Nigeria in race to Meet 2030 target to end tuberculosis

COVID-19 May Make TB Deadlier, Untreatable

As the dreaded novel Coronavirus Disease (COVID-19) sweeps across the world leaving over 200, 000 infected and more than 8, 000 dead, there are concerns that the pandemic would make tuberculosis deadlier and untreatable.

According to scientists, COVID-19 might lead to the neglect of most programmes tailored to end the TB epidemic by 2030 and consequently the emergence of most resistant TB.

Statistics of TB-associated deaths in the country are at best frightening. Matters are made worse by the fact that less than half the amount that is meant to contain TB in the country was available for use last year.

In other words, of the $278m needed for the control of tuberculosis in Nigeria, only 40 percent of it was available last year, and in a country where 432 persons die daily from the disease.

These and many other facts emerged on Thursday at a press briefing, in Abuja, on the Pre-World TB Day, by the Stop TB Partnership Nigeria.

According to the Country Director of KNCV, Dr. Bethrand Odume: “Despite significant progress over the last decades, Tuberculosis remains the world’s deadliest infectious killer, and requires acceleration of efforts to end TB epidemic globally and in Nigeria.

“Each day, nearly 4, 500 people lose their lives to TB and close to 30, 000 people fall ill with this preventable and curable disease. Global efforts to combat TB have saved an estimated 58 million lives since the year 2000 and reduced the TB mortality rate by 42 per cent.

This apparent feat notwithstanding, the emergence of drug-resistant TB is seen as posing dire health threat, and capable of jeopardizing all the gains recorded in efforts geared toward ending TB.

“In 2018, about 1.4 million people globally died of TB-related causes including over 205,000 children. And over 95 percent of TB deaths occur in low and middle-income countries especially Africa.

Odume continued: “Nigeria is one of the countries with a high burden of the disease globally. According to the 2018 Global TB Report, Nigeria is among the 30 high burden countries for TB, TB/HIV, and MDR-TB. It ranked sixth among the 30 high TB burden countries, and first in Africa.

“TB kills 18 Nigerians every hour. Also, 49 Nigerians develop active TB, seven of whom are children, every hour. One of the major challenges of TB response in Nigeria is attributed to low TB case findings both in adults and children. This is as a result of low TB treatment coverage and poor knowledge about TB that influence the health-seeking behaviour of people.

“To accelerate the TB response in countries to reach targets, heads of state, including His Excellency, President Muhammadu Buhari, came together and made strong commitments to end TB at the first-ever United Nations High-Level Meeting in September 2018.”

This year’s theme, “It’s time to end TB in Nigeria,” therefore stresses the need for all stakeholders to galvanise efforts towards ending the TB epidemic in the country.

The National Coordinator of the National Tuberculosis and Leprosy Control Programme (NTBLCP), Dr. Adebola Lawanson, did not mince words in establishing the country’s TB burden during the event.

Lawanson said: “TB burden is so huge in Nigeria and a lot of efforts have gone underway in the past to see that we fight this disease. The Federal Government, in collaboration with partners, is providing quality patient-centred prevention treatment care and support that is free for the control of TB.

“Specifically, we have increased the number of diagnostic facilities, which we call the Gene Xpert machine, which can diagnose not just the simple TB, but the complicated one, which is called the drug-resistant TB,” said the NTBLCP national coordinator.

“Over the years we started with a few numbers and right now we have over 399 scattered all over Nigeria. We know that Nigeria is big, so we aspire to have one machine per local government,” she stated, adding, “right now, we have 40 per cent of our local government covered. However, currently, there are efforts by donor organisations and the Federal Government to increase this number so that we can get to the universal health coverage that is being articulated by the health sector.

“We have expanded the treatment of TB services to 12, 254 healthcare facilities around the country, both– public and private. Also, TB services have been included in the Primary Healthcare Minimum Healthcare package to ensure the achievement of universal healthcare and access to care.”

Despite the effort, as the continent’s greatest TB sufferer, Nigeria was supposed to detect at least 429, 000 cases of TB every year. That it has spectacularly failed to do.

According to the National Professional Officer in charge of TB at the World Health Organisation (WHO), Dr. Ayodele Awe, “last year was the greatest number that has ever been detected over the last 10 years; we were able to detect 120,000 cases.

Awe asked: “Where are the 300, 000 cases that are still coughing? Every undetected Tuberculosis case can spread the disease to 15 persons in a year. Multiply that with how many we have each year.

“There are free drugs everywhere, the target elimination for Tuberculosis is 2030, this is 2020, therefore, the progress we are making is not enough. The total number of funds needed for Tuberculosis each year is $278m, we are having only 8 per cent as domestic. There is a huge gap of $157m gap that was supposed to help us for advocacy; for increasing service coverage.

“Tuberculosis is transmitted innocently, the government needs to look at this infectious disease, everybody is prone to Tuberculosis,” Awe added.

Nigeria is also among the 14 high burden countries for TB, TB/HIV, and Multi-drug Resistant TB. About two years ago, she was ranked seventh among the 30 high TB burden countries, and second in Africa.

The problem of TB in the country has been made worse by issues of drug-resistant TB and the HIV/AIDS epidemic.

It is estimated that 407, 000 people in Nigeria have TB each year. This is the estimated number of HIV negative people. Also, there are an estimated 63, 000 HIV positive people that get TB each year. An estimated 115, 000 HIV negative people die from TB in Nigeria each year, and an estimated 39, 000 HIV positive people also die.

Achieving the reduction in TB incidence rate for the attainment of the 90-90-90 target of the End TB strategy remains a mirage if something drastic is not done. The incidence rate is the number of new cases of TB in a population within a given time, which is usually a year.

The United Nations (UN) Sustainable Development Goal (SDG) 3.3 includes a target of ending the TB epidemic by 2030. And the World Health Assembly-approved Global TB Strategy aims for a 90 per cent reduction in TB deaths, and an 80 per cent reduction in the TB incidence rate by 2030, compared with 2015 levels.

The strategy established milestones for 2020 of a 35 per cent reduction in TB deaths, and a 20 per cent reduction in the TB incidence rate from 2015 levels.

The UN Political Declaration on TB in 2018 includes four new global targets: treat 40 million people for TB disease in the five years 2018-22 (seven million in 2018); reach at least 30 million people with TB preventive treatment for a latent TB infection in the five-year period (2018-22); mobilise at least US$13b annually for universal access to TB diagnosis, treatment, and care by 2022, and mobilise at least US$2b annually for TB research

Countries are due to report back to the UN General Assembly on progress in September this year.

But with COVID-19’s emergence, scientists say the world rather needs a damage control plan, and the Global Fund has warned that COVID-19 could derail progress on Human Immuno-deficiency Virus (HIV), TB and malaria, through disruption of treatments or other interventions in supply chains of medicines and medical supplies.

It said that experience from the 2015 Ebola outbreak in West Africa suggested that unless mitigating action is taken, additional deaths from existing diseases such as TB and malaria could be at least as high as those from the outbreak itself.

To address the situation, the Global Fund announced new guidance to enable countries to strengthen their responses to COVID-19 by using existing grants in a swift, nimble and pragmatic way.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is an international financing and partnership organisation that aims to “attract, leverage and invest additional resources to end HIV/Acquired Immune Deficiency Syndrome (AIDS), TB and malaria to support attainment of the United Nations Sustainable Development Goals (SDGs).”

Working within its mandate to fight HIV, TB, and malaria and to strengthen systems for health, the Global Fund is encouraging countries to reprogramme savings from existing grants and redeploy underutilised resources to mitigate potential negative consequences of COVID-19 on health and health systems.

In exceptional cases, countries may be able to reprogramme funding from existing grants to COVID-19 response.

Executive Director of Global Fund, Peter Sands, said: “As was the case with Ebola, we are committed to a pragmatic and flexible approach in supporting countries to fight against COVID-19.

“Our priority is to ensure continuity of lifesaving programmes to end HIV, TB, and malaria. However, COVID-19 could knock us off track. People infected with HIV, TB, and malaria could prove more vulnerable to the new virus given that their immune systems are already under strain.”

Also, in many countries, today, fragile health infrastructure and workforce shortages make it difficult to provide timely diagnosis and the right treatments for TB. Weak reporting systems are another problem: health providers may treat people but fail to report cases to national authorities, leaving an incomplete picture of national epidemics and service needs. Further, up to 80 per cent of TB patients in high burden countries spend more than 20 per cent of their annual household income on treating the disease.

According to the Director-General, World Health Organisation (WHO), Dr. Tedros Adhanom Ghebreyesus: “As the Coronavirus moves to low-income countries, we are deeply concerned about the impact it could have among populations with high HIV prevalence or malnourished children. We are calling on every country and individual to do everything they can to stop the transmission.”

Nigeria, India and South Africa have declared COVID-19 a “national disaster” and have imposed sweeping travel restrictions. But these countries are currently testing very few people for COVID-19.

While experts continue to express concerns that unless efforts are redoubled, the country may not meet the 2020 target in eradicating Tuberculosis (TB) the Chairman House Committee on Tuberculosis, HIV/AIDS and Malaria, Abubakar Dajiru, has assured that there would be increased legislative engagement on TB to reduce the scourge.

Speaking in Abuja ahead of the 2020 World Tuberculosis Day, Dajiru said each legislator would purchase a tuberculosis-testing machine, called Gene Xpert machine for their constituencies as a way of aiding diagnosis.

He said: “In the coming week, you will see a debate on tuberculosis because of the serious attachment we have for the health sector. And after this debate, I assure you that each member will buy the tuberculosis testing machines.”

Dahiru blamed the budget office for not releasing enough money to the health sector to tackle various challenges.

He assured that the House was working assiduously to ensure the adequate release of funds for the health sector.

Also raising concerns over the health threat posed by the drug-resistant TB, Dr. Odume stressed the need to continuously put TB on the political agenda, as well as build a multi-stakeholder partnership to address the socio-economic impact of the disease on individuals and the country as a whole.

“We call on our political leaders to invest more in TB control, the civil society to continue to call for accountability and the media to always help in creating the needed awareness. It is a call to scale up research funding, human rights and accountability to end TB in Nigeria.”

TB Team Lead, United States Agency for International Development (USAID), Temitope Odusote, said there was a need to adopt a multi-sectoral approach to ensure that the country meets up with the 2020 target to end TB.

Odusote who stressed the need for at least one Gene Xpert machine in each local council area said it was no longer enough to build clinics with the hope people would troop in to seek healthcare to treat TB at no cost.

“We are seeing the end of the target in sight; we want to focus more on multi-sectoral collaboration for TB. We have all forms of healthcare practitioners in Nigeria and its important that we reach out to them, including the orthodox medical doctors. We have to work with the executive, legislature, politicians, and all those people, who go to the grassroots. We have to reach out to corporate organisations, and other sectors.”

The Director, Institute of Human Virology Nigeria (IHVN), Dr. Ronke Agbaje, who disclosed there was an expansion of TB treatment and services to 12, 254 healthcare facilities (both private and public), however, lamented that only 40 per cent of local council areas have got the Gene Xpert machines.

“Right now, we have 399 Gene Xpert machines all over Nigeria. We know Nigeria is big and we aspire to have one per local government. However, with the 40 per cent coverage already in place, there is a lot of ongoing efforts by all our donor partners and the Federal Government to increase this number so that we can get to the universal healthcare coverage.”

To address the impact of COVID-19 on TB, scientists have called for anticipating and mitigating the damage.

They said the TB community has the opportunity to anticipate and mitigate the disruption of COVID-19 on TB services, with the first step in this direction being the taking of an inventory of all the likely pathways by which COVID-19 can affect TB.

For instance, TB patients and survivors often have lung damage. Although there are no data yet, it is believed that lung damage might make TB patients more prone to COVID-19 and its negative outcomes.

Secondly, TB sufferers also tend to have comorbid or living conditions that increase their vulnerability. These include conditions such as malnutrition, HIV, silicosis, diabetes, homelessness, and smoking. Consequently, scientists recommend that high TB burden countries must do everything that they can to protect patients and survivors from COVID-19 exposure.

Thirdly, the global COVID-19 response will likely result in the diversion of the healthcare workforce and resources away from routine TB services, or reduction in the number of health workers because of illness and self-isolation. Therefore, TB wards could become COVID-19 wards.

Such diversion of resources or workforce could result in poor quality TB care (which is not great, to begin with), treatment interruptions and inadequate follow-up.

Furthermore, the diversion of TB funding towards COVID-19 is a real concern. Every effort should be made to minimise this. The bigger concern, in the longer term, is that countries would cut expenditure on TB, because of the massive economic loss due to COVID-19. TB is already under-funded by about $3b/year. Donor support (including United States President’s Emergency Preparedness Fund for AIDS Relief/PEPFAR, Unitaid), therefore, might be critical to tide over this looming crisis.

TB causes more deaths globally than any other infectious disease, with 10 million new cases and 1.5 million deaths recorded in 2018 alone. It is also responsible for up to a third of all mortality associated with antimicrobial resistance (AMR).

In line with the 2020 theme of World TB Day, “It’s Time for Action!,” It is indeed time for the country to pull all stops and encumbrances and end this preventable and curable, but very deadly disease.

Already, the WHO, partnering with the Global Fund, and Stop TB has launched a joint initiative “Find. Treat. All. #EndTB” to accelerate the TB response and ensure access to care, in line with WHO’s an overall drive towards Universal Health Coverage.