By Onche Odeh

The overwhelming attention being given to COVID-19 interventions may have worsened the situation of Tuberculosis (TB) in Nigeria, raising fears that recent gains made on TB control are being lost.

The concern comes on the heels of the gory TB statistics in the country.

Nigeria currently has the highest tuberculosis burden in Africa and is among the 30 countries with the highest burden globally. The situation may have worsened within the last one year as the country battles to control the COVID-19 pandemic.

Executive Secretary, Stop TB Partnership programme in Nigeria, Mr Mayowa Joel  reveals that a modeling study done by the organisation shows that COVID has negatively impacted on the goal to achieve the Stop TB.

“It has really set us back many years,” Joel told AfricaSTI.

“It has also affected resources for TB intervention. Resources for TB have not been enough. With COVID, it has further reduced the available resources,” he added.

In 2019, Nigeria needed 278 million for TB interventions. Of this, the government provided 8%, while donor agencies and development partners provided 32%, leaving a 60% resource gap. There was a major resource challenge for TB interventions in Nigeria.

Some other challenges also came with the intervention strategies used for curbing the pandemic.

Giving credence to this, Joel told AfricaSTI that “The lockdown really disrupted the treatment for most TB patients who are on the Directly Observed Treatment Short-course (DOTS) in Nigeria, and case finding and diagnosis were hardly done or done skeletally within the period, transportation for TB patients to access their drugs was difficult,” adding that it was even worse for patients with drug resistant TB.

This, according to him represents one of the negative impacts of COVID-19 and the skewed attention it has received leading to morbidity and mortality among TB patients in the country.

Available records have shown that, in Nigeria not less than 18 people die from TB every hour. This translates to over 432 deaths per day from the highly infectious disease.

The lockdown is over. But a new wave of COVID-19 has hit Nigeria. This, according to Joel has also come with its own challenges.

“Right now there is no lockdown. So TB patients are able to access their treatment services. But the effect on TB is that the symptoms are very similar. Many cases of people coughing are treated as COVID-19,” he told AfricaSTI.

“It has also affected resources for TB intervention. Resources for TB have not been enough. With COVID, it has further reduced the available resources,” he said.

In 2019, Nigeria needed 278 million for TB interventions. Of this, the government provided 8%, while donor agencies and development partners provided 32%, leaving a 60% resource gap. There was a major resource challenge for TB interventions in Nigeria.

Further challenges that came with the intervention strategies used for curbing the pandemic include disruption in access to TB treatment and other logistic issues.

“The lockdown really disrupted the treatment for most TB patients who are on the Directly Observed Treatment Short-course (DOTS) in Nigeria, and case finding and diagnosis were hardly done or done skeletally within the period, transportation for TB patients to access their drugs was difficult,” Joel told AfricaSTI.

He said “It was even worse for patients with drug resistant TB.”

                                      Dr Odubanjo

Public Health Physician and Past Chair, Association of Public Health Physicians of Nigeria (Lagos), Dr Doyin Odubanjo who lent credence to Joel’s position said COVID-19 and TB are two distinct diseases with some common symptoms, a reason many cases of TB are either lost or mismanaged in recent times across the country.

“In terms of presentation, the two are not really the same. One (COVID) is a one-time thing; the other (TB) is a long term problem that has been there for a while,” Dr Odubanjo, who is also Executive Secretary, Nigeria Academy of Science (NAS) told AfricaSTI.

Explaining further, he said “Any respiratory disease now is big risk. The moment somebody presents with a cough in any hospital these days, such a person is asked to go get tested for COVID first before being attended. Chances are that the person with such condition would not get the treatment attention on time and may die.”

Commenting on reports of health facilities in Nigeria that would insist that a patient who has coughs and other symptoms similar to COVID-19 do a COVID test before being attended to, Dr Odubanjo said, “There is nothing wrong in asking a patient to go for COVID-19. What is wrong is that, in a country where most people live under one US dollar per day, asking someone to go and do a test that would cost them 50 thousand naira would mean losing such a person.”

“The implication is that we are going to be losing time and patients. The target is for quick diagnosis and a situation whereby a person is given timely intervention in a case where TB is suspected and to commence treatment as soon as possible,” he said.

Stating it succinctly, Dr Odubanjo said, “COVID-19 testing has become a barrier to access to healthcare, especially for TB patients.”

Stop TB Nigeria’s Joel used the scenario during the lockdown to depict the broader consequence of COVID testing on access to TB services in Nigeria.

He said, “During the peak of the COVID-19 pandemic, many people with TB were afraid of going to health facilities. People were just at home coughing and passing the infection because they could not access the health facilities This increased the prevalence of people with TB, especially the cases of Drug Resistant TB.”

Dr Odubanjo also shares similar views as Joel’s.

He said, “TB progress made in Nigeria is being reversed. Everything is being disrupted by COVID. What that means is that many of the diseases that are supposed to be halted early are going to become more difficult to handle. Accessing specific treatment for these disease may be delayed, that is if the person seeking them is not dead yet. We are losing grounds on many diseases including TB.”

The Nigerian government recently announced that it will be deploying 300 GeneXpert machines in the country to scale-up COVID-19 diagnosis. Projections are that this will have a negative impact on basic and essential TB control efforts, including routine diagnosis of TB cases and treatment monitoring.

Joel, however, sees a line of opportunity to bridge the increasing TB intervention gap in this.

“This could be a positive if the officers of the National Tb and Leprosy Control Programme of Nigeria and the COVID intervention team would realize that you don’t rob Peter to pay Paul. The GeneXpert machines were originally meant for TB diagnosis. Hence if you want to use them for COVID diagnosis, you don’t downplay TB for which it was originally meant for.  It can be used for both. This is potential positive especially in terms of diagnosis.”

Toyin Togun, Assistant Professor and Co-Director of The TB Centre, and colleagues at the Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), London, UK and UCL Centre for Clinical Microbiology, Royal Free Campus, University College London, London, UK and Respiratory, Division of Medicine, University College London,  in an article published in May 2020 edition of the Journal of clinical Immunology – Annals of Clinical Microbiology and Antimicrobials anticipated the impact of the COVID-19 pandemic on TB patients and TB control programmes.

Writing on the interactions between COVID-19 and TB, which still ranks as the leading cause of death from a single infectious disease globally, they projected that there may be grave consequences for existing and undiagnosed TB patients globally, particularly in low and middle income countries (LMICs) where TB is endemic and health services poorly equipped.

“TB control programmes will be strained due to diversion of resources, and an inevitable loss of health system focus, such that some activities cannot or will not be prioritised. This is likely to lead to a reduction in quality of TB care and worse outcomes,” Togun and colleagues wrote.

The World Health Organisation (WHO) has also warned that an additional 1.4 million TB deaths could be registered globally as direct consequence of the COVID-19 pandemic Between 2020 and 2025.

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