emergence of TB. 
The literature indicates that M. tuberculosis is usually transmitted 
from one person to another by the respiratory route. Considering that 
the majority of people in Mombasa not only sleep in the same room but 
also eat from the same plate, the potential thread of this airborne disease 
to uninfected susceptible persons is very high. 
It is clear, therefore, that a more concerted effort by the NLTP is 
needed to inform the public. In particular, the role of NLTP in offering 
effective and free medical services should be prioritized through the 
mass media such as posters, radio and television, audio-visual 
programmes and films shows. These efforts will boost public awareness 
not only of the dangers of the infection and spread of TB but also of the 
appropriate treatment centres and free medical services. 
There are many unanswered questions that await further research. 
These include the reasons for occurrences of relapses, defaulters and 
treatment failures (such as the human factor, chronic TB and counterinfection 
of a disease other than TB) as well as their repercussions. 
Such studies should' also investigate the problems related to drug 
administration such as the use of too many drugs for a long period of 
time and multi-drug resistance, to see whether or not there is a link. 
Also, there is a need to look into the possibility of producing a single 
dosage that is more patient-friendly to lessen the long time the patient 
must take to complete the prescribed dosage or treatment regime 
(Kibitok 1997). 
References 
Barnes.P.F. and Barrows, S. A. 1993. Tuberculosis in the l99Os.Annals 
of Internal Medicine, 119 5 400-410 
Barnes, P.F. Block, D. and Paul, T. 1991. ifeview article of current 
concepts: Tuberculosis in human with immunodeficiency virus infection. 
New England Journal of Medicine, 32423 1644-1650 
Bobbin, C. 1984. Pathological Basis of Disease, New York, Saunders 
VOL 18 NO 2 JULY 2003 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA 131
Centre for Disease Control 1992. National plan to combat multi-drug 
resistant TB: meeting the challenge of multi-drug resistant TB. Morbidity 
and Mortality Weekly Report, 41RR-116 
Darbon, C.J. and Grange, J.M. 1993. HIV/AIDS and its implication for 
the control of animal TB. British Veterinary Journal, 149 405-417 
Diers, D. 1979. Research inNursing Practice, Philadelphia, Lippincott 
Emokor, M.A. and Tukei, P.M. 1982. Medical Priorities in Kenya, 
Nairobi, Kenya Medical Research Institute 
Evans, C. C. 1994. Historical background. In: P. Davis (ed.), Clinical 
Tuberculosis,London, Chapman and Hall, 1-17 
Fawcett, J. and Downs, F.S. 1986. The Relationship of Theory and 
Research, Norwalk, CT,Appleton-Century-Crofts 
Festenstein, F. and Grange, J.M. 1991. Tuberculosis and the acquired 
immune deficiency syndrome review. Journal of Applied Bacteriology, 
7219-30 
Glaser, B.G. 1978. Theoretical Sensitivity, Mill Valley, CA, Sociology 
Press 
Glaser, B.G. and Strauss, A.L. 1967. The Discovery of Grounded Theory: 
Strategies for Qualitative Research, New York, Aldine 
Holmes, A.C. l964.Health Education in Developing Countries, London, 
Thomas Nelson 
Hughes, D.T.D. and Marshall, P.T. 1974. Tropical Health Science, 
Human and Social Biology, London, Cambridge University Press 
Kibitok, N.K. 1997. Tuberculosis re-emergence after a decade of 
successful effective treatment and control. Unpublished Trade Project, 
Mombasa Polytechnic, Kenya 
Kochi, A. 1991. The global tuberculosis situation and the new control 
strategy of the World Health Organization. Tubercle, 72 1-6 
National Leprosy and Tuberculosis Programme (NLTP) 1996. Annual 
Report, Ministry of Health, Kenya 
Pratt, R. 1995. HTV and AIDS: A Strategy for Nursing Care, London, 
Edward Arnold 
WHO 1997. Press releases. WHO/TB cap.200 
132 JOURNAL OF SOCIAL DEVELOPMENT IN AFRICA VOL 18 NO 2 JULY 2003