How Stakeholders’ Intervention Increased TB Patients Diagnosis to over 40,000 in Four Years

As part of efforts to reduce the high prevalence of Tuberculosis in Nigeria, interventions by stakeholders appear to be yielding desired results with over 40,264 TB patients diagnosed within four years. Adedayo Akinwale writes

In 1988, the federal government established the National Tuberculosis and Leprosy Control Programme Framework as part of plans to reduce the prevalence of tuberculosis and leprosy to a level at which they no longer constitute public health problems in the country.

Despite these proactive steps taken by the federal government, decades later, the country ranks first in terms of Tuberculosis (TB) prevalence in Africa and the 6th in the world, according to the World Health Organisation (WHO).

The problem of TB in Nigeria has been complicated by the emergence and spread of drug resistant TB and a high burden of HIV/AIDS. People with HIV are more likely to develop active TB.

The Federal Ministry of Health in its 2019 annual TB report said there had been a consistent increase in the number of TB cases in the country in the past four years. It said the increase recorded between 2018 and 2019 was the highest ever since the programme was established in 1989.

It added that Taraba state has the highest increase of 49 per cent. The increase in case notification in five of the states (Taraba-49 per cent, Cross River-45 per cent, Katsina — 42 per cent, Niger-40 per cent, Akwa Ibom 28 per cent and Bauchi-26 per cent), contributed to the national increase of 13 per cent.

Stakeholders’ TB Intervention

Against this background, KNCV Tuberculosis Foundation Nigeria is implementing the Tuberculosis Local Organizations Network (TB-LON) Regions 1&2 projects and the Stop TB Partnership DATs project.

The projects funded by United States Agency for International Development (USAID) is providing comprehensive TB care and treatment services across 14 states in Nigeria: Akwa Ibom, Cross River, Rivers, Anambra, Delta, Imo, Bauchi, Benue, Kaduna, Kano, Katsina, Plateau, Nasarawa and Taraba states.

The Executive Director of KNCV Nigeria, Dr. Bethrand Odume said different interventions introduced by the KNCV include Health Facility based active TB case finding; Tracing contacts of known cases of TB; Targeted active community case finding; Public Private Mix (PPM) which involves the engagement of the Private for Profit (PFP) and Patent Medicine Vendors (PMV) and Community Pharmacists in TB case finding and treatment within the communities.

Others are: Wellness on Wheels (WoW) Truck, mobile diagnostic vans; TB case finding among the nomadic populations in Bauchi State, while Delft Light Backpack (DLB), is a Digital x-ray with artificial intelligence for active case finding among the hard-to-reach population.

For instance in Kano state, Odume said Patent Medicine Vendors (PMV) were engaged and trained on how to identify TB signs and how to collect sputum or stool for further diagnosis. The use of informal private sector PMV was launched in Kano and 150 PMVs were engaged across five local government areas. Most of them (PMVs) are well-known communities when it comes to the provision of semi-formal health service.

He explained: “Once a client is screened and found to be presumptive TB, he/she is linked by the screening officer to the DOTS unit where details are entered into the presumptive TB register, the specimen examination form is filled and the sputum or stool (in the case of children who are not able to produce sputum) sample is collected and sent for GeneXpert analysis. When the result is retrieved, they are updated in the presumptive register and those positive for TB are contacted for counselling and treatment initiation.

“The delft-light Backpack known as DLB is a miniature or carry-on digital X-ray machine, equipped with CAD4TB artificial intelligence software used for on-the-spot screening and diagnostics services among contacts of TB patients right at their doorsteps. It has improved access to TB services by reducing the cost of x-rays, transportation time and money.”

Interventions in hard-to-reach Communities

Odume emphasised that during Active Tuberculosis Case Finding (ACF), the DLB was first used to screen TB contacts and people at risk of TB within very hard-to-reach locations using the miniature x-ray with artificial intelligence. It is presently in operation in high TB burden locations in Akwa Ibom state.

He noted, “The WoW truck from October 2017 to date, has screened 133,675 people, identified 18,362 TB presumptive, evaluated 16,000, diagnosed 2,397 and 2,176 placed on treatment.”

Odume said GeneXpert was the first line diagnostic option for TB in the country, however, the TB Lamp is a new technology for TB diagnosis. Both technologies are presently being used. The TB LAMP has been piloted in two states and further scaled up to an additional five states in Nigeria. Both use the same principles for TB diagnosis, being molecular based PCR tests.

He added that TB Lamp is user friendly which requires 2 – 3 days training and does not require a highly skilled cadre of staff for operation and as such can be used in peripheral facilities in very hard-to-reach locations where there is also a dearth of human resources.

Odume stressed, “The TB Lamp diagnoses more TB samples in a day; 56 to 70 tests per day while GeneXpert processes 12 to 20 tests per day. The sample processing time in TB Lamp is 55mins and 70 mins for GeneXpert ultra-cartridge and 2hrs for the regular cartridge.”

“From the start of the TB LON 1 & 2 project across 14 states, a total of 40,264 TB patients were diagnosed out of which 37,775 TB patients started on appropriate treatment among which 3,691 are children less than 15 years.”

However, funding has remained a key challenge to TB control in Nigeria. Odume said there was a need to drive States Domestic Resource Mobilisation activities across the 14 supported states to increase funding for TB control activities and integrate tuberculosis care into State Health Insurance Schemes minimum health benefit package.

He also lamented the huge funding gap for TB control in Nigeria. He said of the $384 million National TB budget for 2020, there was a 70 per cent funding gap, adding that out of the 30 per cent of the available funds for TB control, seven per cent was domestic and 23 per cent from international donor agencies, specifically USAID.

Experience of Staff Implementing the Project

KNCV Senior Program Officer in Bauchi, Dr. Simon Maju, said his experience implementing TB LON project in hard-to-reach communities of Bauchi state involves continuous engagement of leaders at all levels – the Ministry of Health, facility managers in the public and private sectors, as well as community leaders.

He said, “Community outreaches by local teams to key populations such as nomads and Internally Displaced Persons in host communities, to identify presumptive TB patients and link to diagnosis has led to increased TB case finding in the state despite the challenges of insecurity, poor access and difficult terrain. Also, the screening of all attendees at high burden facilities by TB screening officers has reduced missed opportunities and linked more patients to treatment.”

On his part, KNCV Senior Program Officer in Imo State, Dr. Golibe Ugochukwu said implementing the project in hard-to-reach communities was stressful, but it exposed the team to the realities of life in the hinterland in Nigeria.

Testimony of Beneficiaries

One of the beneficiaries, Mr. Sanusi Adamu was diagnosed with TB after a visit to Moh’d Habibu’s chemist shop (A PMV Vendor) located in Layin Fango Brigade Gawuna Area in Kano state.

Adamu, 45, had been coughing and feverish for over two months. He eventually visited Habibu who had been trained by a TB specialist named Ali DOT in Murtala Muhammed Specialist Hospital in Kano and by the KNCV team led by Dr. Mamman Bajehson.

When he tested positive for Drug resistant TB he was immediately linked with the Nasarawa Local Government Tuberculosis and Leprosy Supervisor.

Routine contact investigation showed that his wife and eight children tested negative for TB. Adamu was enrolled for treatment at the Multi Drug Resistant TB treatment center at the infectious disease hospital Kano.

Adamu said, “I am still on admission, this is my third month. I am feeling much better, I have no side effects to the drugs. I am grateful to my wife and the Chemist who encouraged me to go to the hospital for treatment.”

Similarly, Mr. Munka Ila, said two weeks before he was diagnosed with TB, he was having catarrh and cough which he treated for one week, but had no relief.

Munka and his wife were taken to the clinic where their Sputum was collected for testing and they tested positive for Tuberculosis.

His said, “When the nurse told me I had TB, I felt very bad because I have heard of it before and how it kills people. The nurse told me to try and bring my wife so they can start treatment and my children as well so they can also test them. They collected the sputum and stool of my little children for the test and all of them were positive for TB”.

Munka and his family were referred to PHC Yelwa East in Shendam where they were immediately placed on treatment.

It should be noted that SDGs Target 3.3 includes ending the TB epidemic by 2030, while the WHO with its “END TB” strategy has a vision to eliminate TB as a public health problem by 2050. While KNCV intervention is acknowledged, there is need to intensify efforts and strengthen programmes to further reduce the burden of TB in Nigeria.

“This story has been supported by Nigeria Health Watch through the Solutions Journalism Network, a nonprofit organisation dedicated to rigorous and compelling reporting about responses to social problems, solutionsjournalism.org”

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Community outreaches by local teams to key populations such as nomads and Internally Displaced Persons in host communities, to identify presumptive TB patients and link to diagnosis has led to increased TB case finding in the state despite the challenges of insecurity, poor access and difficult terrain