|How to cite this article:
Ukwaja KN, Onyedum CC. The performance of a tuberculosis control program in a high burden country: The Nigeria situation. Ann Trop Med Public Health 2013;6:500-2
|How to cite this URL:
Ukwaja KN, Onyedum CC. The performance of a tuberculosis control program in a high burden country: The Nigeria situation. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Aug 7];6:500-2. Available from: https://www.atmph.org/text.asp?2013/6/5/500/133695
The fight to control tuberculosis (TB) has benefited from unprecedented increase in global support, finance, and scientific advances. This success has resulted in the containment of TB in many high- and middle-income economies. However, TB control has remained a major global health challenge in 22 countries dubbed the “high burden countries.” In this issue of the journal, Otu A present the findings of their comprehensive review on the challenges and prospects of the National TB and Leprosy Control Program (NTBLCP) of Nigeria. The authors reviewed the performance of the TB control program based on the level of success in achieving the NTBLCP Strategic Plan (2010-2015). 
Two main indicators to access the quality of a TB control program are case detection and treatment success rates (TSR). Nigeria currently has a poor estimated case detection rate of 45%.  This suggests that majority of tuberculosis cases in the community are undetected and may be transmitting the disease. Also, the national treatment success rate for smear-positive TB is currently 84%.  This suggests that Nigeria has almost met the WHO TSR target of 85%.  The positive news is that 11 of the 36 States of the Nigerian federation reached the WHO TSR target since 2009. , Therefore, there is a need for improved monitoring, supervision, home visits, better reporting systems, and DOTS expansion in States yet to achieve the target treatment success rate in Nigeria. This will improve case notification, reduce morbidity/mortality due to TB, and prevent the development and spread of drug resistant TB.
Although Nigeria has achieved full geographical DOTS coverage since five years ago,  differences in timing of introduction of DOTS services between States in northern and southern Nigeria meant that DOTS services reached some parts of northern Nigeria more than a decade after it reached the south. However, with the support of several development partners, case notifications from northern Nigeria have increased. The NTBLCP has created a population target of one DOTS center per 25,000 population. With the current 1:43,943 population, there is a need for further quality DOTS expansion in Nigeria, particularly in the north east zone, which has the lowest number of DOTS centers per population. 
Important but often neglected factors, which hinder a TB control program, are the health-system and community level factors. The health system suffers from inadequate front-line TB health care workers in primary care services, especially in rural communities. Due to poor remuneration and incentives, the health systems fails to retain the services of majority of these community level workers. Also, even when they are available, they are poorly trained / equipped to confront the present realities of tuberculosis control (childhood TB, TB infection control, TB/HIV, drug-resistant TB e.t.c).  In the absence of a sustainable DOTS strategy using community health workers, the alternative approach is to involve family / community members as DOTS supporter – the community DOTS approach. For community-DOTS to be effective, there is a need to ensure high community level knowledge of TB. However, due to ineffective advocacy, communication, and social mobilization strategy in Nigeria, community awareness about TB is poor. 
TB treatment default rates in some settings in Nigeria are up to 29%.  This high default rates suggest that these places may be high breeding grounds for resistant strains of tuberculosis. Due to inadequate laboratory capacity, the true situation of multi-drug-resistant (MDR) – TB has not been well-documented in Nigeria. Since majority of these yet to be diagnosed cases of MDR-TB are mingling freely in the community, it suggests that in Nigeria, we may be sitting on a MDR-TB time bomb. There is an urgent need to provide bacteria culture facilities to diagnose and treat MDR-TB. The MTB-Rif Gene Xpert technology (provided through the WHO TB-reach program), which is currently being scaled up in high burden countries, may contribute in early detection of rifampicin-resistant strains of TB and in turn help estimate the burden of drug-resistant TB in Nigeria.
In Nigeria, the private sector is currently an important stakeholder in TB control – through the public-private mix (PPM) initiatives.  The PPM initiatives contributed 39% of total TB case notification in 2010.  A study in Kaduna northern Nigeria comparing private versus public sector TB services showed that case notification and treatment success rates were higher in the private sector compared to the public sector.  Currently, only 11 states in Nigeria practice PPM for TB.  There is, therefore, need to expand PPM for TB in States where they are available or commence it in others where they are not available. This should go hand-in-hand with private sector expansion of TB/HIV collaborative services.
Finally, the Nigeria NTBLCP has made giant strides in TB control, but much more still needs to be done. The authors highlighted some of the weaknesses facing the Nigeria NTBLCP, which among others included; Poor MDR-TB surveillance, care and reporting system, shortfall in TB laboratories and quality assurance services, inadequate funding, and poor implementation of TB infection control strategies. More importantly, there is a need to strengthen TB contact and defaulter tracing. This will reduce community transmission of TB and reduce the breeding of drug-resistant TB. Moreover, there is also a need to reduce stigma against TB and catastrophic expenditures associated with TB care,  and financial and social protection services should be provided for individuals treated for TB not only in Nigeria but in all high burden countries.
|1.||Federal Ministry of Health, Department of Public Health. National tuberculosis and leprosy control programme: Workers manual. Revised 5 th ed. Abuja, Nigeria: Federal Ministry of Health; 2010.|
|2.||World Health Organisation. Global Tuberculosis Control: WHO report 2012. Geneva: WHO; 2012.|
|3.||Federal Ministry of Health Nigeria. National Tuberculosis and Leprosy Control Programme 2009 Annual Report. Abuja: FMOH; 2010.|
|4.||Ukwaja KN, Alobu I, Ifebunandu NA, Osakwe CP. Trends in treatment outcome of smear-positive pulmonary tuberculosis in Southeastern Nigeria, 1999-2008. Ital J Public Health 2012;9:e8660-7.|
|5.||Ukwaja KN, Alobu I, Onu EM. Frontline healthcare workers′ knowledge of tuberculosis in rural Southeast Nigeria. Afr J Respir Med 2013;9:7-10.|
|6.||Intergender Development Centre. Desk review on tuberculosis in Nigeria – Executive Summary. Available from:http://intergender.org/reports/2010/TB%20KABEP_Desk%20Review%20Report(FINAL).pdf. [Last accessed on 2013 Apr 15].|
|7.||Ifebunadu NA, Ukwaja KN. Tuberculosis treatment default in a large tertiary care hospital in urban Nigeria: Prevalence, trend, timing and predictors. J Infect Public Health 2012;5:340-5.|
|8.||WHO: Global Tuberculosis Control: WHO report. Geneva: World Health Organisation; 2011.|
|9.||Gidado M, Ejembi CL.Tuberculosis case management and treatment outcome: Assessment of the effectiveness of Public-Private Mix of tuberculosis programme in Kaduna State, Nigeria. Ann Afr Med 2009;8:25-31.|
|10.||Ukwaja KN, Modebe O, Igwenyi C, Alobu I. The economic burden of tuberculosis care for patients and households in Africa: A systematic review. Int J Tuberc Lung Dis 2012;16:733-9.|
Source of Support: None, Conflict of Interest: None