1. AFRA COUNTERPARTS MEETING, 15TH – 17TH NOVEMBER, 2017, NACOSTI, NAIROBI.

2. TOPIC: NUCLEAR MEDICINE PRACTICE IN KENYA
PRESENTER: Dr. David Ndirangu Theuri
Nuclear Medicine Physician 1/c
and
RAF6051 AFRA Project Counterpart – “Strengthening Education and Human Resource Development for Expansion and Sustainability of Nuclear Medicine Services in Africa”
Nuclear Medicine Unit
Cancer Treatment Centre
Kenyatta National Hospital (KNH)
Tel:

3. Kenyatta National Hospital

4. WHAT IS NUCLEAR MEDICINE?
Nuclear medicine is a medical specialty that relies on the use of nuclear technology in the diagnosis and treatment (therapy) of diseases.
PRINCIPLE OF NUCLEAR MEDICINE
Nuclear medicine uses the principle that a certain radiopharmaceutical (tracer) will at a certain point in time have a preferential uptake by a particular body, tissue or cell.
This uptake is then imaged by the use of detectors mounted in gamma cameras or PET (positron emission tomography) devices.

5. WHAT IS PECULIAR ABOUT NUCLEAR MEDICINE?
Unlike other radiation applications for medical use, nuclear medicine uses open (unsealed) sources of radiation. The tracer is introduced into the body of the patient through several routes (oral, intravenous, percutaneous, intradermally, inhalation, intracapsular etc) and s/he becomes the source of radiation.
This radiation in the patient can then be detected (for diagnostic use) or used to kill some selected unwanted body cells such as cancer cells (therapeutic use).

6. ADVANTAGES OF NUCLEAR MEDICINE
Ability to image the whole body in a single sitting at a comparably short time hence increased patient throughfare with no added radiation burden to the patient.
The dosages used in diagnostic nuclear medicine are usually very small – hence minimal radiation burden to patients, personnel and the environment.
When compared with conventional radiology imaging (e.g. X- rays, CT scan, MRI, U/S, etc), nuclear medicine imaging is able to give information on cellular activity at an earlier stage. The difference is about three (3) months in plain X-ray imaging.
Early diagnosis of diseases coupled with associated timely therapeutic intervention will lead to better prognosis.

7. DISADVANTAGES OF NUCLEAR MEDICINE
Uses very costly and sophisticated equipment.
Requires highly trained personnel.
Since the source is unsealed (open), there are higher chances of radiation exposure and hence radiation accidents (including spillages and contaminations) are more likely to occur when compared with the sealed sources such as Cobalt 60. This becomes a matter of great importance to radiation safety.

8. CURRENT STATUS OF CLINICAL NUCLEAR MEDICINE PRACTICE IN KENYA
In a country with an estimated population of 48 million in 2017, Kenya has only two (2) nuclear medicine facilities (units). Furthermore, both of them are small units and both are in Nairobi and within about two (2) Km of each other as follows:
Aga Khan University Hospital
– Private facility. Payments at commercial rates.
– One (1) nuclear medicine physician, two (2) technologists, two (2) medical physicists who are shared with Radiology.

9. CURRENT STATUS OF CLINICAL NUCLEAR MEDICINE PRACTICE IN KENYA (CONT…)
Kenyatta National Hospital
- Public facility. Payments highly subsidized by the Government of Kenya.
One (1) dual-head gamma camera (Mediso from Hungary). Was commissioned in No back-up. It is capable of performing most of the nuclear medicine imaging procedures including SPECT (Single Photon Emission Computed Tomography).
One (1) nuclear medicine physician, two (2) technologists (one trained and one awaiting training), four (4) medical physicists shared with radio-oncology, one (1) Radiation Protection officer shared with radio-oncology. Other shared staff include nurses, records officers and copy typists.

10. CURRENT STATUS OF CLINICAL NUCLEAR MEDICINE PRACTICE IN KENYA (CONT…)
- Staff from Biomedical Engineering Department are called in when equipment breaks down. - Other smaller equipment include: Two (2) dose calibrators One (1) gamma probe One (1) rectilinear scanner One (1) wipe test counter and decontamination kit One (1) delay/decay tank One (1) radioiodine fume hood One (1) radioiodine uptake probe One (1) treadmill – has always been non-functional Five (5) survey meters

11. However, in the 5 - year plan of the Ministry of Health in Kenya, there are proposals of not only expanding the existing facility, but also to develop four (4) other facilities up- country.

12. HOW DO WE CREATE AWARENESS OF EXISTENCE OF NUCLEAR MEDICINE SERVICE IN KENYA?
Being a relatively new medical discipline in Kenya, several measures have been taken by the clinical nuclear medicine team to create awareness at various levels as follows;
At the hospital level –
giving awareness talks during the various Continuous Professional Development (CPD) and Continuous Medical Education (CME) seminars.
Presentations during annual conferences of various clinical disciplines such as urologists, orthopedic surgeons, physicians, etc.
Presentation during the annual KNH/UoN Scientific Conference.
At the individual level, patients are counselled and given free brochures/pamphlets to read on their own.

13. HOW DO WE CREATE AWARENESS OF EXISTENCE OF NUCLEAR MEDICINE SERVICE IN KENYA? (CONT…)
orientation of staff that are sent to rotate with us from national academic institutions such as universities and medical training centers offering medical degrees, diplomas and certificates.

14. HOW DO WE CREATE AWARENESS OF EXISTENCE OF NUCLEAR MEDICINE FACILITIES IN KENYA?
Awareness to the referring doctors – a booklet titled “Introduction To Nuclear Medicine Diagnosis and Treatment” published by the International Atomic Energy Agency (IAEA) in was distributed for free to the doctors in African countries that were participating in IAEA AFRA Project RAF I am glad to inform you that I was the chairman of the Task Force that had been formed to compile this booklet. This booklet is available for free in the IAEA website.

15. HOW DO WE CREATE AWARENESS OF EXISTENCE OF NUCLEAR MEDICINE SERVICE IN KENYA?
Local awareness at the community level –
Exhibitions during annual Agricultural Society of Kenya (ASK) Shows including Nairobi International Trade Fair (NITF).
Exhibitions and presentations during the annual Kenyatta National Hospital “Cancer Day”, “Cancer Month” as well as “Open Day”.
Giving talks to interest groups such as churches.

16. HOW DO WE CREATE AWARENESS OF EXISTENCE OF NUCLEAR MEDICINE FACILITIES IN KENYA?
Awareness to other local users of nuclear technology –
Presentations during the regular meetings (including this one) organized by the National Council of Science, Technology and Innovation (NACOSTI) for all stakeholders in Kenya that are also utilizing or regulating nuclear technology including water, electricity, agriculture, as well as the teaching institutions sub-sectors.
Awareness at the international level –
Presentations during numerous international nuclear medicine seminars and training courses held locally or abroad including those on radiopharmacy (two of which have taken place in Nairobi in 2013 and 2016) mainly with the support and facilitation of NACOSTI and the IAEA.

17. SUPPLY OF RADIOPHARMACEUTICALS
Kenya does not manufacture radiopharmaceuticals. We therefore have to import them from abroad and this makes them quite expensive, and the process demanding. Currently we import radioiodine (NaI-131) from AEC Amersham SOC Ltd in South Africa. The technetium-molybdenum generator and the associated labeling kits (MDP, DTPA, DMSA, MIBI, HINDA, Sulphur colloids etc) are imported from IDB Holland BV, in Netherlands.

18. TRAINING OF NUCLEAR MEDICINE STAFF
There is no local training in nuclear medicine and staff have to be sent abroad for training, making this quite expensive and cumbersome.
The IAEA compliments this training by arranging and sponsoring numerous training courses for Continuous Professional Development (CPD) to all cadre of staff involved in the daily running of our nuclear medicine facility. The hosting of these training courses is rotated among the African countries that are participating in the AFRA IAEA Projects. We are happy to have successfully hosted two (2) of these seminars in Kenya.

19. WHAT NUCLEAR MEDICINE PROCEDURES DO WE DO AT KNH?
Type of procedure
Radionuclide bone scans
Radionuclide thyroid scans & whole body Radioiodine scans
Renal scans (DTPA & DMSA)
Lymphoscintigraphy
MIBI parathyroid scans
Liver (HIDA) scans
Myocardial Perfusion Imaging (MPI)
Lung perfusion scans
Merkle’s diverticulitis scans
Percentage of total
70%
20% 6%
0.2%
3.8%

22. 5,251 patients have undergone diagnostic nuclear medicine studies by 31 December 2016 as follows;
TYPE OF PROCEDURE
NO OF CASES OVER THE YEARS
2006 &2007
2008
2009
2010
2011
20 12
2013
2014
2015
2016
Totals
RADIONUCLIDE BONE SCANS
112
101
125
652
521
724
295
329
413
436
3,708
THYROID SCANS 62 86
223
109 28 65 99
984
RENAL SCANS 14 3 6 64 41 58 27 48 42
344
LUNG PERFUSION SCANS 16 2 20
LYMPHOSCINTIGRAPHY 7 4 15 17 19 11 30 43 22
170
LIVER (HIDA) SCANS 1 8 10
MYOCARDIAL PERFUSION IMAGING (MPI)
MECKLE’S DIVERTICULITIS o
MIBI PARATHYROID SCANS
211
196
235
973
707
912
361
487
570
599
5,251

23. WHAT THERAPEUTIC ACTIVITIES DO WE DO?
So far, the therapies that we do are two (2);
Thyroid ablation therapy in differentiated thyroid carcinoma with the use of oral radioiodine (oral NaI- 131). Last year (2016) we treated 24 such cases Thyroid cancer is one of the 30% human cancers known to be curable when diagnosed and treated early.
Suppressive therapy in patients with hyperthyroidism (Grave’s disease, etc) with the use of oral radioiodine (oral NaI-131). Last year (2016) we treated 31 such cases.
In future we hope to also give palliative bone pain therapy with Samariam-153, Strontium-89 and Rhenium-186 etc, in patients with multiple bone metastases especially those from prostate cancer and breast cancer among others.

25. SWOT ANALYSIS Strengths
We have a committed, well trained personnel with well coordinated teamwork.
We have suitable infrastructure.
Weaknesses
Sporadic down-time of the gamma camera – the gamma camera was crashed between July 2013 and January 2014 (6 months) and no scans were done during this time since there are no back-ups.
We lack some vital equipment such as treadmills hence we are not able to perform some very important studies such as myocardial perfusion imaging (MPI).

26. SWOT ANALYSIS (CONT…)
Lack of locally available radiopharmaceuticals makes the service very expensive and hence not affordable to some needy patients.
There has been sporadic lack of radiopharmaceuticals supply arising from delayed payment to the suppliers abroad and this has greatly hampered optimizing the service provision. Currently we have not had any supplies since 19th May 2017 (6 months) due to procurement challenges and so we have not been able to do any scans the whole of this period!
There is inadequate awareness of the existing nuclear medicine services – the use therefore has not been optimized. However, we are hoping this will improve with the new publication as mentioned above.

27. SWOT ANALYSIS (CONT…) Opportunities
The facility is within the Cancer Treatment Centre and hence it makes it easy to get patients with the relevant indications for nuclear medicine service.
Our hospital is a referral hospital for the whole country and deals with all kinds of disease specialties. During the devolution of health services to the 47 County Governments (in keeping with the new Constitution of 2010), KNH was retained with the National Government and is therefore not affected by local dynamics. We also offer services to some patients referred from our neighboring countries including South Sudan, Somalia, Rwanda, Burundi, Democratic Republic of Congo (DRC), among others.

28. SWOT ANALYSIS (CONT…) Threats
The rate of training of staff is not commensurate with the demand for personnel to effectively sustain the service in future.
Prolonged delays in radiopharmacutical procurement makes the KNH facility sub-optimal in offering the service.
The lack of some of the vital equipment and the slow adaptation to technological advances such as PET, PET/CT and PET/MRI end up making our service ineffective, inefficient, inadequate or even obsolete in the long run.

29. OBSERVATIONS
One of the objectives of our country’s “Vision 2030” is to develop nuclear energy.
The availability of locally produced radionuclides will make them not only cheaper but also probably make it possible for PET studies such as 18F-FDG.
For the time being, we have to make-do with the current circumstances and try to sustain and optimize the service.

30. RECOMMENDATIONS
In order to effectively sustain nuclear medicine in Kenya;
More needs to be done to ensure continuous supply of radiopharmaceuticals – action by the hospital management.
More personnel should be trained – action by the hospital management with partnership with the IAEA.

31. CONCLUSION
With concerted effort by all stakeholders at the individual, national and international level, it is possible for Kenya to effectively sustain clinical nuclear medicine service not only as a diagnostic tool in many disease entities, but also play an increasingly important role in therapy.

32. THANK YOU