The COVID-19 pandemic came with a lot of disruptions. Priority was given to its containment efforts, which sadly, left other public health challenges like tuberculosis with little attention. JUSTICE NWAFOR, after a visit to Imo State, southeast Nigeria, reports how over- prioritising the pandemic’s containment efforts affected TB patients in the state and its impact on Nigeria’s treatment and control efforts.
Augustine Chukwuma, 76, was not surprised when he started experiencing prolonged cough especially at night. Just a few days back, he had suspected that his then best friend had poisoned the dried bush meat he offered him when he stopped by at his red-mud house to catch some breath, having spent the best of the day in the bush harvesting bamboo for sale — before proceeding home.
But when he started seeing blood particles in the phlegm that secretes with the cough, he was alarmed. He had heard of tuberculosis and how coughing out blood was one of its symptoms. So, he listened when the eldest of his 10 children advised him to visit a hospital. Augustine travelled more than 25 kilometres from his sleepy Obinugwu community to the Imo State University Teaching Hospital in Orlu, Imo State.
When Nigerian Tribune visited the community, the road was not in a bad shape but the major means of moving in and out of the community was by motorcycle. So, the frail 76-year old man endured a near hour-long ride to receive the bad news that changed many things for him and his family.
Papa–as he would be fondly called at the treatment centre — was confirmed drug-susceptible TB positive and placed on drugs. He was given drugs to last him two weeks and was advised to return biweekly for further dosages. Drug-susceptible TB treatment takes place for six months. During this period, the patient is expected to take the drugs religiously.
COVID-19 disruptions to TB treatment
The WHO declared COVID-19 a public health emergency of international concern on January 30, 2020, seven days after its International Health Regulations (IHR) Emergency Committee had advised countries to be prepared for containment. Twenty-eight days later, an Italian expatriate was diagnosed with the virus and Nigeria was drafted to the map of infected countries. Governments at the national and subnational levels intensified efforts to contain the spread through the Nigeria Centre for Disease Control (NCDC).
In Imo State, as in other states, restriction of movement was ordered and security personnel enforced it. This restriction meant movement from one part of the state to another was stopped, including to public services such as hospitals.
When Augustine’s two weeks supply of drugs ran out and he needed to go get the next dosage, security personnel on the Nkwito axis of Orlu enforcing the lockdown would not allow him and others to get to the hospital. Neither could nurses at the treatment centre get the drugs across to him.
For Chioma Oparaugo who works as a TB community volunteer in Owerri West LGA of Imo State, connecting with TB patients was one of the greatest challenges she had during the lockdown. “I received several calls from patients saying they could not come to (Directly Observed Treatment Centres) to pick their drugs,” she said. “When I tried going to give them the drugs, security personnel would stop me and would not even want to see my pass”. Oparaugo complained that even when she would want to follow some of the routes not manned by the security personnel, there would be no means of transportation. And if she eventually found transport, the fare would be too costly for her.
COVID-19 and TB share similar respiratory symptoms. During the heat of the pandemic, many Nigerians were averse to Covid tests, alluding to conspiracy theories. This aversion affected some locals so much so that they were skeptical of anything that had to do with COVID-19-related symptoms.
This affected case finding efforts — which are at the heart of the drive to eliminate TB by 2035 — even after the lockdown. One of the efforts that were badly hit is the ‘TB/COVID-19 house to house search’ organised by the Imo State TB control programme at the State’s Ministry of Health, with sponsorship from the WHO.
Amaka Chizoma, Owerri West Local Government TB and Leprosy supervisor told Nigerian Tribune that in the area which she supervises, residents of some communities she visited were repulsive and that she was discouraged.
“When we get to the houses, people would say ‘COVID-19 people have come’. Even people who had been coughing for months would say they were fine”, Chizoma said, shaking her head in displeasure.
Oparaugo’s experience was not totally different from Chizoma’s but for some residents accusing her of planning to tell them they were COVID-19 positive, while she actually went for TB test sample collection.
“When you talk about TB, they’d say what they know is coronavirus. And when I’d want to collect their samples to test, they’ll say no, that I want to test them for coronavirus.”
‘We lost track of most patients’
The effort to control and eradicate TB in Nigeria follows through well-established structures. At the national level, the National Tuberculosis and Leprosy Control Programme (NTBLCP), which was established in 1989, coordinates the efforts. It works in partnership with non-governmental organisations and donor agencies. These efforts trickle down to the states which then coordinate activities at the local government and community levels.
A primary aspect of the control effort is to follow up on cases that were identified through testing to treatment and management and final certification of recovery. Any break in the chain has dire consequences. For instance, if the patients are not followed up on properly, there are chances they will abandon their drugs and that has heavy consequences for the control efforts (including new variants of Multi-Drug Resistant TB) says Dr Golibe Ugochukwu, senior programme officer at KNCV Tuberculosis Foundation Nigeria, in Imo State.
Dr Charles Okafor is the State’s TB Programme Manager at the Imo State Ministry of Health. He told Nigerian Tribune that the COVID-19 lockdown set his team back and reversed the progress of the national target to achieve a 50 per cent reduction in prevalence rate and 75 per cent reduction in mortality rate by 2025.
“Before COVID-19, we used to have a monthly clinic for our TB patients,” Dr Okafor said. “But with the lockdown, we lost track of most of them”. Given that 448 out of the 2020 cases of 1,803 were diagnosed in the first quarter, it can be concluded that “most” means they lost track of up to half or more of their patients. This estimation is used because the state’s ministry of health could not provide exact numbers. Dr Okafor said due to the suddenness of COVID-19 protocols, the state “couldn’t plan for a mode of drug delivery before the lockdown. So it became difficult for us to track the patients to deliver drugs to them.”
Consequences of TB treatment disruption
TB patients’ failure to take their drugs as and when due enables the bacteria to mutate to a new variant which would develop resistance to the drugs. According to Dr Golibe, this erodes the gains the treatment had achieved and could lead to complications and death. This manifested in Augustine. “I spent close to one month without taking the drugs and I began to cough more often,” he told Nigerian Tribune.
“When the restriction was eased a little, I returned to collect my drugs at IMSUTH. But I was told my case had worsened and that I needed to be transferred to Federal Medical Centre, Owerri, where I’d be hospitalised and given another set of (stronger) drugs.”
The treatment centre he was referred to is the ward set apart for the treatment of multidrug-resistant TB patients. What this means is that Augustine developed Multidrug-resistant TB (MDR TB) which is caused by TB bacteria that is resistant to at least isoniazid and rifampin, the two most potent treatments for drug-susceptible TB. MDR TB is just a step away from the most dreaded stage — Extensively drug-resistant TB (XDR TB) — a rare type of MDR TB that is resistant to isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-line drugs (amikacin, kanamycin, or capreomycin).
Also, at this stage, the fatality rate is much higher. “XDR-TB patients can be cured, but with the current drugs available, the likelihood of success is much smaller than in patients with ordinary TB or even MDR-TB”, the WHO says.
Augustine is just one of the millions of patients globally who the Director-General of WHO, Dr Tedros Adhanom Ghebreyesus said could not get continued essential care as a result of the many disruptions the COVID-19 pandemic caused.
Not many were as lucky as Augustine, who as of the time Nigerian Tribune visited him had recovered largely, having spent more than five months at the facility at FMC, Owerri. Two hundred and forty-five thousand Nigerians die of TB and about 590,000 new cases occur annually, according to estimates by the Copenhagen Consensus Center.
While this data is grim enough, it’s an improvement on previous years’ cases and progress in the drive to the 2035 target. But the pandemic has clogged this wheel. Here’s why: the report the WHO released recently on the impact of the pandemic on TB detection and mortality in 2020 shows a very negative trend. In 2020, the number of reported cases — 4.9 million — (provisional), decreased from the 6.3 million reported for 2019. The WHO said this is a result of the pandemic which also tanked the relative case notifications (2020 vs. 2019) by 21 per cent.
For Dr Anyaike, it means there is now more work not just for the government but for the partners: more funds and commitment would be needed to “increase the momentum in order to turn around the impacts”.
Detection of cases is one of the most important steps in the chain of actions to eradicate the disease. And this drawback caused by COVID-19 could result in half a million additional TB deaths, which would sadly set the world back by more than a decade to the level of TB mortality in 2010, the WHO estimates.
Different research data from the Stop TB Partnership said this impact has negated the progress of 12 years, back to the dire situation of 2008. It said the pandemic response pushed aside tuberculosis outreach and services, resulting in a 20 per cent drop in diagnosis and treatment worldwide.
Economic impact on patients of disruption to TB treatment
He told Nigerian Tribune that he specifically refused to be admitted to the centre because it would drain him psychologically. To allow him to stay at home, Chizoma led her Owerri West LGA team to visit and give him specific instructions and arrange for a nurse who would administer drug injections to him daily for four months. Every day, during the nine months duration of the treatment, she kept tabs on him.
Taking the drugs was one of Chimaobi’s major challenges. “My room had a heavy stink of drugs”, he said. “Most times I’d take them and they would react — I’d roll on the floor for many hours.”
Chimaobi said he kept to the treatment because he wanted to be alive. “I had to consider my mother. I had to keep my mother alive by staying alive because I knew if I gave up, my mother would die.”
But by far, one of the worst-hit aspects of Chimaobi’s life was his phone and phone accessories business. Even though he had some people he referred to as ‘my boys and girls’ who ran the business while he was confined at home, his absence disrupted the growth trajectory he had planned for.
“My business was so affected that the monthly sales dropped because there were customers who would come and demand to see me. If they don’t, they would leave.”
Chimaobi is younger than Augustine, but the economic impact knows no age limit. The 76-year-old told Nigerian Tribune that before he developed resistance to the earlier drugs, he continued with his bamboo-harvesting business. On some days, he could harvest about 100 of them, sell and make money to take care of himself, his visually impaired wife and two of his 10 children who are still with him in Obinugwu.
“But now I depend on my brother”, he said with the kind of ‘I am tired’ look that spells of desolateness.
Augustine and Chimaobi are just a few of the TB patients in Nigeria who face dire economic challenges. The WHO said in its 2020 global TB report that 47 per cent of the estimated 590,000 TB patients in Nigeria face “catastrophic” income losses associated with loss of employment or time lost while seeking or staying in care, compared to Zimbabwe’s 44 per cent and Myanmar’s 48 per cent.
TB treatment budget skyrockets following COVID-19 disruptions
Going by the federal ministry of health’s figure of 21,000 MDR TB patients in its 2019 report, it means it would cost about N51.3 billion annually to treat MDR TB patients. On the other hand, the WHO’s provisional TB data portal presents much lower figures than the Copenhagen Consensus Center’s annual estimate.
The WHO provisional data portal shows that in 2019, the number of new and relapse TB cases in Nigeria was 117,320, an increase from the 2018 figure of 103,921. Then in 2020, it spiked to 135,638.
A breakdown of the figure shows that in the first quarter of 2020, there were 32,289 cases. The figures dipped in the second quarter to 26,755 and started a new growth trajectory in the third quarter by increasing to 35,444 and to 41,150 in the fourth quarter. The growth did not abate as it jumped to 43,838 in the first quarter of this year.
Nigerian Tribune did the mathematics — estimated the costs and gap by using the WHO estimated cost of treatment per patient with stats from Nigeria’s Ministry of Health and the WHO’s provisional TB data portal.
This means it would cost Nigeria N44.55 billion to treat the drug-susceptible variant of the disease in 2020. The figures would increase to N95.900 billion when the cost for MDR is added. On the other hand, the cost for the drug-susceptible variant in 2019 was N38.54 billion. Hence, the gap between 2019 and 2020 created an additional funding burden of about N6 billion.
Narrowing this down to Imo, the state’s TB effort was able to diagnose 473 cases and MDR 12 cases in the first quarter. But the number reduced to 381 cases and by 25 per cent to nine MDR cases in the second quarter due to the lockdown. After the lockdown was eased a little, diagnosed cases increased to 473 and MDR cases spiked by a little below half (40 per cent) to settle at 15. In the last quarter of the year, it was 500 and the MDR cases reduced by 13.3 per cent to 13 and climbed by 28 per cent to a new high of 18 in the first quarter of 2021.
If the percentage increase of the WHO provisional data in the 2020 figures — 15.61 per cent — is also used to factor the MDR increase, it means the national figure of 21,000 could increase by 3278.1 to 24,278.1. This could sadly spike the cost of MDR treatment for the year to about N59.35 billion, creating an additional N8 billion funding burden.
Amidst the challenge of inadequate funding for the TB control effort in the country and the healthcare sector entirely – policymakers should have factored the unique nature of diseases like TB into lockdown protocols. Among African countries in the top 10 high burden countries, Nigeria has the highest burden of funding gap.
The country’s total budget in the national strategic plan for TB in 2020 is $384 million (N146.7 billion). Out of this, domestic funding (from the government and other local sources) is $27 million (N10.3 billion) while international donor funding is $89 million (N34 billion). This means the total funding available for the effort is $116 million (N44.3 billion), translating to 23 per cent domestic funding and 77 per cent funding from international donors.
Disturbingly, this leaves a wide funding gap of $268 million (N102 billion) or 70 per cent. Another estimation is here: in 2019, the budget for TB efforts in Nigeria was $121 million (N46.2 billion) out of the required $336 million (N128.3 billion). This left a funding gap of $215 million (N82.1 billion), about 64 per cent. This shows that in 2020, the funding gap increased by about N20 billion.
Even though there is no data as to how much the government released for the effort as the NTBLCP has no distinct budget line in the 2020 budget of the federal ministry of health, there are doubts if the entire budgeted amount was fully released.
This is no surprise. Nigeria has a history of inadequate healthcare funding. The Abuja Declaration of 2001 advocates allocation of at least 15 per cent of national budget to healthcare. But since then, Nigeria has not allocated more than half of the agreed percentage. For instance, in budgetary terms, from 2012 to 2018, Nigeria’s federal government was only able to allocate N307.937 billion to healthcare. Of this amount, only N201.002 billion was released, leaving N106.935billion unreleased.
Implications of funding, treatment gaps
With the huge funding gap, which Dr Odume says will likely spike when another report is released, the Nigerian government needs to do more to complement the efforts of foreign donors and partners. First, provide more funding for healthcare in the country and take real ownership of the fight, he said. Also, the state governments should add TB care to the minimum benefit package of the state health insurance scheme — an advocacy KNCV TB Foundation Nigeria is particular about. “This is to maintain sustainability and ownership because the (foreign) funding will not remain forever”, he emphasised.
Working to close the gaps is particularly important because Nigeria is a TB-high burden country. In 2019, the 30 TB-high burden countries accounted for 87 per cent of new TB cases. Eight countries account for two-thirds of the total, with India leading the count, followed by Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa.
And the infectious nature of the disease makes the situation really dire. People with active TB can infect 5–15 other people through close contact over the course of a year. This means decreased efforts in 2020 would have devastating implications in the coming months and years.
On funding, every $1,000 not invested now means an additional $5,000 to $15,000 has to be found by end of the year. Sadly, this will keep multiplying by 10 to 15 every year.
It also has huge implications for HIV efforts in Nigeria. The country has the 4th biggest HIV epidemic globally and without proper treatment, 45 per cent of HIV-negative people with TB on average and nearly all HIV-positive people with TB will die, the WHO says.
The trauma of stigma: ‘I cried every night for five months’
Discrimination, stigmatisation and loneliness are some of the factors that affect the mental health of TB patients, especially the inpatients. For Elizabeth James (original name concealed to protect her privacy), nothing was more psychologically draining than leaving school, family and friends to be confined in a secluded ward with all other patients being males. When Chizoma — the Owerri West TB supervisor — told her she’d be moved to the facility at FMC Owerri, she didn’t quite understand what it meant.
But when she saw nurses walk into her room fully clad in Personal Protective Equipment, and walk out immediately after administering her medication for the day, Elizabeth said she felt like dropping dead immediately. “I felt like I was toxic, but really I was.” Then she would burst into tears later that night and would do that every night throughout her five-month stay at the facility.
“Friends didn’t come to see me because it was actually not safe for them. My mum would only come once in a while for her safety. I refused to take my medications for some days and passed out on several occasions. It was a traumatising experience.”
But the silver lining for Elizabeth was the presence of Augustine in the ward. She said sometimes when she would want to give up but learnt that the 76-year-old was still sticking to his drugs, she fought on.
“Papa was a huge encouragement for me”, she said with a chuckle.
• This report was facilitated by the Wole Soyinka Centre for Investigative Journalism (WSCIJ) under its Free to share project.
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