Burden of tuberculosis disease in Nigeria

Depending   on   the  prevailing   social factors such as socio-economic status of the people, malnutrition, crowded living conditions, incidence of HIV/AIDS, level of development of health infrastructure, quality of available control programmes, degree of drug resistance to anti-tuberculosis agents, etc, prevalence, and patterns of presentation, outcomes of treatment from TB     can vary from  one country to another and from one region of a country to the other.

Tuberculosis is a big global  problem  such  that  the  disease  led  to the  development of Directly Observed Treatment  Short  Course (DOTS) by WHO in1995, and more recently, the Stop TB strategy in 2006.

In Nigeria, the DOTS programme has been implemented in all states and local government areas in the country and  over 3,000 DOTS centres have been operating across the country since 2006.

However, inspite  of all  the DOTS centtres, Nigeria for  over  10 years,  has  remained on the  4th position of  countries  with  the highest burden of  TB in the world.

For long,  hhe federal government  has not done much in concrete terms in the intervention in TB control, and this dates back to the days of German Leprosy and TB Control Association (GLRA) in the East and some parts of the West, and Damien Foundation Belgian (DFB), funding TB control in Oyo State.

President of the Nigeria Thoraxic Society, Prof Gregory Erhabor recalled that in 1993 when the WHO rolled out the list of 23 countries with the highest TB burden, the body proffered certain steps that must be taken by these countries, including Nigeria. This includes the implementation of the directly observed treatment, short-course (DOTS) among other things.

Another alert came in 1998 from WHO that most of the countries have not done much, and Nigeria topped the chart again.

It was only recently, with the outbreak of Multi Drug Resistance Tuberculosis (MDR-TB), Extremely Drug Resistance Tuberculosis (EDR-TB) all over the world and the worst case scenario of combining diabetes mellitus (DM) or HIV with TB that  much   more efforts was made in Nigeria towards TB control and the most significant effort coming from donor agencies.

Efforts  at detection and  cure

One of the indicators of the performance in TB control is the number of cases detected and cured. The world health body sets a benchmark of 70 per cent for detection and at least 85 for cure. Erhabor said that the country is actually detecting more cases of TB.

He stated, “while we have met the 85 per cent cure rate of those detected, we have not met the 70 per cent rate of detection.”

There are many more cases in the communities that are undetected. While the annual detection rate in the country has in the last few years increased from about 20, 000 to over 79, 000 (as at 2009), the burden is still considered high. “We are still lingering around 30 per cent detection rate in Nigeria”  

“We had 460,000 new cases of all forms of TB in 2007, though from a 2009 report. For the TB active cases, there are 195,000 but only 79,000 were detected of all forms of TBs. That is 24.3 per cent detection rate. That is to tell you the gap from 70 per cent benchmark. Though, the number of cases detected is improving over the years.”

Progress so far

Though most of the findings are from the WHO, Nigeria is currently carrying out a prevalence survey to know the actual prevalence in the country.

Indeed, Tuberculosis (TB) is an infectious deadly disease that affects everyone who breathes. One active TB case in the community will in a year infect another 12 people. Some of these cases have been found to be incurable.   

“This is because if a TB patient is not properly treated, he or she will go into the community and before the end of the year, infect about 12 new people. If a TB patient has MDR-TB, it means that the patient would not be cured and the patient will be in the community infecting others.”

Erhabor observed that some TB patients, perhaps due to poor compliance, are now having TB bacteria resistant to the first line drugs.

 In the treatment of TB, there are five first line drugs: rifampicin, ethambutol, isoniacide, pyrazinamide and streptomycin. The treatment of TB requires first-line drug but it is second-line drugs in the treatment of MDR, which takes a longer time and a lot more expensive.

According to the President  of  the  Nigeria Thoraxic  Society, “No matter the kind of X-ray the patient does, it cannot be detected that  he or she has TB or bacteria that is resistance to the drug and killing it (MDR-TB) without getting to the lab. No matter the quantity of drugs given to that patient, the bacteria will be there multiplying.”

Nigeria has just a few  MDR-TB wards. One  in   Ibadan ( commissioned  July 2010 and managed by Damien Foundation); Global Fund, this year commissioned  another one  in Lagos; there is another one   at the Zonal Reference Lab in Calabar. Others are currently planned for Kano, Zaria and Port Harcourt to accommodate the increasing cases of MDR-TB in the country.   

Treating MDR is not only expensive but also complicated. Caregivers said that it requires about $4,000 (about N600, 000) to treat a case of MDR-TB in a year.   

While efforts of Global Fund and some donor partners make drugs and treatment (under the supervision of the government) possible, “If those drugs are not properly used by patients, it leads to Severe Drug Resistance (SDR) TB. It is the TB that has no cure! And you can imagine a carrier staying in the community infecting other people with incurable TB.”   

While the experts await the latest national survey, earlier estimates show that among those who have been treated for TB, at   least, once in Nigeria, about 9.4 per cent are living with re-occurring TB and so has MDR-TB.    

Way Out

The basic solution, according to experts consensus, is taking TB awareness very  seriously, having in mind, the enormous    problems and risk to the communities. Everyone must be aware of the key symptoms of TB.   

They include: Anyone who has had cough that lasted for two to three weeks is a suspect (it is an emergency in this part of the world). We must encourage that person to go to a DOTS centre for estimation. Diagnosis and treatment of TB is   free    at   the    DOTS centers and they are available.

They added that person with TB infection must realise that he or she has a public health duty to self and others. To self, do laboratory test. The fellow must strictly adhere to treatment and use drugs for as long as it is required.  

To the community, “you must make sure that you do not spread the TB.”

Practice cough hygiene by covering your nose and mouth when coughing or sneezing with a handkerchief. The aim is to avoid pushing the TB (aerosol) into the environment. One sneeze can release one million infectious TB germs into the air. The germs pushed into the air hang around for days without dying, and easily infects anyone who breathes around it.

Daunting as the challenge is, Erhabor is optimistic that there is hope for a well-controlled TB in Nigeria with improved awareness through communities, churches, mosques, motor parks and markets.

Source: Leadership Newspapers