As Nigeria joins other nations to celebrate this year’s World TB Day, Oni Idigbe, a Professor of Microbiology and chairman National Committee on Control of Multi-drug Resistant TB, MDR-TB, speaks to our reporter, Abiose Adelaja Adams, on challenges of combatting disease in the country.
What is this year’s World TB Day all about?
Let’s start by reminding ourselves that the World TB Day stands for the way we mark the anniversary of the discovery of TB bacteria by Robert Koch in 1882. Ever since, the World Health Organization, WHO, has decided to mark that day as a day set aside to carry out advocacy and sensitization on the disease. We are saying that TB is still very much with us and all hands should be on deck to ensure that we control it within our communities.
Every World TB Day in the past years had a theme that WHO wanted to address. But the issue is that in the past two or three years, there has been a burning issue of not getting access to most of the people that are infected with the disease.
Thus, the theme in the past three to four yearshas virtually remained the same. This is because every year, about nine million people globally get infected. And out of these nine million, three million are locked out; they don’t have access to any kind of care. So the thrust is to create awareness for the three million who are elusive; to develop strategies on how to reach these three million, cure them and treat them.
Thus the theme of TB day this year is to reach three million, cure every one. Against this background, we in NIMR (Nigeria Institute of Medical Research) mark the day through symposium where we bring together major stakeholders and international partners, to take stock of what we have been able to do within the last year, what we identify as the gaps and what we think should be the way forward.
Why are these three million people elusive?
These three million people are mostly those who live in the communities with no access to any form of TB care. TB is a disease of the poor. It is also a disease that could easily be spread through congestion.
Although it is a disease of the poor and could be located at the community where poverty level is high and where people believe the myth that it is caused by a witch in the village, we can also look at cosmopolitan areas, where the population density is high. But most of the care facility for TB is usually focused in cosmopolitan areas.
Most hospitals in the communities are not equipped with TB care and that is where you have most of the cases. That is why WHO has said that emphasis should be on going to these communities. Now some of these communities, not only are they poor, they are hard to reach and healthcare facilities are far away from them.
But whose responsibility is it to provide this care? And why is it not being given?
The services are supposed to be available at the primary health centres, PHCs, at the various local government areas. There are 774 Local government areas in the country. But if you see some of our PHCs, they are not really what you can call a care centre.
There is still a lot of need to reach the communities. I tell you that in 2014 and early 2015, WHO estimated that the world still needs $2billion every year to fill the resource gap of implementing the existing TB programs. Then you can imagine the situation in countries which are very poor. So it is an issue of resource – as well as getting to find the cases where they are and treat them.
How will this be done in the communities?
First is to provide the TB care. And then train community volunteers who will work within the community and train the community dwellers on the signs and symptoms of TB. Most community people don’t know they have TB. If they have that kind of cough, they believe it is some witch.
There are lots of myths around TB that people need to be educated about. There has to be a high level of awareness on the signs and symptoms, where to go to for treatment and let them know that it is absolutely curable.
If globally there is a deficit of funds, what is the situation in Nigeria?
For now, most of the community TB care is sponsored by international partners. I know that there are so many community TB programmes running in Lagos, but they are all sponsored by international partners, foreign NGOs like the Global Fund, USAID, WHO, all putting money into TB. About 90-99per cent (of care programmes) are donor sponsored.
According to Global Tuberculosis Report of 2014, Nigeria’s National TB program budgeted $139million for TB control. It funded only 9 per cent of this. 38 percent was funded by international donors while 53percent of the $139million remains unfunded. That is why we still have the problem of TB we have today.
How big is the TB problem in Nigeria today?
TB is still a health emergency. Nigeria is 11th of 22 high burden TB countries. Most of these countries which account for 95 percent of TB cases in the world are developing countries. Globally we have not really been able to grapple with the detecting and treating it.
TB is 98-99 per cent curable if you use the right combination of drugs and if the patient adheres to treatment, but we don’t always have this kind of result. Somewhere along the line, the correct combination of drugs may not be prescribed or the patient is not adhering to treatment. The result of this is that somewhere along the line the organism (TB bacillus) develops resistance.
Before you go on can you just give us a brief statistics of TB in Nigeria?
TB was almost eradicated in Nigeria and even the world, until it came back in the 90s with the discovery of HIV. It is the major opportunistic infection in people living with HIV. TB progresses faster and causes high morbidity and mortalities in HIV patients because of their compromised immunity.
In 2013, 160,000 people died of TB, while 85,000 people living with TB-HIV co-infection died in 2013. Total prevalence of TB in Nigeria is 570,000 and there are 590,000 new cases as at 2013, according to the 2014 Global Tuberculosis Report.
Currently, the multi-drug resistance TB poses a global challenge and is a major setback in TB treatment.
So what is this MDR-TB?
Multidrug resistance TB was first observed some years back and, before you knew it, it spread like wild fire. As of 2014, there were about 480,000 cases recorded globally, and most of them are within the developing countries.
It starts like this: there are four major drugs used in treatment of what we call susceptible TB (that is the normal TB). The healthcare personnel ensures that the patient takes the four drugs in his presence for a period of six months. That is why it is called the Directly Observed Treatment (DOTS). Every PHC is supposed to be able to provide these services. Out of these four drugs, there are two most important ones; Isoniazid and Rifampicin. Once a patient develops resistance to any of these two, that patient is classifieds as having multidrug resistant TB.
How serious a threat is MDR-TB?
When people develop MDR-TB, most of the developing countries don’t have the capacities to diagnose it. It was only recently, when we started developing the molecular biology techniques like the Line Assay, the LPI and the Gene extract that the developing countries started detecting it.
TB is spread through droplet of infection, when somebody coughs, it spreads through the sputum and then a susceptible host inhales it. Either of two things can happen. If the person’s immune system is intact, the TB stays in the lungs, rests there, doesn’t cause any harm to the body and remains there as dormant infection. But as soon as there is a drop in the body’s immunity, the aggressive nature of the TB overtakes the body immune, and that organism that was sitting and enjoying himself now starts multiplying and that dormant infection progresses into what we call an active infection.
Once a case of TB not treated, it has the potential of infecting 10-12 people. So imagine the geometric progression.
How can MDR-TB be spread?
If somebody with MDR-TB coughs into the air, he transmits the strain. This then becomes primary drug resistance in another person.
Once a person develops an MDR-TB, they will place him/her on second line drugs, which are more expensive and toxic. They take longer duration of treatment – a minimum of one year to 18 months, and this also includes injectables. You can imagine someone taking drugs for these long periods and some of them are injectable. Also, that is for second line drugs.
What are first line drugs and are they available?
First line drugs are those four combinations I explained earlier and they can be used for a period of six months to achieve results. They are available everywhere and they are free of charge.
But second line drugs are not available everywhere. And they are more expensive, much more toxic, takes you a longer duration of treatment. The second line drugs are available at specialized centres which we call MDR treatment centers.
One needs to obtain approval from the WHO’s Green Light Committee to be able to get these drugs. The country has to obtain permission.
What really causes drug resistance?
Due to the nature of DOTS treatment, where the patient has to come to the clinic every day to collect and use the medicine in the presence of a health worker, there are cases where the patient may miss some days because he does not have transport fare. If this continues, the organism will develop resistance to the drugs and thus a new strain called the MDR-TB sets in. In some other cases, the drug combination may not be always available.
What is the prevalence of MDR-TB in Nigeria?
According to the latest Global TB report of 2014, it Is about 2.9 per cent. There were 10,410 cases tested for MDR-TB in 2013 and 669 laboratory confirmed cases. Out of these, only 426 were started on treatment.
How about the extensive drug resistanceTB?
In treating MDR-TB patients, there are some who have also started developing resistance to the second line drugs. Now when MDR-TB patients start developing resistance to some of the second line drugs, then we go into a more serious situation called extensively drug resistant TB (XDR-TB).
Do we have the capacity from diagnosis to the treatment of these resistant strains?
Initially, we said MDR TB cases should be treated in MDR-TB wards that are dedicated. There is one in Yaba, Calabar, Port Harcourt. They are not many.
The problem again is that because they are not many, you may have an MDR case in Kano and the patient is brought to Lagos. The social component of it is that the patient is separated from the family to a new environment. The stigma also as the family in Kano will be asking where is your brother, or sister’ so because of inadequacy in the number of specialized treatment wards, the country is now trying to adopt what it calls, community MDR care where a patient is identified by a TB control officer to administer the drugs. We are still experimenting on it but that still has its own complication as well.
Now some of the problems we are having is that should the caregiver go to the patients house every day to give injection, community people will start asking questions. The other option is that should the patient go to the health facility. Again, there is the cost of transportation to consider.
The challenges are indeed enormous
Yes but that is not to say that if things are put in place we can’t cure TB. WHO says TB mortality has fallen over 45 percent worldwide since 1990 and incidence is declining. New TB tools such as rapid diagnostics are helping transform response to the disease and new life-saving drugs are being introduced. But the funding gap is still very wide.