By Arinze Chijioke

When Ntui Agom, 37, started coughing in 2020, she thought it was normal. With no money to go to the hospital, she visited a chemist in her community, where she was told that she had malaria and was given medication.

After she took the medication, the cough subsided and she thought she was okay. One month later, it started again. This time, she could hardly breathe, work, trek long distances or carry loads. Because she could not do anything, it became difficult to feed herself and her six children.

“I had to always beg neighbours for food,” Agom, a resident of Iyamoyong, one of the communities in Oburbra LGA of Cross River State, said. “I became worried and hardly slept.”

After she told neighbours what she had been going through, they told her it was an attack and took her to a traditionalist in the community who gave her herbs. But it worsened, and they abandoned her, thinking she would die, she said.

When she returned home, Agom noticed there was blood in the phlegm whenever she coughed. She became increasingly worried and resigned to her fate.

One day, as she ambled to her farm – she needed to work to feed her children – she passed through the playground at Iyamoyong and saw a big truck and people gathered around it and receiving treatment.

“I stopped and inquired about what was happening and they told me that some health workers were attending to people who were coughing,” Agom said. “Immediately, I dropped my farm tools and queued up.”

When it got to her turn, she was enrolled with her details – name, address, phone number, and symptoms – after which she was asked to climb up to a compartment inside the truck for a chest X-ray, which was the screening test. Thereafter, she was asked to check her result in another section, and it was found that her score was high based on analysis of the X-ray by CAD4TB artificial intelligence (AI) software.

A sputum sample was collected for a diagnostic GeneXpert test. Her result was ready in less than two hours, and she was diagnosed with drug-susceptible TB.

After the GeneXpert test, she was directed to the client waiting area, where she met a healthcare worker who explained the outcome and gave her drugs to last for two months and was referred to the Iyamoyong health centre to continue her treatment since she would require a six-month course of four anti-TB drugs – a standard treatment for active, drug-susceptible TB disease.

Agom did not pay for the entire process, which also helped eliminate the delay she would have had in accessing healthcare services. She feels better now, having completed her six months of treatment. What remains is for her local government TB supervisor to declare the outcome at the end of the treatment.

Intensifying case finding

A report by the World Health Organization (WHO) shows that the COVID-19-related disruptions to the provision of and access to TB diagnostic and treatment services caused an increase of about 100,000 in the global number of TB deaths between 2019 and 2020.

The 2021 Global Tuberculosis Report by WHO also showed that there was an alarming drop in 2020 in the number of people who were newly diagnosed with TB and registered in their health systems – from 7.1 million in 2019 to 5.8 million in 2020.

In March 2021, the Stop TB Partnership (STP) reported that TB detection and treatment enrolment numbers in nine countries that account for 60 per cent  of the global TB burden had fallen during the pandemic in 2020 to levels not seen since 2008, a loss of 12 years of progress.

While diagnosis and enrolment for TB treatment fell globally due to responses to the COVID-19 pandemic between 2020 and 2021, active case findings – which are vital in combating the scourge of the disease – actually rose in Nigeria.

In 2020, notification increased by 15 per cent, with a total of 138,591 cases notified, a significant increase from 106,533 and 120,266 cases notified in 2018 and 2019 respectively. In 2021, the country notified 207,785 TB cases, which is 50 per cent higher than the number notified in 2020.

Among the interventions contributing to identifying cases was the Wellness on Wheels (WoW) Mobile Diagnostic Units – using digital X-rays, artificial intelligence analysis and GeneXpert machines.

Funded by USAID under its Local Organization Network (LON) TB Project, which is a 5-year programme that commenced in April 2020 and will end in September 2024, the WoW is implemented by the KNCV Tuberculosis Foundation in collaboration with the National Tuberculosis, Buruli Ulcer and Leprosy Control Programme (NTBLCP) and state ministries of health.

In Cross River, one of the states which benefited from the initiative, residents such as Agom did not need to go to hospitals or laboratories to get tested. Instead, diagnosis and treatments were brought to their doorsteps.

Programme manager for tuberculosis in the state, a doctor, Bassey Offor, said that the WoW raised the awareness of TB remarkably and improved access to quality diagnostics across communities.

Global Fund TB Grant Programme Management Unit Team Lead at the NTBLCP, Dr Emperor Ubochioma, said that key enabling factors for the community strategy during the pandemic included building on an existing structure, and multi-stakeholder collaboration and increased community sensitization for TB, as well as political will with necessary government support.

“The staff intensified community effort, targeted hard-to-reach communities and vulnerable populations (for example urban slums, persons living in internally displaced camps, or migrant populations) and provided the platform for access to early diagnosis and linkage to care,” Ubochioma said.

As of April 9, 2021, a total of 16,265 people were enrolled across Boki, Ogoja, Ikom, Etung and Obubra LGAs in Cross River. Out of this number, 16,206 were screened, 1,305 presumptive cases were identified and tested, and 187 were diagnosed and referred for TB treatment.

Among those were some of the most marginalised people, who otherwise may have had little chance of access to diagnosis and treatment.

How the WoW truck works

According to KNCV’s Active Case Finding Coordinator, Southern Region,a doctor,  Eze Chukwu said the WoW truck features a digital X-ray machine and systems which can diagnose eight TB patients in less than two hours. The truck carries a high-capacity solar system, a mobile generator to power the cooling system, and potable water storage, permitting them to operate in some of the country’s remotest locations.

Through an “Active Case Finding” approach, health specialists diagnose and treat people with TB who have not sought diagnosis or care on their own, thereby removing any kind of spending involved in accessing care by communities.

During the process, presumptive TB individuals whose results are negative on GeneXpert have their X-ray films along with their symptoms further sent to radiologists across various teaching hospitals in Nigeria and beyond for further clinical diagnosis.

“This process has now been automated into a web-based application known as XMAP for a seamless review of our chest X-rays and optimization of clinical results,” Chukwu said.

He explained that chest X-ray and AI analysis have more far-reaching benefits beyond diagnosing tuberculosis alone, because malignancies and other medical issues are picked up in the field. The individuals are then referred to teaching hospitals for treatment and care.

During testing, the setup and workflow were done following COVID-19 rules. Staff wore facemasks and shields and maintained appropriate distances between people. Those diagnosed with TB were referred for treatment and care to a health facility through the LGA TB supervisor, who also provided the treatment outcome of referred patients at the end of the treatment programme.

Ensuring the smooth running of operations

According to Chukwu, the WoW truck coordinator is responsible for planning and implementing the intervention and decides the location for TB active case finding, guided by an early warning outbreak response system (EWORS) alert and hot-spot analytics.

The first step before any outreach involves contacting the local government TB supervisor and the director of primary healthcare, after which the programme itinerary is drafted.

The second step involves an advocacy visit to the local government chairman with a formal letter introducing the organisation and the intervention and a further visit to the community’s paramount ruler, who in turn disseminates the message to all the traditional leaders, chiefs, and members of the community through town criers.

“We also visit religious leaders, the town union leaders, and suggested influencers in the community, who will help drive down the message before and during the outreach,” he said.

The WoW consists of a 7-member team who goes into the communities and sets up the workstation – bearing infection prevention and control principles in mind – in strategic locations to allow more people access to the truck.

The workstation is divided into the enrolment area, screening area, result-checking/registration of presumptive TB and on-the-spot sputum sample production area, laboratory area, WoW truck Jingles Mix-a public address system used to play TB and other contemporary songs to grab the attention of people to the facility in an engaging way and the clients’ waiting area.

Apart from ensuring smooth and orderly workflow, this arrangement helped to prevent the crowding of clients as staff try to maintain the appropriate 2-metre distance between clients. While they have their protective equipment on during work, they also ensure that facemasks and hand sanitisers are available on all the tables for clients’ use.

Sustainability concern

Although initiatives involving the government are wont to fold even before their time elapses, Ubochioma said that the deployment of WoW trucks with staff experienced and skilled in advocacy, community engagement, and active case search remains key to the success of the intervention.

“The community strategy provides an opportunity for staff to engage and participate in community awareness, in addition to individuals who are screened, diagnosed and linked to care,” Ubochioma said.

He further explained that the participation of local government tuberculosis supervisors, including training of key personnel and engagement of existing Directly Observed Treatment (DOTS) sites for TB care, was also key to the sustainability plan.

On his part, KNCV Executive Director Dr Bethrand Odume said that TB treatment services in areas visited experienced increased service uptake even after the truck left the location. He said it shows the extent of awareness creation and sustainability of the WoW.

Challenges with implementation

Although the WoW initiative recorded huge success, there were challenges with its implementation. COVID-19 and TB share similar respiratory symptoms. Because of this, residents of communities in Cross River were suspicious of the programme, seeing the truck for the first time during a pandemic.

“They thought we would test them for COVID-19 and report them to authorities for quarantine,” Chukwu said, adding that some had said that they did not need TB testing, but rather treatments for COVID-19.

He explained that while some community members refused to participate during the pandemic, most had realised its importance and were now joining the programmes.

According to him, many communities also wanted a broader range of services, as they had so many people with other ailments needing treatment. The communities visited covered vast terrain that was difficult to navigate and workers had to spend some 5-6 hours daily travelling down rough roads.

To overcome these challenges, the team continued its advocacy and mobilisation which involved different approaches, such as working to ensure influential people were tested before other community members, who would then be encouraged to sign up too. After testing, the organization made the influential leaders TB brand ambassadors.

“I can work for hours and trek long distances without feeling tired now,” Agom said. “I am grateful for the WoW initiative because I did not know what I would have done (otherwise)”.

*inde