Godwin Haruna
23 March 2008
Lagos — The World Health Organisation (WHO) Tuberculosis (TB) Report for 2007 says Nigeria has the fourth largest TB burden in the world and indeed, the largest in Africa.
According to statistics obtained from the Nigerian Institute of Medical Research (NIMR), tuberculosis remains a serious public health problem in Nigeria. An estimated 390,000 Nigerians are infected with active TB yearly and over 107,000 people die from the infections annually. Expectedly, this has placed a huge burden on the shaky public health index in Nigeria.
As World Tuberculosis Day is being marked across the world today, many agencies and development partners working on the control of the deadly disease in Nigeria, say a lot still requires to be deployed to tame the epidemic. With the WHO theme: "I am Stopping TB", individuals are required to work collectively to checkmate the enormous human and material resources lost to the pandemic annually. It commemorates the day in 1882 when Dr Robert Koch announced that he had discovered the cause of tuberculosis, the TB bacillus.
What really is tuberculosis? Dr. Daniel Gobgab, director, Public Health Programme, Christian Health Association of Nigeria (CHAN) says it is a contagious disease. He adds that like the common cold, it spreads when people cough, sneeze, talk or spit; they propel TB germs, known as bacilli, into the air. A person needs only to inhale a small number of these to be infected, Gobgab states. Left untreated, each person with active TB disease will infect on average, between 10 and 15 people every year. He states further that people infected with TB bacilli will not necessarily become sick with the disease. "The immune system 'walls off' the TB bacilli which, protected by a thick waxy coat, can lie dormant for years. When someone's immune system is weakened, the chances of becoming sick are greater", he says.
Dr. Jonah Okesola describes the onset of the disease to THISDAY thus: "When the disease becomes active, 75 per cent of the cases are pulmonary TB. Symptoms include chest pain, coughing up blood, and a productive, prolonged cough for more than three weeks. Systemic symptoms include fever, chills, night sweats, appetite loss, weight loss, pallor, and often a tendency to fatigue very easily"
Okesola says treatment for TB is the use of antibiotics to kill the bacteria. The two antibiotics most commonly used are rifampicin and isoniazid. However, he says instead of the short course of antibiotics typically used to cure other bacterial infections, TB requires much longer periods of treatment (around 6 to 12 months) to entirely eliminate mycobacteria from the body. "Latent TB treatment usually uses a single antibiotic, while active TB disease is best treated with combinations of several antibiotics, to reduce the risk of the bacteria developing antibiotic resistance. People with these latent infections are treated to prevent them from progressing to active TB disease later in life', he adds. However, he says treatment using Rifampin and Pyrazinamide is not risk-free. The Centers for Disease Control and Prevention (CDC) notified healthcare professionals of revised recommendations against the use of rifampin plus pyrazinamide for treatment of latent tuberculosis infection, due to high rates of hospitalization and death from liver injury associated with the combined use of these drugs.
WHO estimates that the largest number of new TB cases in 2005 occurred in the South-East Asia Region, which accounted for 34 percent of incident cases globally. However, the estimated incidence rate in sub-Saharan Africa is nearly twice that of the South-East Asia Region, at nearly 350 cases per 100 000 population.
It is estimated that 1.6 million deaths resulted from TB in 2005. Both the highest number of deaths and the highest mortality per capita are in the Africa Region. The TB epidemic in Africa grew rapidly during the 1990s, but this growth has been slowing each year, and incidence rates now appear to have stabilized or begun to fall.
In 2005, estimated per capita TB incidence was stable or falling in all six WHO regions. However, the slow decline in incidence rates per capita is offset by population growth. Consequently, the number of new cases arising each year is still increasing globally and in the WHO regions of Africa, the Eastern Mediterranean and South-East Asia.
According to Mr. Ben Nwobi, national coordinator, National Tuberculosis and Leprosy Department of Public Health, Federal Ministry of Health (FMOH), those within 15-35 age brackets are the most vulnerable in the country. Nwobi says the significant impact on the TB epidemic is evidenced by a drift to the younger age groups, who have higher HIV sero-prevalence, which Nigeria ranks second largest in Africa.
He says to address this situation; the FMOH adopted the Directly Observed Treatment Scheme (DOTS) strategy for TB control with the assistance of German Bank for Reconstruction. He adds that by 2000, only 50 per cent of states in the country were implementing the DOTS strategy. The slow pace, he stressed, necessitated the development of a five-year strategic plan for DOTS expansion by the National Tuberculosis and Leprosy Control Programme (NTBCCP) of the ministry of health covering the period 2001-2005.
Nwobi said the plan received the support of the Canadian International Development Agency (CDA) and the United States Agency for International Development (USAID). The 100 per cent coverage is to be achieved for the entire country in consonance with attaining the global target for TB control and to abide by the Federal government policy of giving TB treatment to Nigerian patients free of charge.
Also speaking on the problems of accessing the needed resources to control TB, Mr. David Omorebokhae, director of advocacy, CHAN, said the national budgetary allocation to health has remained at about six per cent of the national budget. This, Omorebokhae says, is a far cry from the WHO recommended minimum allocation to health and Abuja 2001 agreement by 40 African Heads of State to allocate 15 per cent of their annual budget to health.
"This has created a big vacuum in the effort to effectively fund the treatment of TB in the country. It explains the partnership of CHAN, NTBLCP and other foreign organizations in submitting proposals to Global Fund in 2005 to access the Global Fund Round 5 TB Grant worth about $68,000 for five years. The project with CHAN commenced on January 1, 2007 with NTBLCP as a major sub-recipient", Omorebokhae stated.
Also speaking on TB control in the country, Mr. Patrick Kwakfut, secretary general, CHAN, says the Global Fund grant has really scaled up control activities in the country. Before the grant, Kwakfut says the statistics on case detection showed that it stood at 26 per cent, but today, it has increased to 31 per cent.
According to the secretary general, the programme, whose rating by Global Fund stood at B2 by middle of last year, has moved up to B1 by the beginning of 2008. However, he says despite the above increase in TB scorecard of Nigeria, the target for the country is to increase case detection from 26 per cent to 70 per cent.
"We have not reached even 35 per cent case detection. Many Nigerians are still suffering from TB undetected when the services/treatment and drugs are free. This is the challenge before CHAN and NTBLCP and others, who are the major drivers in the process of stopping the onslaught of TB in the country.
"We should not forget that in the projection to treat at least, 85 per cent of detected cases, we have only achieved 79 per cent. We need to improve on logistics and supervision to make Nigeria TB free", Kwakfut says.
According to Mr. Louis James de Viel Castel, President of World Lung Foundation, beyond the proven economic returns, TB control programmes have an obvious impact on each individual's well being and his or her ability to contribute to society in many other positive ways. Better health, he adds, yields many more intangible returns than are capable of being measured.
"The World Lung Foundation strongly urges all governments and public health agencies to make a stronger financial commitment to global TB control, not just because of the proven returns on such an investment but for the improved health and welfare of each citizen whom they serve", Castel said in a published report on the dangerous disease.
Another aspect of the issue is the fact that HIV and TB form a lethal combination, each speeding the other's progress. According to Dr. Jerry Gwamna, programme manager, Global Fund TB, CHAN, HIV weakens the immune system. "Someone who is HIV-positive and infected with TB bacilli is many times more likely to become sick with TB than someone infected with TB bacilli that is HIV-negative. TB is a leading cause of death among people who are HIV-positive. In Africa, HIV is the single most important factor contributing to the increase in incidence of TB since 1990", he says.
WHO and its international partners have formed the TB/HIV Working Group, which develops global policy on the control of HIV-related TB and advises on how those fighting against TB and HIV can work together to tackle this lethal combination. The interim policy on collaborative TB/HIV activities describes steps to create mechanisms of collaboration between TB and HIV/AIDS programmes, to reduce the burden of TB among people and reducing the burden of HIV among TB patients.
Gwamna stresses that the Global Fund funded project in Nigeria was aimed at reducing the burden, socio-economic impact and transmission of tuberculosis. It would also expand coverage of microscopy centres to 1488 (one per 100,000) and increasing treatment centres to 5677 (one per 25,000).
"The overall objectives are to strengthen technical and managerial capacity of NTBLCP, promote behaviour change in the community, increase case detection from 26 per cent to 70 per cent, successfully treat 85 per cent of detected cases, reduce TB incidence among people living with HIV/AIDS by 25 per cent, increase detection of the estimated TB cases that are successfully treated and reduce number of TB-related deaths.
"Others are to reduce proportion of TB-related deaths among diagnosed patients, reduce incidence of active TB among PLHWA and to respond promptly to issues of health and promote improved communication with relevant bodies and organizations working in TB health-related issues in Nigeria", he says.
Last month, Minister of Health, Prof. Adenike Grange formally commissioned the refurbished human virology laboratory at the Nigerian Institute of Medical Research Yaba, Lagos. Same day, the Standards Organisation of Nigeria (SON), was on hand to present the ISO-9000 certificate to NIMR for its acquisition of the first rate laboratory. The feat was made possible by the grants from the Global Fund Round Five on Tuberculosis and HIV/AIDS whose principal recipient in Nigeria is the Christian Health Association of Nigeria (CHAN).
In an address, the visibly elated health minister stated that she was happy that the twin events happened during her tenure. Grange noted that Nigeria's national health indicators were still poor and unacceptable, especially as the country was ranked 187 among 191 member-countries of the World Health Organisation. She said maternal, infant and under-five mortality rates were among the highest in the world.
"Our disease burden resulting from communicable and non-communicable diseases is equally very high. Childhood immunisation coverage nosedived from 80 percent in the early 1990s to 13 percent in the mid 2000", the minister said.
She publicly agreed that tuberculosis was still a major public health problem in the country. She said in the mid and late 1990s, a global upsurge in TB cases was recorded. She added that the upsurge has remained unabated in most of the countries of sub-Saharan Africa, Asia and East Europe.
The minister said to be able to check the TB menace, Nigeria applied for and received the Global Fund Round 5 grants; adding: "One of the activities being implemented under this grant is the establishment of an effective laboratory network to enhance national case detection rates and carry out laboratory-based research to generate important national data".
She expressed her gratitude to all the national and international partners, who contributed to the establishment of the TB reference laboratories, which has placed NIMR in a better position to contribute significantly towards improving the health and socio-economic impact of HIV and TB in the population.
On his part, Dr. Oni Idigbe, director-general, NIMR said as a sub-recipient to CHAN, the institute, under the Global Fund Round 5 grant, has been charged with the responsibility of establishing six zonal TB reference laboratories in the six geo-political zones. Idigbe said the institute established a DOTS centre for TB patients two years ago and over 800 patients are currently on treatment at the centre.
He said with the ISO certification, NIMR has become the only health laboratory in Nigeria so certified, which is a significant milestone for healthcare delivery. He said the institute has facilitated the preparation of protocol and logistics for a national baseline survey and routine surveillance for Multi Drug Resistance and Extensively Drug Resistant Tuberculosis (MDR-TB and XDR) in the country.
"As part of our efforts to sustain the improvement of our health research strengths, we commend the relevant process for the International Certification of the Human Virology Laboratory of the institute some two years ago. This was informed by a CDC review of health laboratories in developing countries which documented that as at 2005, there was no health laboratory in Nigeria with ISO certification for quality management and services", Idigbe said.
Okesola says TB prevention and control takes two parallel approaches. In the first, he says people with TB and their contacts are identified and then treated. Identification of infections often involves testing high-risk groups for TB. In the second approach, he says children are vaccinated to protect them from TB. Unfortunately however, no vaccine is available that provides reliable protection for adults. Many countries, he adds, use BCG vaccine as part of their TB control programmes, especially for infants.
The WHO report, Global Tuberculosis Control 2008, released last week, finds that the pace of the progress to control the tuberculosis (TB) epidemic slowed slightly in 2006, the most recent year for which data were available. The new information documents a slowdown in progress on diagnosing people with TB. Between 2001 to 2005, the average rate at which new TB cases were detected was increasing by 6% per year; but between 2005 and 2006 that rate of increase was cut in half, to 3%.
The reason for this slowing of progress is that some national programmes that were making rapid strides during the last five years have been unable to continue at the same pace in 2006. Moreover, in most African countries there has been no increase in the detection of TB cases through national programmes. Other studies have also shown that many patients are treated by private care providers, and by non-governmental, faith-based and community organizations, thus escaping detection by the public programmes.
"We've entered a new era," said Dr Margaret Chan, WHO Director-General. "To make progress, firstly public programmes must be further strengthened. Secondly, we need to fully tap the potential of other service providers. Enlisting these other providers, working in partnership with national programmes, will markedly increase diagnosis and treatment for people in need."
This is the twelfth annual WHO report on global TB control, and is based on data given to WHO by 202 countries and territories. There were 9.2 million new cases of TB in 2006, including 700 000 cases among people living with HIV, and 500 000 cases of multi-drug resistant TB (MDR-TB). An estimated 1.5 million people died from TB in 2006. In addition, another 200,000 people with HIV died from HIV-associated TB.
The report highlights two aspects of the epidemic that could further slow progress on TB. The first is multidrug-resistant tuberculosis (MDR-TB), reported by WHO last month to have reached the highest levels ever recorded. To date, however, the response to this epidemic has been inadequate. Given limited laboratory and treatment capacity, countries project they will provide treatment only to an estimated 10% of people with MDR-TB worldwide in 2008.
The second threat to continued progress is the lethal combination of TB and HIV, which is fuelling the TB epidemic in many parts of the world, especially Africa . Although TB/HIV remains a massive challenge, some countries are making strides against the co-epidemic. Almost 700 000 TB patients were tested for HIV in 2006, up from 22 000 in 2002--a sign of progress but still far from the 2006 target of 1.6 million set by the Global Plan to Stop TB 2006-2015.
The report also documents a shortage in funding. Despite an increase in resources, especially from the Global Fund and some middle-income countries, TB budgets are projected to remain flat in 2008 in almost all of the countries most heavily burdened by the disease. Ninety countries in which 91% of the world's TB cases occur provided complete financial data for the Report. To meet the 2008 targets of the Global Plan to Stop TB, the funding shortfall for these 90 countries is about US$ 1 billion.
"We look forward to working with all partners to further assist countries to achieve TB targets for 2015 and beyond," said Dr Michel Kazatchkine, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. "Together we are bringing hope to the individuals and communities suffering from the enormous burden of TB." In recognition of World TB Day, Dr Jorge Sampaio, former President of Portugal and the UN Secretary-General's Special Envoy to Stop TB, called for enhanced leadership to address TB/HIV. "TB is a leading cause of death among people living with HIV/AIDS," he said. "Several countries have shown that targets relating to TB/HIV are achievable and have put in place measures that will have an impact on the lives of those at most risk. But this is a restless battle. We still need to do much more and much better."
As the World TB Day is being marked today, stakeholders have renewed their call on the Federal Government, and indeed, other tiers of government, to allocate more of their resources to health in line with the Abuja declaration of 2001. They also canvassed for the building of capacities of healthcare providers at all levels of delivery in order to remove or at best, reduce to the barest minimum the TB burden in the country.
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