1 July 2012

Nigeria: Burden of Tuberculosis Disease in Nigeria

Tuberculosis (TB) has emerged as the single leading cause of death from any single infectious agent and has continued to be a major public health problem all over the world.

Of the over 14 million cases worldwide reported by World Health Organisation (WHO) in 2010, Nigeria ranked fourth in terms of incidence.

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

Tuberculosis is such a big global problem such that the disease led to the development of Directly Observed Treatment Short Course (DOTS) by WHO in 1995, 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, in spite of all the DOTS centres, Nigeria for over 10 years, has remained on the fourth position of the countries with highest burden of TB in the world.

For long, the government of Nigeria has not done so much in concrete terms in the intervention in TB control, and this dated 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 Oyo State.

President of the Nigeria Thoraic Society, Prof Gregory Erhabor recalled that in 1993 when the World Health Organisation (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 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 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 was actually detecting more cases of TB. "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 about 30 per cent detection rate in Nigeria," Erhabor stated.

"We had 460,000 of 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 case detected is improving over the years."

Progress so far

Most of these findings are from the WHO. Nigeria is currently carrying out a prevalence survey to know the actual prevalence.

Indeed Tuberculosis (TB) is an infectious deadly disease that affects everyone that 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, they 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 there 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 lot more expensive.

"No matter the kind of X-ray that you do, it cannot be said that the patients 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 was commissioned in Lagos; there is another 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 use 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 that 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 problem and risk to the communities. Everyone must be aware of the key symptoms of TB.

They include: Anyone who has hard 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 adherence 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.

Practise 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 in the air. The germs pushed into the air hang around for days without dying, and easily infects anyone that breathes around it,"

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

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