How machine shortage slows down Nigeria’s fight against TB

Nigeria grapples with the highest prevalence of Tuberculosis (TB) in Africa with an estimated total of 479,000 cases in 2022. Yet, the inadequacy of a revolutionary diagnostic tool impedes the nation’s fight against this infectious disease, ALFRED OLUFEMI reports.

At the crack of dawn every morning, Mver Foga, a 56-year-old farmer from Agasha, an agrarian community in Nigeria’s Benue State, embarks on an arduous journey to his cherished farmland.

On some days, he navigates the rugged terrain on foot, while on others, he mounts his trusty old motorcycle.

However, this routine that caters to a family of six was disrupted when Mr Foga began falling ill repeatedly in January 2022. It all started with a dry cough.

At the initial stage, he purchased flu medication from a nearby drug store, hoping the cough would disappear with time. But instead, it worsened, leading to frequent bouts of illness that made him stay away from farming.

The mysterious cough was later identified as a symptom of the infectious disease, tuberculosis (TB) when Mr Foga was tested two months later that same year.

Mr Foga had his sputum sample collected during a TB testing drive held in March 2022, a World TB awareness month.

According to him, some health workers visited the Agasha Comprehensive Health Centre in Guma Local Government Area, where many residents were screened for TB.

“I heard about it and presented myself for the test at the health centre. That was where they tested me and diagnosed me with Tuberculosis; they told me it was the reason I have been coughing,” Mr Foga said.

The health workers who took his sample suspected he was infected, but they had to send the sample to the state capital in Makurdi for a confirmation test and it came back positive.

“I had to make sure that all my family members got tested also. Thank God I was the only one who had it,” he added.

Following a positive diagnosis, Mr Foga underwent a six-month treatment plan, which he completed later in 2022.

“I started the treatment in March and completed it in September. Altogether, it took me six months. I’m very well now,” he said in July (2023), breathing a sigh of relief.

Deadly disease

The early detection and subsequent treatment plan cured Mr Foga of a disease that could have killed him or left him maimed.

Tuberculosis, caused by a bacterium called Mycobacterium tuberculosis, is spread by airborne transmission. While its primary impact is first on the lungs, it can also target other vital organs like the brain, kidneys, or spine if not treated early enough.

According to the Center for Disease and Prevention (CDC), tuberculosis is curable; but without proper treatment, it can be fatal for those affected.

The World Health Organization (WHO) described the infectious disease as one of the world’s deadliest infectious killers, causing 1.6 million deaths each year and affecting millions more.

Nigeria ranks first in Africa and sixth in the world, accounting for about 4.6 per cent of the global TB burden, according to the global body.

Introduction of advanced diagnostic tool

The World Health Organization in 2010 recommended the use of rapid molecular diagnostic tests as the initial diagnostic test in all persons with signs and symptoms of TB.

“These have high diagnostic accuracy and will lead to major improvements in the early detection of TB and drug-resistant TB,” the organisation’s media advisory read.

One of the rapid tests recommended is the Xpert MTB/RIF, a Nucleic Acid Amplification (NAA) test that uses a disposable cartridge with the GeneXpert machine, a technology developed by Cepheid, an American molecular diagnostic company.

To conduct the test, a sputum sample is collected from a suspected TB patient and mixed with a reagent. A cartridge containing this mixture will then be placed in the GeneXpert machine.

At this point, the process is automated and the result can be obtained in about two hours as against conventional methods such as microscopic examination and chest X-ray that may take weeks.

GeneXpert shortage in Nigeria

This revolutionary technology, Xpert MTB/RIF was first introduced to Nigeria in 2011 through a collaboration between WHO and KNCV Tuberculosis Foundation and some were installed in eight health facilities.

By 2016, Nigeria’s federal ministry of health had fully adopted the use of the technology alongside the conventional methods and the plan was to have at least one machine in each of the 774 local government areas.

However, seven years later, this goal has remained unmet.

The National Coordinator for the National Tuberculosis and Leprosy Control Programme, Chukwuma Anyaike, in an interview with this reporter, noted that there are currently 503 GeneXpert machines across the country but recognises the existing gap of over 250 machines.

“Our plan is to have at least one in every of the 774 local government areas,” he said.

He then urged the federal government to provide adequate funding for the purchase of more machines to make the target a reality.

The Director of Technical Programmes at KNCV Tuberculosis Foundation, Sani Useni, stated that the shortage poses a significant challenge to the country’s testing targets.

“Going by the estimate of the country, if you look at Nigeria’s population, we are expected to detect at least 219 cases in 100,000 population.”

“As long as these machines are not available across the LGA’s where a client can conveniently access them, the numbers of persons who are presumed to have TB will not be detected and by extension, the backlog (body of people) who are transmitting the diseases to the communities will not reduce.”

He added that this situation puts communities at risk as many infected individuals like Mr Foga could unknowingly spread the disease.

“For persons who are not found, detected and put on appropriate treatment, this will result in at least 15 to 20 people being infected in a year,” Mr Useni noted.

The case of Benue State

Benue State, where Mr Foga resides, is one of the states in Nigeria, with a high TB prevalence, exacerbated by a high rate of HIV/AIDS.

In 2021, over 40,000 residents of the state were at risk of contracting TB, according to the former Programme Manager for Tuberculosis and Leprosy Control in the state, Igbabul Ishember.

He also revealed that between 2020 to 2022, more than 10,500 people diagnosed with TB in Benue State were placed on a six to twelve-month treatment plan.

However, in many places in Benue, especially rural areas, GeneXpert machines are not readily available for TB testing. Suspected patients are often directed to distant health facilities for testing.

Unlike Mr Foga who had his sputum collected during the testing drive campaign, 27-year-old Joseph Edache had to travel 30 kilometres to get tested.

Mr Edache, a resident of Ojali community in Ohimini Local Government Area (LGA) of the state, was suspected to have been infected but had his sputum collected in a health facility in Idakpe, the headquarters of his LGA.

“At the health centre, I met a nurse who carried out my registration and educated me on how to take the drug – firstly, four tablets a day for two months. Then, I was told to go for another test which I did at my local government headquarters in Idekpa, Ohimini LGA.”

Seven LGAs without GeneXpert

The Programme Manager of the Benue State Tuberculosis and Leprosy Control Programme, Terrence Akighir, in an interview with this reporter, said there are currently 28 GeneXpert machines distributed across 16 out of the 23 LGAs of the state.

He said the distribution was informed by the burden of tuberculosis in the different areas of the state.

“So, some places have two (machines) while others have one and others none at all. It was based on the burden where TB was commonly diagnosed.”

According to the official, seven of the LGAs without the GeneXpert machine include Apa, Ogbadigbo, Agatu, Ado, Guma, Ohimini and Obi.

While he explained that those LGAs had had fewer or no cases in the past, he admitted there is a dire need for them to have the GeneXpert, considering the prevalence and spread of the disease.

”As I told you, TB can be spread,” he said. “Supposing (sic) somebody has TB, he can go to church, sneeze and then release the TB germ in the church so two or three people might pick it up, take it home and like that it will start spreading. Maybe they were not looking for them in those places but now we are getting them so there is a need for those LGAs to have GeneXpert machines.”

The traditional head of Ohimini community, John Ochayi, also emphasised the need for GeneXpert machines in his community, citing how communal living exposes residents to a higher risk of infection.

“At the subclinical level, there is a high prevalence rate of TB and the presence of not testing with high sensitivity machines; some of my people may have it without knowing. We need this machine in Ohimini LGA so it will be easier to pick up cases of infection,” he said.

Urban Health Centres experience surge in visits

Findings by this reporter showed that in certain local government areas, mostly urban, where GeneXpert machines are present, they are often installed within a healthcare facility. As a result, these facilities experience a surge in the number of visitors.

For instance, in Makurdi local government, the state capital, the machines are found in Benue State University Teaching Hospital (BSUTH), Federal Medical Centre (FMC), Nigerian Air Force (NAF) hospital and Bishop Murray Medical Centre.

When this reporter visited FMC’s AIDS Prevention clinic, many suspected TB patients were observed taking turns to be attended to.

The clinic days, according to staff, are scheduled for Mondays, Wednesdays and Fridays.

A staff member, who asked to remain anonymous because he is not authorised to grant interviews, said the clinic serves a minimum of 100 patients per clinic day, with most being diagnosed with TB using the GeneXpert machines.

A medical officer at the facility, Ode Michael, also told this reporter that the clinic records an average of 20 TB cases monthly.

“It’s alarming but this is a federal medical centre. It’s a tertiary institution, not just what you see in town (sic). Some people come from far places and neighbouring states on referrals, so that’s one of the reasons we have such numbers. As we are having new cases, we are also getting some treated and discharged.”

He, however, mentioned that not all the people seen by the reporter are new cases. “Some are coming for their drugs and some for follow-up after treatment,” he said.

Commenting on the situation in Benue, Mr Useni, the KNCV Tuberculosis Foundation director, advocated for more GeneXpert machines and in the interim, an effective linkage system that connects the people to the existing ones.

“Definitely there’s a need to access GeneXpert machines across the state. A number of machines may not be appropriate but when you come to individual local governments it becomes very obvious,” he said.

“The linkage mechanism should be such that if the person cannot access GeneXpert machine there has to be that specimen transport system for clients that are presumed to have TB. Once they’ve produced their specimen, state and local Government personnel can create that support where specimens can be transported.”

Despite the high prevalence of HIV in Benue, Mr Useni believes that if the system is enhanced, people will have access to quality diagnoses and will be put on the right course of treatment.

This work was produced with the support of the Africa-China Reporting Project at the Wits Centre for Journalism, University of the Witwatersrand, Johannesburg, South Africa. The opinions held are of the author(s).