The A, B, C of Tuberculosis in Nigeria

Introduction

TB is currently the leading cause of morbidity and mortality from an infectious disease and while a lot of progress has been made in the identification and treatment of tuberculosis, the WHO still estimates that about 4 million cases   of TB were missed in 2017. Improving basic standards of TB care can attract more patients by ensuring that they receive the care that they deserve and     that providers offer better services, improve adherence, diagnosis and treatment, and reduce lost to follow-up rate, ultimately contributing to  reducing the burden of TB disease.

Nigeria ranks as one of the high-burden TB countries in the world and contributed 4% of all TB cases in 2017, ranking her in the 6th position globally in terms of percentage contribution.

Catching them early

Standards set by the International Standards for Tuberculosis Care (ISTC) provide a reference point for assessing provider or system performance and quality of care which help to identify the current and expected levels of quality in health care delivery. The failure of providers or systems to adhere to the defined standards of diagnosis, care and treatment of TB compromises the quality of services provided to the patients.

Understanding the quality of care will enable policy makers and program implementers to strengthen TB care and prevention, by positively influencing timely diagnosis, treatment adherence, and treatment completion in Nigeria. This brief presents findings from an examination of the adherence of TB services in Nigeria to the international and national standards guidelines to ensure that TB services are delivered in an accessible, timely, safe, effective, efficient and equitable manner.

Quality of Care; Where? How… And then?

Quality of care can be said to consist of three key elements, namely: structure of the resources available at a health facility; process or the interaction between providers and patients; and outcomes or the consequences of care.

In a recent study carried out by the Academy for Health Development (AHEAD) Nigeria, supported by the National Tuberculosis and Leprosy Control Program and Challenge TB project funded by United States Agency for International Development (USAID) and The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Quality of Care of Tuberculosis was assessed in a total of 144 facilities across 12 states in a bid to understand how care is accessed and received, uncover loopholes and opportunities in the care delivery system and make recommendations for improving the overall access, delivery and outcomes of care and treatment for tuberculosis.

Structure (Where)

Structure includes all of the factors that affect the context or enabling environment in which care is delivered. This includes the physical facility, equipment and human resources as well as organizational characteristics such as staff training and supervision. We measured structure through  the availability of services, infrastructure, capacity of TB providers, and management of TB services.

TB drug supply

The NTBLCP continues to address challenges to the maintenance of an uninterrupted supply of anti-TB drugs by working to improve stock status at the state and LGA levels, train staff on proper anti-TB drug stock management, and advocate at the Federal and State Ministries of Health to improve and expand storage conditions for anti-TB drugs at all levels. TB drug monitoring mechanisms are in place at different levels to ensure an uninterrupted supply of quality-assured anti-TB drugs, which will help prevent the emergence of drug-resistant TB.

Trained TB Care Providers

Staff training is essential for keeping health workers updated with knowledge, skills, and technical competence to maintain high quality or improve the quality of TB care services. This study assessed whether TB providers received any formal or structured in-service training related to the services they offer in the 24 months preceding the survey.  The findings from the facility audit/checklist (with the health facility unit in-charges as respondents) indicate that a majority of staff (73%) received in-service or training updates on TB care and treatment in the last 24 months.

Process (How)

Process is the sum of the interaction between service providers and patients during which structural inputs from the health care system are transformed into health outcomes. Findings presented measured process through the level of TB awareness among TB patients, patient-provider interaction and communication, barriers to TB care and access to follow-up care.

The most common barrier to accessing TB care mentioned by patients is the distance to the facility providing TB diagnosis and treatment (22%). Lack of adherence   to   a   patient’s   treatment   plan   for   TB   can   lead   to   prolonged infectivity, drug resistance and poor treatment outcomes.

Access to follow-up care through Directly Observed Treatment (DOT) seeks to improve adherence to TB treatment by observing patients while they take their anti-TB medication. This study shows that approximately 40% of patients did not have access to DOT.

Patients on treatment who were observed taking their TB medication by a health care provider (DOT)

Outcome (And then)

Outcome in the context of our conceptual framework refers to the effects of health care on patients, including changes in their health status.

Treatment outcome is defined based on the 2013 WHO definitions that have two broad classifications namely; treatment success and unsuccessful treatment  outcomes. In addition, the two classifications are sub-divided into 6 distinct outcomes, namely; cured, treatment completed, died, treatment failure, loss to follow-up, and not evaluated.   The addition of “cured” and “treatment completed’ is defined as treatment success. Patients with PTB with bacteriologically confirmed TB at the beginning of the treatment who had proven negative microbiological results upon completing treatment are defined as cured. Treatment completed is used  for the patients with no evidence of clinical failure, but without the record to show negative microbiological results after taking anti-TB drugs for the prescribed length of time, either because tests were not performed or because no biological material was available (e.g., patient without sputum production). Patients with treatment outcome such as treatment failure, death, loss-to-follow-up and not evaluated are classified as unsuccessful. A patient that failed to appear in the health facility for more than 2 consecutive months after the scheduled appointment is referred to as  lost to follow-up.  If a patient dies for any reason during the treatment, the outcome  is classified as died.

For patients that move to another health clinic regardless of the cause, the outcome is defined as transferred. Patients transferred out are excluded from the analysis because of the challenges of determining the outcome based on the WHO definition. Outcomes are classified as treatment failure if a patient has positive sputum smears throughout the treatment period or at the end of treatment (even if the patient initially converted from positive to negative). Patients without treatment outcomes are classified as not evaluated either because the tests were not performed or have not completed the treatment.

RECOMMENDATIONS

A key policy outlined in this study is the need to improve the factors highlighted that affect the quality of care. Availability of proper equipment and an increase in service providers for tuberculosis will be effective in addressing the needs of the number of identified patients and enable better detection and identification  of  otherwise  missing cases. This recommendation can be achieved through the following ways:

  • Collaboration with private health organizations at the state and local government levels for more primary facilities to be set up in the rural areas with emphasis placed on  reduction  of  patients’  commute  time  and  increment  of  health  service providers at

The study showed that only 14% of facilities had been implementing risk assessment for TB infection, prevention, and control annually. This statistic can be improved by including in the supervision carried out by the LGTBLS, the assessment of the availability of other important documents such as up-to-date    TB policies and guidelines.

Starting Right at School (StaRS): To This Point

The Starting Right at School (StaRS) Project is a study aimed at understanding the gender socialization norm among very young adolescents. It is funded by the International Development Research Centre (IDRC) and implemented in three different countries. In Nigeria, it is currently being carried out by the Academy for Health Development (AHEAD) in Osun state, Nigeria.

The project which is comprised of 3 stages; baseline, intervention and endline phases has just rounded up the baseline phase.

BASELINE

STEP 1: FIELD WORK

In January following a week-long training of research assistants, field work was carried out in 8 selected schools (5 served as control schools and 3 served as intervention schools). Using a questionnaire developed by the World Health Organization and adapted by AHEAD, the researchers sought to understand the young adolescents’ point of view on sexual and reproductive health, gender norms, bullying and violence and other matters regarding gender socialization. A total of 1032 adolescents were interviewed.

Following this, a few of the young adolescents were selected and taught the art of photovoice and how it can be used as a tool for advocacy.

The students then went into their schools and communities and identified and photographed issues surrounding sexual and reproductive health, gender socialization and gender norms.

STEP 2: ANALYSIS

The study analysis showed that of the 1032 students interviewed in the 8 schools studied, 3.49% of students had had sexual intercourse while about 9.3% claimed to have friends or know someone who had had sexual intercourse.

The boys who reported experiencing bullying were about 82.3% of those interviewed and 81.3% of girls interviewed reported the same. This is similar to global statistics.

STEP 3: COMMUNITY DIALOGUE

In June, after analysis of the results had been done, AHEAD invited the students, parents, teachers and principals, school board, education commission and other stake holders to a community dialogue to present the findings from the study, the challenges and risks from the captured gendered norms and their proposed solutions to effectively tackling these issues.The Community dialogue was opened by the Permanent Secretary of State Universal Basic Education Board, represented by the Osun State Middle Schools Director, Mrs A. K. Oladimeji who thanked AHEAD for the initiative. She reminded teachers that a lot of students have more belief in them than in their parents and that even though gender roles are mostly determined by culture, parents and religions, the negative ones need to be rectified.

AHEAD gave a presentation on the objectives of the study and the different stages of the project. It was explained that the community dialogue signified the end of the first stage, the base-line stage and that it would be followed by the implementation and the end-line stages.

A presentation by the students followed immediately, explaining the photos they had taken using photovoice to depict issues surrounding gender socialization and gender norms that they identified in their schools and communities; the pictures were grouped in five thematic areas:

  • Water and Sanitation Hygiene (WASH) Matters, which included pictures of unsanitary toilets and environments,
  • Violence and Bullying which showed images of male and female students bullying their colleagues and students fighting.
  • Safe Environment, revealed pictures of unsafe play areas and potentially dangerous areas in the schools.
  • Gender Equality which depicted images of unfair and unequal treatment of female students such as, boys at play while girls were doing chores, and
  • Gender Sexuality showing images including those of segregation of male and female students in the class and at play.

Days 2 and 3 were aimed at developing interventions; Dr Obioma Uchendu of the Inspire Network gave an insightful presentation on violence in children and adolescents and shared the seven inspire strategies for addressing this problem.

A member of the AHEAD team gave a presentation on identifying and promoting the opportunities that exist for the fostering of gender equity in schools using the Gender Equity Movement in Schools (GEMS) as a reference.

Stakeholders were grouped according to the schools they represented and they discussed and outlined the gender socialization challenges faced by their schools in order of priority; they also shared their visions for the schools and designed a road map tailored after evidence-based strategies for gender-socialization for the realization for the visions shared.

We are moving to the second phase of the StaRS Project; the implementation phase.This will consist of the collaboration of the organization and the school stakeholders to judiciously and effectively channel the funds into selected appropriate and sustainable interventions. Implementation will run for about 6 months after which the endline phase of the project will commence and this will be a post-implementation analysis of the project, its impact and recommendations on sustainability and future projects.

Analysis of Selected Key Indicators of TB Clients in Nigeria between 2012 and 2017, and the Emerging Policy Implications

As the global community moves towards a TB free world and the achievement of SDG 2030, Nigeria still has the highest burden of Tuberculosis in Africa despite numerous intervention programmes by national and international government agencies. These interventions have focused on programmatic framework, outcomes and few on the TB clients. Very few studies have reported changes in key indicators of TB clients. The TB clients in Nigeria give an insight into the various intervention programmes done and their effectiveness. This research summary compares selected key indicators of TB clients in Nigeria over 5 years (2012-2017) using data from the National Knowledge, Attitude and Practice survey 2012 and 2017.

Knowledge of HIV infection as a risk factor for TB


Figure1: Proportion of TB patients who knew HIV infection is a risk factor for TB

The proportion of TB patients in Nigeria that knew that HIV infection is a risk for TB decreased minimally from 26% to 25% between 2012 and 2017. This pattern was not constant however in all the states. This minimal decrease may reflect the level of health education available for the TB patients in Nigeria presently

HIV Test and results


Figure2: Proportion of TB clients who had HIV test done



Figure3: Proportion of TB patients who collected HIV test results

The proportion of TB patients that were tested for HIV and collected their results improved over the last five years. Nationally, there was a 10.7% increase between 2012 and 2017, while there was 6.6% increase in proportion of TB patients that collected their test results.

Cough


Figure4: Proportion of TB patients who presented with cough > 3 weeks

The proportion of TB patients who presented with cough > 3 weeks to health care facility decreased by 8.9% from 2012 to 2017. This may be because the national guideline now specifies cough > 2 weeks for TB testing now. Also, patients might have had an intervention before presenting at the health facility.

Self-medication


Figure5: Proportion of TB patients who used self-medication

The proportion of patients who used self-medication on the suspicion of TB increased between 2012 and 2017 by 5.3%. This increase may be due to weakness in community sensitization, focus of the intervention programmes and the health seeking behaviour in Nigeria communities.

Diagnosis

The period of diagnosis within three weeks of the onset of symptoms was assessed in 2012 and 2017. There was a 2.8% decrease nationally in proportion of TB patients that were diagnosed within three weeks of onset of their symptoms.

Policy Recommendations:

From the above research summary, the key indicators for TB clients have not improved between 2012 and 2017. Based on this, the following policy recommendations are made:

  • Strengthening of integration of TB programmes into existing health care system and not as “stand alone” programmes
  • Full engagement of the community in sensitization, implementation, monitoring of the TB programmes in individual community
  • Efforts should be made to ensure prompt diagnosis by the use of gene expert and other technologies. In addition, commencement of the medication should be immediately diagnosis is made

“KNOW YOUR STATUS”

These are three words that are central to the control of HIV/ AIDS globally. As the world celebrates the world AID day, it is best to reflect on what it really means and how it aligns with global goals and the SDG of 2030. These words resound with some points to every individual:

  • Get tested for HIV and collect your results
  • Stay healthy and ensure people around you are healthy when you get your results

(If your test result is negative, continue living with precautions and activities that would ensure you remain negative, and if you test positive, go to the nearest health facility immediately to get anti-retroviral so you can stay healthy and ensure you do not spread the virus)

  • Encourage your partner and friends to get tested for HIV

By taking these few steps individually, we can all make the progress towards achievement of the 2030 goal of ending the burden of HIV thus making the SDG a reality.

Towards a Tuberculosis free Nigeria: Comparative Analysis of Knowledge of Tuberculosis in Nigeria General Population over 5 Years and its Policy Implication

Tuberculosis (TB) continues to be a global Public Health challenge despite significant progress made in the global progress towards a TB free world, however this progress is not uniform in every country. In 2015, Nigeria was ranked as the 4th on the list of six countries contributing 60% of the new TB cases and as the African country with the highest TB burden within the African continent. Several initiatives have been implemented in Nigeria to address the challenge of achieving a TB-free country with focus on improving knowledge of TB among the general population, however very few literatures have reported changes in the proportion of the general population on the knowledge of Tuberculosis in Nigeria. This report compares knowledge of TB in Nigeria general population over 5 years (2012-2017) using selected key indicators from the National Knowledge, Attitude and Practice survey 2012 and 2017 data.

Awareness of TB and Knowledge of the Causative Germ

Awareness of TB among the general population is integral in the progress towards a TB free Nigeria. There was no appreciable difference between the percentage of the population aware of TB in 2017 when compared to the 2012 proportion. This was also true of the percentage distribution of the general population that knew the causative agent of TB. This minimal percentage change in awareness and knowledge of causative organism reveals that the several intervention efforts in Nigeria over these five years are not reaching all of the targeted audiences.

Knowledge on Risk Factors

Risk factors are conditions that can predispose an individual to being infected with TB but most of them are modifiable. The knowledge of risk factors to TB in the general population over the 5 years under review showed slight improvement in the knowledge of respondents about poor ventilation (2.3 percentage points) and overcrowding (2.5 percentage points), as risk factors for TB when compared to the 2012 findings. However, knowledge of poor nutrition, presence of HIV, poverty and infection at young age as risk factors had varying degrees of decline in the general population.

Knowledge of TB Symptoms

Knowledge of TB symptoms

The knowledge of some TB symptoms in the general population over the 5 year period showed an improvement in the knowledge of participants about persistent cough as a symptom, but there was appreciable decline in percentage of general population who had knowledge of productive cough, weight loss and shortness of breath as a symptom of TB.

Knowledge on correct duration of treatment

The knowledge of the correct duration for the treatment of PTB in the general population was compared over the 5 years. There was a modest but significant increase (7 percentage points) in knowledge of the general population about the correct duration of treatment while there was varying degrees of reduction in incorrect knowledge.

Tuberculosis Knowledge, Attitude and Practice (TBKAP) Follow-up Survey in Nigeria

Did you know that in 2016, there were an estimated 10.4 million new (incident) cases of tuberculosis in the world? That’s 5 times more people than the entire population of Slovenia and a little over 10 times the population of the Bahamas. Did you also know that TB tends to affect more men than women and those in the economic productive age range (15 -59 years) are the most affected?

In Africa currently, Nigeria has the most number of TB incidents, and in order to combat this, the Federal Government through the National Tuberculosis and Leprosy Control Programme (NTBLCP) a body under the Ministry of Health set up to control TB and Leprosy in Nigeria and with the support of organizations like the World Health Organization, and the Global Fund for AIDS, Tuberculosis and Malaria (GF), in 2007/2008 conducted a baseline study to determine the true burden of TB and refine her strategy for improved programme implementation and outcomes. This study was conducted in Benue, Ebonyi and Ondo states. Following this another survey was carried out in 2012, this time to determine the Knowledge, Attitude and Practice of people in urban and rural communities across the country regarding TB. This survey was carried out in 6 states across the 6 geo-political zones of the country.

This report gives a summary of results from a 2017 study conducted by AHEAD in conjunction with the Association for Reproductive and Family Health (ARFH) and NTBLCP, done on the same topic in a bid to compare current levels of knowledge, attitude and practice with the results of the 2012 study. The study was carried out in 48 urban and rural communities and a total of 448 healthcare facilities across Benue, Plateau, Adamawa, Gombe, Katsina, Kaduna, Ebonyi, Imo, Akwa-Ibom, Delta, Ondo and Lagos states were sampled.

Results show that there was no appreciable change in awareness of the general population about TB although Katsina showed an appreciable increase in awareness and Ondo showed a noticeable decline. While there was moderate improvement in the knowledge that persistent cough is a symptom of TB among the general population, there was a decline in other knowledge parameters evaluated.

Among patients with TB, there was an increase in those who self-medicated and a marked decline in patients’ knowledge of risk-factors. Even though, there was only a very slight decline in the proportion of TB patients who know that HIV infection is a risk factor for TB. And the figures show that compared to baseline, some people in Ebonyi state still believe witchcraft is a cause of TB.

Among patients with HIV, there was an improvement in the knowledge of the causes of TB although patients who identified casual contact such as kissing as a cause of TB showed an increase compared to baseline. And there was a 40% jump in the number of patients who were at the facility for follow-up sputum examination.

The proportion of health workers trained in the management of TB cases showed significant increase although knowledge of this management is still low. Also the proportion of health workers with knowledge about the drugs used in the management of TB showed a decline.

Overall, there has been progress in some areas, but there is still some work to be done in the prevention, diagnosis, and management of tuberculosis and the achievement of the goal of a Nigeria free of TB.