As the Ebola epidemic in West Africa slows and falls away from the headlines, there is a temptation to view this outbreak as an isolated event and go back to life as usual. In Nigeria, the fairly successful response to the Ebola epidemic has brought a bit of credibility to the Nigerian health sector, with many Nigerian public health professionals smiling when confronted with the question “How did you guys do it?” While there is definitely some satisfaction to be gained in the response to the Ebola outbreak in Nigeria, it does not change the fact that we are still in a precarious situation with several other infectious disease threats, which kill thousands of people in Nigeria. No other disease illustrates better our collective inability to deliver the essentials of a modern public health response to those who need help the most, in the most timely and efficient manner, than our response to tuberculosis (TB).
While diseases like Ebola kill swiftly and produce horrific and acute symptoms, TB consumes many of its unknowing victims over a long period. It often goes undiagnosed for months, if not years, while it multiplies in families and communities. People infected with TB are often poor, marginalised and voiceless. Individuals who are ill with TB and not treated, can spread the bacteria through the air. Without correct treatment, more than 80 percent of people who fall ill will eventually waste away — coughing up blood while their bodies are ravaged by the disease — until they die. The difference is that they do not die in days, but in months … sometimes years.
For many years, there has been widespread suspicion that most of the cases of TB occurring in Nigeria are not detected by the system and are never able to access care. Under-diagnosis is probably the most significant reason for the low numbers of cases reported in Nigeria. TB diagnosis and care is only available in the public sector and in a few faith-based healthcare facilities. However, these sites are very unappealing for patients, as they are often poorly maintained inaccessible and located at the corners of hospitals.
The first ever population based TB prevalence survey, (an attempt at measuring the burden of TB ) was conducted in Nigeria in 2012. Data from this survey provides some context to the low case notification data. The survey revealed a doubling of the estimated overall prevalence (the total number of people with TB) and a tripling of the estimated incidence (the total number of new cases) from previous WHO estimates. Based on the survey’s findings, Nigeria’s population of 170 million , in 2012, the estimated number of new cases of all forms of TB should have been about 550,000. However, Nigeria notified a total of only 97,000 new cases of all forms of TB in 2012, revealing a huge gap in case detection. Using these updated figures, Nigeria’s case detection rate for all forms of TB currently stands at approximately 17 percent, one of the lowest case detection rates in the world. Based on the 2012 prevalence survey data, the country and WHO have updated their estimates for TB prevalence and incidence in Nigeria. This data is publicly available here.
In recent decades, we’ve seen a surge in the number of people falling ill with strains of TB that are highly resistant to conventional treatment , which left untreated, kill rapidly. These strains are called multi drug resistant tuberculosis (MDR TB). Overall, the mean annual percentage increase in MDR-TB exceeded 100% in Nigeria, while MDR-TB case detection in 2012 was <10%. This means that most of the estimated 3,000 case of MDR TB in Nigeria are not diagnosed and do not enter the care pathway.
All over the world, tuberculosis is a difficult disease – difficult to diagnose and difficult to treat. But for the first time in years there is some real excitement on the TB scene with more rapid accurate diagnostic tools becoming available. Xpert MTB/RIF is a new test that simultaneously detects both the bacteria that causes TB and resistance to rifampicin, one of the main drugs used for its treatment directly from sputum in under two hours. WHO has recommended the use of the technology since December 2010 and is monitoring its global roll-out to promote coordination. A list of all the sites that have procured this new diagnostic option can be found here.
More than ever before, the Ebola outbreak presents the responsible public health departments and agencies in Nigeria with an opportunity to engage the attention of the Nigerian people to call for collective action to prevent future outbreaks and build capacity to respond to ongoing ones. We have a moral obligation to lend our voices to this broader struggle. We have learnt from the HIV/AIDS global epidemic that robust health systems are critical in mounting and sustaining a vigorous response to an emerging disease threat. This 2014 Ebola outbreak provides a unique opportunity to rebuild and strengthen health systems and should lead to much more robust investment in public health.
To find out how Nigeria has spent the US$ 147,354,856 that it received from the Global Fund in grants since the inception of the fund, go to their website here. To find out more about the Nigerian National TB Control Program, we would normally refer you to their website, but … it is “down”. To find data on TB in Nigeria, sadly, you will have to go to the WHO website here.
On World TB Day, 24 March, WHO is calling for new commitments and new action in the global fight against tuberculosis. The call is most urgent in Nigeria. We are sitting and watching a ticking bomb. With the release of the first ever nationwide MDR TB and TB Prevalence surveys in Nigeria, one would have expected a massive scale up in the response, but very little seems to have changed …