Dr Mansur Kabir is National Coordinator of National Tuberculosis and Leprosy Control Programme. Here, he speaks on tuberculosis cases generally, including the discovery of multi-drug resistant tuberculosis that is currently on the increase in Nigeria as well as effort by government and other donor agencies to procure the second-line TB drugs to tackle the dreaded disease.

In 2002 Nigeria ranked the 4th among the 22 high TB burden countries in the world; what is the situation now?

You are quite correct. The stop TB partnership and the World Health Organization have recognized that 22 countries mostly from the developing world constitute 95 percent of tuberculosis that is detected globally. And sometimes ago Nigeria was considered to be the 4th largest country with tuberculosis. But within the last two or three years some changes have taken place because of South Africa. In South Africa a lot of TB is being seen, which is not unconnected with epidemic of HIV/AIDS that is ravaging sub-Saharan Africa and South African sub-region in particular. So I think that is the reason why we have fallen behind to become number five rather than number 4 which is still a bad situation.

Why has TB become a major public health problem in Nigeria?

Tuberculosis, HIV/AIDS and malaria are considered very serious communicable diseases globally, and particularly in developing countries here in Africa. Tuberculosis has constituted to be a problem in Nigeria for several reasons. In the first place, a lot of people with tuberculosis are not detected and they are not able to access the treatment. Secondly, tuberculosis is on the increase in the country, and this is because of the epidemic of HIV/AIDS. HIV/AIDS virus knocks up the immune system, and it predisposes an individual to reactivation of tuberculosis and contracting new cases of TB. In addition, we are also experiencing some challenges, because getting the TB programme to provide drugs and TB services to all the communities is not being made available to all the citizens despite government efforts and non-governmental organizations. But I believe with the kind of atmosphere being created by this administration, we are in the process of providing care and support to all patients that require TB treatment in the country.

What is the scope of your operations?

The National Tuberculosis and Leprosy Control Programme is part of the Federal Ministry of Health; it is under the department of the ministry's public health, and it was created in 1989 with the mandate of putting in place structures, guidelines, policies and programmes nationwide as well as partnering with developing partners and non-governmental organizations to ensure that tuberculosis is no more a public health problem in the country. The major thing we do at the federal level actually is to give a policy guideline, to give technical support to states and local governments; and in conjunction with the development partners to make sure that anti TB drugs and services are available to all our clinics. The states and local governments also have responsibility to ensure implementation of the national TB guidelines which have been approved by government. So one of the things I do here is to ensure that TB services are provided in every community in the country, in every local government, in every state; and to ensure that quality drugs are also available. We are faithfully implementing the principles of DOTS. DOTS is a concept that has been approved by the World Health Organization (WHO) and it means Directly Observed Treatment, Short-course (DOTS), and it involves political commitment to the provision of TB services to all citizens, diagnosis of TB using microscope and ensuring that patients take the drugs according to the standard guidelines. Apart from the DOTS, recently we also have the Stop TB Partnership Strategy which includes tackling special problems like multi-drug resistant TB (MDR TB), integrating HIV services with TB, engaging all stakeholders whether in the health sector or otherwise, and carrying out relevant research to ensure that tuberculosis is tackled decisively in our communities.

It appears cases of TB are on the increase in the country despite the effort of government and that of international donor agencies in tackling the disease.

The problem we have is that there is no adequate awareness among the communities, especially the leadership of the communities and the citizens about TB, its manifestation, its causes and modalities for treatment. And I think that is changing quite rapidly. It is very difficult to control TB in our country because of epidemic of HIV/AIDS; and HIV/AIDS doesn't have a cure, it doesn't have vaccines to stop it. We are in the middle of the epidemic even though we have observed some decline in HIV/AIDS rates in the country. We still have a lot of people infected. And some statistics have shown that 35% of TB patients have HIV/AIDS. So you can see that there is a strong relationship, and as long as HIV/AIDS is a public health problem. TB will continue to be a problem in our country.

What is the level of DOTS implementation in the country?

We are supposed to ensure that every community within five kilometers has access to a DOTS centre in the country, and our target is that by the year 2010 we are going to have about 5,000 health facilities providing DOTS in the country. As at the end of 2007 we had about 3000 DOTS clinics in the country. So you can still see we are working very hard to ensure that all nooks and corners of our country have DOTS facilities. But I am happy to say that DOTS is implemented in all states of the federation, and in virtually all the local government areas. We really have come quite along way from where we were some five years ago.

What are the economic benefits of DOTS to Nigeria?

One of the advantages you have about DOTS is because the treatment is provided free of charge, including the diagnoses and the drugs. Secondly, if you are using DOTS, also then there is the need to mobilize the political class both at the federal, states and local governments to provide financial resources and human resources to expand the health care services so that TB patients can be treated. The political commitment will also be used to mobilize the community to educate the people and encourage them to come and take treatment. And with the DOTS, you are expected to achieve about 85% cure. That is the WHO recommendation, which means that in every 100 people that are supposed to be treated for TB supposedly after 9 months, 85 of them should be cured of the disease. TB is basically a disease of the adolescent and the productive age group; and if as many of them as possible are picked early and given free treatment and cured, they will continue go back to the community and society, and be economically productive. Another advantage of DOTS is because the drugs are free and the diagnoses are also free. And the best way to prevent the spread of TB in any community is to treat the cases immediately because it is a disease that usually infect other members of the community. Scientifically, it has been estimated that every case of TB can infect about 12 to 15 other citizens. With DOTS now you are able to treat people quickly so that they don't infect the remaining members of the community. So I think there is alot of economic benefits to our country by the utilization of DOTS system.

How do you source money to procure all these free drugs?

These drugs are given free of charge because there is an international commitment. When I said international commitment I mean international development partners which include USAID, CEDA, WHO, Global Drugs Facility, Stop TB Partnership and other international organizations like Bill Gates, the British Government, the US Government. They all provide money to the TB programme at the global level. And these monies are used to procure the drugs from factories that manufacture quality drugs and they are distributed free of charge to developing countries. So the reason why the drugs are made available is because there is commitment to support those diseases. And it is not only tuberculosis that is benefiting from such kind of free support. Malaria, HIV/AIDS, leprosy and onchocerciasis are getting this kind of support, and I think that is the reason why the drugs are made available and they are free. And then there is also the need for the national government and the states to give political commitment, and that includes providing financial support so that even when the drugs come to the country, government should provide resources to clear the drugs from the ports and distribute them to the states, local governments and health facilities. Drugs are made to the TB patients because most of them are poor. So if you don't provide these services free of charge, the people that are so poor will not be able to access the drugs. So it is considered as an act of public good.

Is there any correlation between TB and AIDS in terms of symptoms and effects on human body and so on?

There is a lot of relationship. Like I have earlier told you TB has been on the increase in sub-Saharan Africa, and one of the reasons why TB keeps on increasing is because you also have epidemic of HIV/AIDS. And I am sure you know HIV/AIDS was discovered in the mid 1980s, and since then, many countries that were denying HIV/AIDS have come to accept that the disease is a real fact. In sub-Saharan Africa it is about 3 million people that are carrying the disease. And because the HIV/AIDS virus knocks up the immune system it makes those with HIV//AIDS virus very weak and vulnerable to infections. The commonest infections that HIV/AIDS patients contract is tuberculosis. In fact, it is estimated that about 70 percent of HIV/AIDS patients die of TB. But the difference is that TB is curable and treatable while HIV/AIDS is not curable but can be controlled using the anti-retroviral drugs. So there is a lot of relationship between TB and HIV/AIDS. And when you look at the statistics, 30-35 percent of TB patients in Nigeria are also HIV/AIDS positive. So it means that HIV/AIDS is igniting and continuing to make TB to be a disease of public health importance in our country.

TB has been classified as the single biggest infectious killer of women; why is it so?

I don't think it is only women. I think the question should be why is it considered that TB is a bigger killer, and the answer is yes. The estimate for us is that may be about 150,000 Nigerians die of TB annually. This is a WHO estimate, and probably over 1.5 million people die every year globally from TB infection. So if about 1.5 million people die every year globally, that disease is a big killer. But I don't think it has got discrimination for women. This is a disease that affects both men and women, and particularly the productive age group - that is the age of 14 - 49.

What can you say of the awareness campaign about TB generally in the country?

I am quite happy to say that this administration has given serious consideration to the issue of advocacy, communication and social mobilization in our country. And I think the level of awareness has increased significantly. Some studies were done in the past, and it has shown that really there has been a rising awareness about TB and HIV/AIDS. But I think we need to look at it carefully because a lot of information needs to go down particularly to the communities, especially the population in the rural areas and among the uneducated people who are located in the urban areas. So a lot of work has to be done, and it is more than government; it requires the mobilization of the community leaders, the civil society groups to ensure that every individual in the country at least has an information about TB and is aware about where to go to access diagnosis and treatment and be compliant when they have the disease. So you need to give this kind of information so that we will be able to treat whoever has TB in the country because the drugs are available and free.

Where in Nigeria, for instance, this disease is more prevalent?

If you look at the statistics, last year we detected about 86,000 - 87,000 cases of tuberculosis both infectious and non-infectious types in the country. And what we found was that the state with the largest number of TB is Lagos, and this is not surprising because of the large population there. And the second state was Kano which is also another large state. We also saw a lot of TB cases in Benue and Nasarawa states. Benue is another place where there is a lot of HIV/AIDS. I think at the last study done on HIV/AIDS it showed that a lot of TB cases are in Benue. Now this shows that there is strong relationship between HIV/AIDS and TB. So you could say that you have a lot of TB while you have a lot of population - high population density. You also have a lot of TB in communities and states where you have a lot of HIV/AIDS.

How would you react to alleged sale of TB drugs in the Nigerian markets?

We have been receiving report of some of our drugs being sold, but it is illegal to sell anti-TB drugs, and the programme has already spoken with NAFDAC, and NAFDAC is the national control agency for drugs in the country. And I think within the shortest possible of time we are going to institutionalize the system so that whoever is found selling our drugs should be arrested and prosecuted. Anti-TB drugs should not be sold, they are free. The problem really is more at the rural level, the drugs come from the federal giving to the states and eventually to the local governments and to the health facilities. We have been talking to the control officers to put their eyes on the drugs to make sure that these drugs are not stolen. But the Federal Ministry of Health will take it very seriously if anybody takes these drugs and sell them in the market. And I believe NAFDAC will soon swing into action to get those people out, and I hope we will utilize the media and the security forces to ensure that whoever is involved in this crime is prosecuted immediately.

How are you tackling the problem of the multi-drug resistant tuberculosis in the country now?

Recently, we have been having some problems of what is called multi-drug resistant tuberculosis. The WHO target is to treat about 85 percent of all TB patients. Recently, we have cases of TB that do not respond to the conventional drugs, and sometime before the 1940s when the anti-TB drugs were not discovered in Europe, people with TB were not giving any treatment, and they eventually go and die quietly. The multi-drug resistant TB is a TB case that doesn't respond to the drugs that we have today. One of the reasons why we have a lot of multi-drug resistant TB in the country is because quite a number of our people default because treatment for TB is for eight-nine months. Many of them will start getting better within two weeks and they stop taking the treatment. The treatment has to continue. And then if you infect another person with the kind of bacteria that you have, that person will not respond to the drugs again. And there is a big problem in South Africa where they have MDR and EDR (extreme). And even in this country we are receiving report of cases of TB that do not respond to our normal drugs, and one of the things that our programme is doing is to carry a national survey to see the extent of the disease. We are submitting a request to the World Health Organization to give us what is called Second Line Drugs. Second-Line Drugs are available, but the drugs are more expensive, and they are not easily available. They are injectable, and treatment has to be for 18 months and the success rate is just about 50-60 percent. So you could see many of them will not respond to the second line drugs, and the danger is if you don't respond to the drugs, you will eventually die. And they are also a danger to the community because if they infect any other innocent person in the community, he will have an MDR, then he cannot be cured. So I think it is very important for the general public to know about the MDR. And the TB patients must try to take their drugs religiously and faithfully so that they cannot come up with the MDR and EDR.

Are the second-line drugs now available in the country?

No. One of the things we need to do is to put an application through the World Health Organization. We have finalized our report and we have submitted to WHO and they will pass it to the Geneva, and if it is approved, the second-line drugs will start coming into the country so that we can have centers where the MDR patients can be kept and be treated there because they will be a risk to be left in the normal society because the society can be infected too.

Will the second-line drugs also be free for the TB patients?

The second line drugs are usually provided free of charge through the international agencies, particularly the WHO. They will come free for the time being and they have to continue to be free. But I think this is one of the things that the National Programme must get prepared for, and we hope that the cases of MDR will not be as bad as we suspect now, and we also hope the international community will keep its commitment to provide the drugs. The issue of MDR is a big problem in South Africa. We doctored the magnitude in Nigeria because we have to carry out the study, and we need to have the equipment to even make the right diagnosis because it is not easy to diagnose it. In countries like Russia and other East European countries, they have a lot of MDR because it is connected to refusal to continue with the normal drugs. That is the place I think we need to go and study and see how they are be able to cope with MDR. I hope Nigeria will be protected from the problem of MDR.

What is the situation of leprosy in the country today?

Unlike tuberculosis and HIV/AIDS, leprosy is an ancient disease. This is a disease that has been ravaging mankind for 4,000 years. Leprosy, fortunately, is on the decline globally including Nigeria. There was a time when we used to have about 50,000 cases of leprosy per annum, but last year we have barely 5,000 cases that were detected. And you know treatment for leprosy is free of charge in many clinics in the country. The only problem we have is that even the 5,000 cases really are too much, because we wish there would be no leprosy in the country. Secondly, we are seeing people with leprosy coming with disabilities which implies that quite a number of people have gone leprosy and they don't show up for treatment until it was late. And you know leprosy is a disease that is communicable. People have to come for treatment early and take the drugs as prescribed. The drugs have to be taken for a minimum of 8 months.

How do you get all these statistics?

The TB and Leprosy Control Programme is a well structured programme. This is a programme that is multi-layered. It starts from the health facility wherever TB leprosy programme runs, and it comes to the local governments and in every local government we have a TB liaison officer who is the officer in charge of TB and leprosy, and after every month he meets with the national programme, state TB and leprosy control officer who is usually a doctor with a post graduate qualification in public health with the ministry of health with the department of primary health care and disease control. And in every quarter, we usually meet at the zones. We have six geo-political zones in the country, and I send my representatives and sometimes I go there myself. So we sit down every three months to look at the statistics from every state, we look at the data and we compile, and then the data comes to my office, and from my office the data will go to the World Health Organization office, and it is even sent to the international community. So we are well structured. We receive a lot of support from the international organizations. All these meetings are usually funded by the international organizations in terms of staff and logistics to facilitate the meetings.

What is the impression of the donor agencies and other international organizations about the country's TP Programme?

I think the donors are very important in the maintenance, sustenance and the growth of the control effort of TB and leprosy in our country. I think we have to be thankful to them because they provide outright financial and technical support; they also provide us with opportunity to build our capacity at the federal, state and local governments; they provide for local people to go for training within the country, and for even some of us to have the opportunity to attend international meetings and conferences and update ourselves and our knowledge. And they also support us with access to internet, books and literature materials, and we really have the opportunity to operate at the global level. So the donors are very impressive with what we do, and they also bring experts into the country to work with us and ensure that we are doing the right thing. So that is the positive side. The other side of it is that some of the things we do in controlling these diseases are too donor dependent, that is to say that there is the need for us to look at our domestic resources and use them because Nigeria is fairly a rich country, and we don't need to depend on donors. And some of the activities we undertake to control these diseases are entirely donor dependent, and one of the new strategies of this administration is that we have to be independent. And I am happy the MDGs under the presidency has given us a lot of resources to support the effort of TB and leprosy programme.