Chapter One

1.0 Introduction to TB:

Characteristics of Tuberculosis:

Tuberculosis is a disease caused by the bacteria known as Mycobacterium tuberculosis.[1] Mycobacterium tuberculosis was identified in 1882 by Robert Koch.[2] It is an acid-fast bacillus and obligate aerobe which grows in about 15 to 30 days at a temperature of 35 to 37 degrees centigrade in an enriched media with a moderately acid base medium.

It has no natural reservoir and its antigenic properties are similar to the leprosy bacillus, the Bacille Calmette-Guerin (BCG) and other typical types of mycobacterium[3].

M. tuberculosis is pathogenic and virulent in nature. Its ability to cause disease depends on the susceptibility of the host as well as the aggressiveness of the invading organism[4] . An electron scan of the bacterium is highlighted below[5]:

Considered one of the most dreaded diseases of the 19th and 20th centuries, TB was the 8th leading cause of death in children between the ages of 1 to 4 years old during the early 1920’s especially in the developed countries of the world like the United States and Britain. As the general standards of living improved in the industrialised nations of the world so too did the decline in TB related incidences.

TB is often classed by the “infection of one of the two variants of the tubercle bacillus which is known to commonly affect man. They are Mycobacerium tuberculosis and bovis”[6].

In Nigeria, majority of the TB related disease is due largely to the M. tuberculosis variant of the tubercle bacillus. The TB infections caused by Mycobacterium bovis which is associated with milk are rare and few and far between[7].

TB can take an “active and an inactive” state of infection. The Word Health Organisation (WHO) describes an active case of TB as “a symptomatic disease due to infection with Mycobacterium tuberculosis”[8]. TB cases are generally classified as either pulmonary or extra-pulmonary.

Patients with pulmonary TB are further sub-divided into “smear-positive” and smear-negative cases[9]. Smear-positive cases are the most important sub-groups for control programmes as they are the source of infection. The WHO has defined a smear-positive patient as:

A patient with at least two sputum specimens positive for acid-fast bacilli (AFB) by microscopy

A patient with at least one sputum specimen positive for AFB and radiographic abnormalities consistent with active pulmonary TB.

A patient with at least one sputum specimen positive for AFB, which is culture-positive for M. tuberculosis.

A smear-negative patient; on the other hand is also defined by the WHO as:

· A patient with at least two sputum specimens negative for AFB by microscopy, radiographic abnormalities consistent with active pulmonary tuberculosis and a decision by a physician to treat with a full curative course of anti-TB chemotherapy

· A patient with a least one sputum specimen negative for AFB, which is culture-positive for M. Tuberculosis; and finally

Extra-pulmonary tuberculosis is defined by the WHO as:

· A patient with a histological and (or) clinical evidence consistent with active extra-pulmonary TB and a decision by a physician to treat with full curative course of anti-TB chemotherapy[10]

1.10 Mode of Transmission:

The transmission of Tuberculosis is done mainly through “droplet infection and droplet nuclei” which is said to be generated when a patient with tuberculosis coughs[11]. For the infection to be transmitted the droplet particles must be fresh in its constituency to carry a viable organism. The spread and transmission of tuberculosis is heightened even further depending on the vigorous nature of the cough and the ventilation provisions in the environment concerned.

1.11 Signs & Symptoms:

The element of signs and symptoms in Tuberculosis is often misleading in the sense that the human body may harbour the bacterium that causes tuberculosis, and the immune system in the body suppresses the resultant effect and prevents the host from becoming sick. It is as a result of this scenario that the medical profession and doctors make a distinction between what is referred to as “Latent TB and Active TB”

Latent TB is a condition where the patient has a TB infection but the bacteria (…) remains in the body in an “inactive state” and therefore causes no symptoms to be shown. Latent TB which is often referred to as “inactive TB” is not known to be infectious.

Active TB on the other hand is the contagious wing of tuberculosis and can make its hosts sick.[12]

The state of active TB develops some clear signs and symptoms in its diagnosis and they include:

Chills and cold spells

Fatigue

Fever

Loss of Appetite

Night Sweats

Unexplained weight loss[13]

Medical evidence has shown that there are varying degrees of Tuberculosis depending on which part of the human body it affects. Tuberculosis often attacks the lungs and its signs and symptoms include:

· Coughing that laughs for three weeks or more

· Coughing up blood

· Chest pain or pain resulting from breathing or coughing[14]

Tuberculosis is known to affect other parts of the body of which include the brain, spine or kidneys. The symptoms depend on the organs that are affected. Tuberculosis of the kidney tends to show signs & symptoms of bleeding in the patient’s urine whilst Tuberculosis of the spine shows cases of back pain.

1.12 Incubation Periods

source – http://www.aarogya.com/index.php?option=com_content&task=view&id=834&Itemid=853

1.2 Public Health Importance

Standard of Living & State of Health In Nigeria

The United Nations Human Development (UNDP) programme has through the early 1990’s paid greater emphasis in human development, welfare and poverty research. Through its Human Development Report, it has published the Human Development Index (HDI) which looks beyond GDP to a broader definition of a nation’s well-being. The link in welfare is a determinant index to health conditions, well being of persons and an insight onto their susceptibility and immunity to disease infection[15].

The economic condition of a nation is a guiding factor to growth, development and living standards of a nation’s citizen. The assumption that a citizen who is paid more per capita has his or her standard of living higher than those who are paid less is not often the case. Levels of livelihood and poverty are not necessary elevated through higher income. 

Nigeria has seen a steady rise in its income per capita over the years. However, a sharp incline in its inflation rate to the economy, poor standard of governance coupled with a dilapidated health care system has seen a decline in its overall standard of living.[16]

The graph below shows this comparison when we see the income per capita of a nation like Madagascar over Nigeria whose citizens receive a higher pay package but have poorer living standards which trigger health concerns[17].

The Human Development Index (HDI) provides a composite measure of three dimensions of human development. These areas include:

· Living a long and healthy life which is measured through life expectancy

· The level and degree of education and literacy of nation’s citizens. This is measured by adult literacy and enrolment at the primary, secondary and tertiary levels; and finally,

· Levels of a decent standard of living which is measured by an individuals level of purchasing power parity (PPP) and income base analysis.[18]

Critics of the process have adhered to the fact that the index is not in any sense a comprehensive measure of human development and a way of monitoring standard of living.

It does not, for example, include important indicators such as gender or income inequality or other indicators such as respect for human rights and political freedoms. However, what it does provide is a broadened prism for viewing human progress and the complex relationship between income and well-being.

In Nigeria’s context, this index measures the country’s standard of living and state of health by comparing certain key sectors such as life expectancy rates and adult literacy rates. The chart below gives a unique view to Nigeria’s position. In this chart, Nigeria has been ranked 158th out of 177 amongst the developing nations of the world with an HDI rating of 0.470.[19]

The evaluation of a standard of living is relative, depending upon the judgment of the observer as to what constitutes a high or a low scale. Another relative index to the standard of living of a certain economic group can be gathered from a comparison of the cost of living and the wage scale or personal income. Factors such as discretionary income are important, but standard of living includes not only the material articles of consumption but also the number of dependents in a family, the environment, the educational opportunities, and the amount spent for health, recreation, and social services.

Nigeria as a nation has a GDP range of 6.4& as at 2008[20] and the number of dependants vary within the populations in the Northern & Southern part of the country. A key example on health grounds are the lifestyles of community citizens in Kano, Kaduna, Zamfara, Sokoto and Bauchi States. The cultural and religious trends of having a male occupant look after both siblings and relatives within a nuclear family as well as the extended family puts a large burden on cost of living, health standards and living quarters.

The research conducted by International medical associations and bodies such as CDC, UNICEF, WHO, Rotary International through the Polio vaccination programme in Kano State are key resources showed a dilapidated and sub-standard level of livelihood amongst the locals in urban regions[21]. Unemployment, low wages, crowded living conditions, and physical calamities, such as drought, flood, political instability, malnutrition etc has brought a drop in the standard of living within such regions in Nigeria.

While standard of living may vary greatly among various groups within the country, it also varies from nation to nation, and international comparisons are sometimes made by analyzing gross national products, per capita incomes, or any number of other indicators from life expectancy to clean water. Overall, industrialized nations tend to have a higher standard of living than developing countries. Nigeria is no exception to this theory. 

Records have shown that since the mid-1970s almost all regions have been progressively increasing their HDI score. A key region that has seen a tremendous rise in their standard of living since the early 1990’s are East & South Asia. Central and Eastern Europe and the Commonwealth of Independent States (CIS); especially Russia and its former Soviet colonies initially had a catastrophic decline in the first half of the 1990s but have recovered and improved their standard of living.[22]

The major exception is sub-Saharan Africa in areas such as Niger, Togo, Cameroon and Nigeria. Records have shown that since 1990 standard of living has not improved but stagnated. Experts believe that this is partly due to economic reversal but principally because of the catastrophic effect of HIV/AIDS on life expectancy.[23]

Poverty is the major consequence of the dilapidated and chronic failure in Nigeria’s healthcare and social service system.[24] The access to standard resources such as good education, improved water supply, good nutritional standards and adequate shelter provisions has rendered Nigeria being ranked 80th amongst 108 developing countries with an HPI-1 value of 37.3 as evident in the chart below.[25] These key trends in life expectancy, standard of living and health conditions explains why the 22 nations targeted and responsible for 80% of the world’s TB infections are found in impoverished and developing nations with a poor level of standard of living and health concerns. 

1.3 Housing and Poor Sanitation

Nigeria; especially Lagos State has had the in-dignified commercial label of being the most expensive “slum” in the world. This gives a clear insight into the high magnitude of housing inadequacy in both urban & rural centres in Nigeria. The dilapidated state of infrastructure and a poor maintenance culture has aggravated the spread of disease and risk in healthy living standards of the vulnerable masses especially in impoverished regions within the country. This can be proven and manifested in both quantitative and qualitative terms.

In developed societies such as the United Kingdom (UK), the local authorities are responsible for things like planning permission needed before erecting structures. Nigeria’s UDB (Urban Development Board) commissions do have rules and regulations in place for buildings, drainage facilities and proper infrastructural displacement but the problem is one of implementation, corruption and share disregard for social, health and economic concerns.

This has over the decades given rise to poor sanitary conditions which can be seen through the severe overcrowding and unsanitary environment characterized by housing in the urban centres. The only resultant factor are the culminating effect and growth of slum areas. The deficiency in housing quality, building materials and the design and spacing of buildings is a key aspect of why the spread of diseases such as Meningitis, Cholera, Malaria and Tuberculosis are rampant in the region.

Take for example the Northern city of Kano State. A city known for its ancient history and strict adherence to Islamic principles, is also known for its vast close knit network of shanty mud houses that lie in close proximity to one another with barely no room for cross ventilation, proper drainage or sewage facility[26]. Sewage is surface borne with the refuse and excreta of humans and livestock being displayed in the open.

The health hazards this poses are many. The question of housing and poor sanitation is nothing new to the African continent and is indeed a key feature in its rural regions which has spread into the urban developed areas of the countries within Africa.

The United Nations in 1969 confirmed that the average annual growth rates were 4.7% and 4.6% between the period 1960 and 1980, and 1980 and 2000 respectively.

A confirmation of this can be found in the table annexed below.[27]

Average Annual Growth Rate

Population (Millions)

1960-1980

1980-2000

1960

1980

2000

%

%

Africa

31

77

190

4.7

4.6

Studies have shown that the rapid rate of urbanisation in Nigeria and the consequential explosion of urban population have not been matched by a corresponding commensurate change in social, economic and technological development[28]

The economic down town in the early 1980’s saw a break in the level of growth and development with the nation’s economy to that of its population boom[29].

The lack of proper & adequate public infrastructure and social services has suffered tremendously and this has affected the process and level of urban planning and zoning in many cases. A practical example of this can be seen in the newly created Nigerian capital – the Federal Capital territory, Abuja.

The capital was built by foreign contractors; Julius Berger, with the idea and layout of a suburban aristocratic society with well spaced buildings proper social and infrastructural amenities and health concerns taking into consideration. But the key problem lay with accommodation and transportation of the work force and working class within the city. 

No provisions were made which forced locals to build shanty accommodations unaided by proper planning authorities with little or no regard for health & safety issues, sanitary considerations or even building regulations.

This idea coupled with the population growth had outpaced the rate of housing provision and created a dilemma in the housing standards and sanitary conditions of millions of its inhabitants. The spread of diseases both air & water borne became eminent and this has been a key problem and contributory factor to disease control in Nigeria. 

1.4 Housing and Poverty:

The spread of disease can be said to be the resultant consequence of a number of socio-economic factors as well as the action and inaction of government over the years. Rural areas and indeed some urban regions in Nigerian States, generally lack vital social services and infrastructure services such as clean water, electricity, and good roads. The absence of these amenities constitutes “push factors” which can be said to have facilitated the migration of rural dwellers into urban centres. 

It is note a surprise that the rate of urbanisation in Nigeria far outpaces the rate of economic development. Despite the enormous amount of money proposed for urban investment in the National Development Plan, very limited investment is made in urban infrastructure. An increasing shortage of urban services and infrastructure characterize the urban areas, and these are only accessible to a diminishing share of the population.

 The existing urban services are overstrained which often times lead to total collapse. A large proportion of the population does not have reasonable access to safe and ample water supply, and neither do they have the means for hygienic waste disposal. It is eminent that these two services are essential for a healthy and productive life and the lack of it are a key contributory factor to the causes of Tuberculosis. 

The quality of the environment in most urban centres in Nigeria is deplorable. This is not so much dependent on the material characteristics of the buildings but on their organization as spatial units. The slow process of urban planning and zoning, in the face of rapid urbanisation in most urban centres, has resulted in poor layout of buildings with inadequate roads between them and inadequate drainage and provision for refuse evacuation. Thus there is a high incidence of pollution through water, solid waste, air and noise and inadequacy of open spaces for other land uses[30].

Studies over the years have shown the deplorable conditions of urban housing in Nigeria. They affirm that 75% of the dwelling units in Nigeria’s urban centres are substandard and the dwellings are sited in slums[31]. This is attributed to the combined effects of natural ageing of the buildings, lack of maintenance and neglect, wrong use of the buildings, poor sanitation in the disposal of sewage and solid waste, wrong development of land, and increasing deterioration of the natural landscape.

There are moderate building facilities in Nigeria but the high level of poverty of most urban households places the available housing stock out of their economic reach. Many of the households resort to constructing make shift dwellings with all sorts of refuse materials in illegally occupied land. This has led to the growth of squatter settlements in many urban centres. The buildings therein are badly maintained and lack sanitary facilities with little access to light, air and good water.[32] 

The United Nations Standard for Nigeria’s room occupancy is 2.20. The World Health Organization (WHO) stipulates the average rating to be between 1.8 and 3.1, whilst the Nigerian Government prescribed a standard of 2.0 per room.[33] 

However, the reality is different as overcrowding is thus a visible feature of urban housing in Nigeria. It is symptomatic of housing poverty and consequential of poor economic circumstances.

1.5 Prevalence of TB:

The term “prevalence” of Tuberculosis usually refers to the estimated population of people who are managing Tuberculosis at any given time. Prevalence and mortality are considered by the WHO as direct indicators of the burden of Tuberculosis which indicate the number of people suffering from the disease at a given point in time and subsequently those dying each year.[34]

A balance and understanding of these terms aids the improvement of the level of control and effectiveness in treatment thereby reducing the average duration of the disease. The Stop TB Partnership link spearheaded by the WHO is aimed at reducing by 2015, the per capita prevalence and mortality rates by 50% in comparison to records in 1990.[35] The optimism is reassuring in most regions of the world with the exception of the African continent. The key factors derailing the efforts will be highlighted in the next chapter.

In order to determine prevalence levels within a region, resort to statistic by way of a “population based survey” is often adopted. These surveys are used to estimate prevalence for those countries with proper census records. Another option is to adopt the method of “estimated incidence” ratings.

Estimates of this nature on TB incidences, prevalence and mortality rates are based on a consultative and analytical process proscribed by the WHO and published on an annual basis.

Records vary from country to country, however the general formulae used is derived from the following key factors:

Estimates of incidence combined with assumptions about the duration of the disease. 

The duration of the disease is assumed to vary in accordance with whether or not the disease is “smear-positive and whether or not the individual receives treatment in a DOTS programme or in a non DOTS programme or is not treated all; and finally

Whether or not the individual is infected with HIV[36]

According to the WHO, nearly two billion people; about one-third of the world’s population, are infected with TB.[37]

In developed regions of the world such as the United Kingdom (UK) and the United States of America (USA), the prevalence levels are much lower than those recorded in high risk regions of the developing world.

Statistic records rendered in 2003 from the Department of Health within the UK suggests the following:

· 42 years was the mean age of patients hospitalised with Tuberculosis in England between 2002-2003

· 69% of hospitalisations for Tuberculosis was for 15-59 year olds in England between 2002-2003

· 10% of hospitalisations for Tuberculosis was for over 75 year olds in England between 2002-2003.[38]

The goal for Tuberculosis elimination in the United States of America (USA) is a TB disease incidence of less than 1 per million US population by 2010. This requires that the Latent TB Infection (LTBI) prevalence level should be less than 1% and decreasing by 2010. 

Current prevalence rate levels of Tuberculosis in the United States are between 10 and 15 million people. In 1998, a total of 18,371 active TB cases were recorded in all 50 states and the District of Columbia[39]

A comparison level of statistical studies in the prevalence levels of patients between 1999-2000 was compared to those of patient’s way back in 1971-1972 and the results were as follows:

LTBI prevalence was 4.2% with an estimated 11,213,000 individuals diagnosed with LTBI

Amongst 25 – 74 year olds, prevalence decreased from 14.3% in 1971-1972 to 5.7% in 1999-2000

Higher prevalence’s were seen in the foreign borns which accounting for 18.7%, non Hispanic blacks and African Americans accounted for 7.0%, Mexican Americans accounted for 9.4% and individuals living in poverty accounted for 6.1%

A total of 63% of LTBI was among the foreign born

A total of 25.5% of persons with LTBI had previously been diagnosed as having LTBI or TB; and

Only 13.2% had been prescribed treatment[40]

The chart below; as well as that in “the annex”, shows the level of new TB cases per 100,000 population and that of prevalence levels in HIV+ people worldwide for the year 2007.[41]

1.6 How Rapid Does TB Spread In Nigeria?:

Part of the Federal Governments programme in curbing the spread has been initiated through the National TB and Leprosy Control Programme (NTBLCP) which is seeking to achieve a 70% TB detection rate and an 85% cure rate by the end of 2010

The programme also aims to ensure that TB patients receive adequate drugs and comply with the slated 8 months period of treatment. 

Mr Omoniyi Fadare; an NTBLCP Programme Officer is quoted to have said in 2005 that the DOTS programme was being implemented in 584 out of 774 local government areas with the country recording between 700,000 to 1 million TB cases annually out of which 105,000 are TB related deaths.[42]

Ideally, the spread of TB should be less bearing in mind that the Nigerian Government has implemented the DOTS strategy in all antiretroviral treatment centres nationwide in an effort to control the spread of Tuberculosis.. 

However, this is not the case as in 2009 the rate of prevalence had risen to over 1.2 million with an annual mortality rate of 150,000. These statistics question the reasons behind the spread of TB in Nigeria.

The spread of TB is made rampant through factors such as poverty and outdated testing equipment which contribute to Nigeria’s high TB prevalence. The lack of awareness, early detection and failure to render immediate treatment are also key factors to the spread of TB in Nigeria as corroborated by Dan Onwujekwe; a Senior Fellow of the Lagos based Nigerian Institute of Medical Research.[43]

A recent study carried out by the Nigerian Institute of Medical Research (NIMR) in 2007 found out that of the 620 HIV/AIDS patients surveyed in June and July, 2006, about 160 had TB without knowing they did have the disease.[44] Other factors which contribute to the growing spread of the disease include:

The lack of sufficient drugs and clinics within close proximity of affected regions has heightens the spread of the disease as infected persons and those willing to undergo medical check ups are discouraged from seeking help.

Poor laboratory infrastructure needed for testing as well as insufficient man power also plague the success and undermine the effective implementation of the TB control activities. Also worthy of note is limited funding for TB control efforts from the Federal and Sate government authorities.

The failure on the part of the authorities stalls the programmes ability to execute necessary activities when due. The issue of funding is a paradoxical point as it points also to issues of embezzlement and corruption that has plagued the country over several decades of mismanagement. The DOTS programme and TB drugs are relatively cheap and free to the public and yet with adequate funding from NGO’s and governments like the EU and the United States; as indicated in the diagram below[45], the problem of funding still remains a key factor that continues to fuel the spread of the disease.

1.7 Aim:

The aim of this study (dissertation) is:

· To provide an insight into the terminal disease of Tuberculosis on an International and national level

· To evaluate DOTS implementation in Nigeria using a series of case detection and treatment outcomes as indicators

· To analyse and evaluate the resulting consequences of the DOTS programme in Nigeria within the 21st century and see if its adoption has favoured a positive control of TB over the years

1.8 Obejetive:

The following are the objectives of this study (dissertation):

· To evaluate case detection rates of smear-positive TB cases in selected areas implementing the DOTS programme within Nigeria

· To evaluate case detection rates of all TB cases notified in Nigeria within the 21st century

· To compare Nigerian experiences, failures and progresses to other developing nations and developed countries of the world affected by TB

· To identify potential weaknesses, strengths and developments in the DOTS programme in Nigeria

· To create, deliver and analyse a survey on the Nigerian public on the implementation of DOTS in Nigeria within selective states and compare the resulting outcomes with available data

1.9 Research Question:

Research questions will be focussed on whether or not the DOTS programme has achieved its object and mandate of reducing the rate of TB infection in Nigeria.

Whether or not the target of 2015 by the WHO is a realistic target that can be met by Nigeria?

Whether or not Nigeria has made progress over the years with the amount of funding hey have had and the exposure the healthcare system has had to curb the growing threat of TB in the country

Whether factors such as cultural, religious, economic and social elements are the cause of the drawback in the successful implementation of the DOTS programme in Nigeria?

Chapter Two

2.0 The Federal Republic of Nigeria:

Nigeria is located in Western Africa on the Gulf of Guinea and occupies a total area of 923,768 km² making it the 32nd largest country in the world.[46] It is comparable in size to the South American country of Venezuela and is about twice the size of the State of California in the United States of America.[47] It is bordered by Benin in the West, Niger in the North, Chad in the North West, Cameroon in the East and has a coastline of at least 853 km with the Atlantic ocean.[48]

The countrys climatic regions are broken down into three categories – the far south which is defined by tropical rainforest climate with annual rainfall of between 60 to 80 inches per annum, the far north where majority of the TB epidemics and polio incidences have been recorded is defined by its almost desert-like climate where rain fall records are set at less than 20 inches per annum and finally the rest of the countrys region between the far south and far north is characteristic of the savanah grove land with annual rainfalls of between 20 to 60 inches.[49]

The country has over 250 ethnic group divisions.[50] The main tribes are the Hausa’s in the Nothern part of the country where majoriy of the TB pandemic is recorded, the Yoruba’s in the Southern part of the country known for is thick mangrove swambs and malaria manifestation and the Igbo’s in the Eastern part of the country where majority of the nations oil explorations and severe environmental degredation & oil spilllages are found.[51]

In a country ranked as the 8th most populous country in the world, the United Nations (UN) estimated Nigeria’s population at 131,530,000 in 2004.[52] The latest censors in Nigeria in 2006 put the countrys population at 150 million; that is almost 3 times the population of the United Kingdom in an area mass of about less than half the size of Nigeria. It is estimated that by 2050, Nigeria will be one of those countries in the world; like China, India and Brazil, that account for majority of the world’s population.[53] It is indeed a statistical nightmare when one considers that most of the world’s current populous nations are amongs the 22 nations in the DOTS programme.

Nigeria as a confederation of states is divided into thirty six (36) states and one Federal Capital Territory (Abuja) which are further divided into 774 LGA’s.[54] This gives you an idea of the logistical difficulties and task ahead of the DOTS programme in curbing a disease that is catalysed by such vices as poor sanitary conditions and tightly spaced housing plans.

Nigeria has six major cities with a population of over 1 million people. They are the cities of Lagos, Kano, Ibadan, Kaduna, Port Harcourt and Benin City.[55] The city of Lagos alone accounts for 8 million people[56]; a region of about the size of Cardiff. This demography and health hazards surrounding a region in comparision to the capital of Wales which accounts for only 2.9 milion citizens. A map of the region showing its states and geographical lo