March 24 is World TB Day, yet for most people that have the privilege of reading this piece, tuberculosis is an abstract term. But, why would a disease that infects about half a million Nigerians every year, and kills about 170,000 annually attract so little attention from the government, the health professions and from the people? The answer is simple – it is a disease that disproportionately affects the poor and marginalised.
It is widely recognised that the poorer the community, the greater the likelihood of being infected with the TB germ and developing clinical disease. A lack of basic health services, poor nutrition, inadequate living conditions and HIV all contribute to the spread of TB. With poor access to health services to diagnose or treat patients, there is a longer delay between disease and treatment, perpetuating the spread of TB. In a hyper-capitalist society like Nigeria, it is not hard to see why patients with tuberculosis fall through the cracks.
The first challenge in Nigeria, as with many other things, is to understand the size of the problem. Over the past 4 years, about 100,000 cases of all forms of TB were diagnosed annually in health centres across the country. However, in 2012/13, the National Tuberculosis and Leprosy Control Programme (NTLCP), under the leadership of Dr. Olusegun Obasanya at the time, conducted the first ever population based national prevalence survey, which revealed some shocking results. The estimated overall prevalence was double what was being estimated and the incidence (rate of new cases) a year was three times previous estimates.
Assuming a resident population of 170 million in Nigeria, the estimated number of new cases of all forms of TB would be about 570,000, revealing a huge gap in case detection. This showed that Nigeria’s case detection rate for all forms of TB currently stood at only 15 percent, one of the lowest case detection rates in the world.
For the cases that are detected, they are almost exclusively managed in the public sector, and the management of TB has been generally limited to “Directly Observed Treatment Short course” (or “DOTS”) centres and “Chest Clinics”, a practice that belongs in the dark ages. Contemporary science suggests that there is no medical or public health reason why patients with TB should be diagnosed and managed in any out-patient setting separate from any other patient. Mycobacterium tuberculosis is such a poorly virulent organism that the risk of transmission in an outpatient clinic in our context is minimal.
This practice has led to a whole generation of doctors who have little experience on how to manage patients with TB, because all they do is refer patients to “DOTS” centres. It is time to change this practice and normalise TB treatment, by bringing it back into all primary health centres in Nigeria. The national TB strategic plan (2015-2020) suggests an expansion of DOTS services to more facilities across the country in order to improve case notification rates. We suggest going a step further: make every public healthcare facility in Nigeria a “DOTS Centre”. Every functional public health care facility should have the capacity and resources to diagnose and manage patients with TB.
To get TB cases into care, they need to be diagnosed. This is being addressed to some extent by the roll of out of the Xpert MTB/RIF assay (carried out in “GeneXpert machines”) in Nigeria. The Xpert MTB/RIF assay is a new test that is changing tuberculosis (TB) diagnosis by enabling the rapid diagnosis of TB disease and drug resistance. The test simultaneously detects Mycobacterium tuberculosis complex (MTBC) and resistance to rifampin (RIF) in less than 2 hours. In comparison, standard cultures can take 2 to 6 weeks for MTBC to grow and conventional drug resistance tests can add 3 more weeks.
As of the end of 2015, there were just over 200 centres with GeneXpert machines in Nigeria. The policy has recently been changed to allow the use of Xpert MTB/RIF assay for the diagnoses of all potential TB cases without restrictions, where the test is available. The GeneXpert equipment is however very expensive, and these costs go way beyond the initial costs. This paper by Abdurrahman et al showed that the “hidden” costs of installing these machines could be up to 3 times the cost of the machines themselves.
In addition, because these rely heavily on constant electricity to work, their utility is limited to centres where this is available. Of the 200 centres in Nigeria, most are in the public sector, with 22 being in the private sector; predominantly faith-based not-for-profit hospitals. This March, the NTBLCP in collaboration with USAID conducted an assessment of the TB laboratory diagnostic capacity in Nigeria, to identify gaps in laboratory infrastructure, technology and human resources capacity, that will further guide the efforts to increase case detection in Nigeria.
Nigeria has the fourth highest annual number of TB cases in the world. We cannot get on top of this by passive detection of TB as is currently the case. Studies such as this one by Oshi et al shows that intensified case finding combined with capacity building, provision of work guidelines, and TB health education can improve TB notification.
For World TB Day 2016, WHO calls on governments, communities, civil society, and the private sector to “Unite to End TB“. WHO and partners are promoting dialogue and collaboration that unites individuals and communities in new ways to end the tuberculosis (TB) epidemic. These efforts cut across disciplines and sectors, and can help accelerate progress towards the Sustainable Development Goals overall by contributing to other areas including poverty elimination, universal health coverage, maternal and child health, social protection and justice.
The World Health Organizations’s End TB Strategy envisions a world free of TB with zero deaths, disease and suffering. It sets targets and outlines actions for governments and partners to provide patient-centred care, pursue policies and systems that enable prevention and care, and drive research and innovations needed to end the epidemic and eliminate TB.
Every country is judged by how it treats its most vulnerable. Maybe it’s time for us to stand up for ours. We can #EndTB, but we must reach the most vulnerable!Watch this short documentary on the rise of Drug resistant Tuberculosis in Nigeria.
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