Analysis of the DOTS Programme in Nigeria

Analysis of the DOTS Programme in NigeriaChapter One1.0Introduction to TBCharacteristics of terabyte tebibyte is a distemper caused by the bacteria cognise as Mycobacterium tuberculosis.1 Mycobacterium tuberculosis was identified in 1882 by Robert Koch.2 It is an acid-fast boron and obligate aerobe which grows in intimately 15 to 30 days at atemperature of 35 to 37 degrees centigrade in an enriched media with a mode treadly acid bagful medium.It has no natural reservoir and its antigenic decorousties are similar to the leprosy bacillus, the Bacille Calmette-Guerin (BCG) and other typical types of mycobacterium3.M. tuberculosis is pathogenic and virulent in nature. Its ability to cause disease depends on the susceptibility of the server as well as the aggressiveness of the invading organism4 . An electron s evict of the bacterium is highlighted below5Considered one of the most dreaded diseases of the nineteenth and 20th centuries, TB was the 8th leading cause of death in ch ildren between the ages of 1 to 4 years old during the proterozoic 1920s oddly in the developed countries of the globe like the United States and Britain.As the general standards of upkeep improved in the industrialised nations of the world so too did the counterbalance in TB related incidences.TB is a lot classed by the infection of one of the ii variants of the tubercle bacillus which is known to commonly affect man. They are Mycobacerium tuberculosis and bovis6.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 take out are rare and few and far between7.TB can take an active and an still state of infection. The Word Health Organisation (WHO) describes an active elusion of TB as a symptomatic disease due to infection with Mycobacterium tuberculosis8.TB cases are generally classified as each pulmonary or extra-pulmonary.Patients wit h pulmonary TB are further sub-divided into smear-positive and smear-negative cases9. Smear-positive cases are the most important sub-groups for control architectural plans as they are the source of infection.The WHO has be a smear-positive patient asA patient with at least(prenominal) two sputum warnings positive for acid-fast bacilli (AFB) by microscopyA 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 outlined by the WHO asA 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 chemotherapyA patient with a least one sputum specimen negative for AFB, which is culture-positive for M. Tuberculosis and finallyExtra-pulmonary tuberculosis is defined by the WHO asA 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 chemotherapy101.10Mode of TransmissionThe transmittance of Tuberculosis is done mainly with droplet infection and droplet nuclei which is said to be generated when a patient with tuberculosis coughs11.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.1.11Signs SymptomsThe element of signs and symptoms in Tuberculosis is often misleading in the sense that the mankind body may harbour the bacterium that causes tuberculosis, and the immune system in the body suppresses the resultant ef fect 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 TBLatent TB is a condition where the patient has a TB infection further 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.12The state of active TB develops some uncontaminating signs and symptoms in its diagnosis and they includeChills and cold spellsFatigueFeverLoss of AppetiteNight SweatsUnexplained weight loss13Medical evidence has shown that there are variable degrees of Tuberculosis depending on which part of the pitying body it affects. Tuberculosis often attacks the lungs and its signs and symptoms includeCoughing that laughs for three weeks or moreCoughing up seamChest pain or pain resulting from breathing or coughing14Tuberculosis 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 patients urine whilst Tuberculosis of the spine shows cases of back pain.1.12 pensiveness Periodssource http//www.aarogya.com/ indicator.php?option=com_content caper=viewid=834Itemid=8531.2Public Health ImportanceStandard of Living State of Health In NigeriaThe United Nations Human organic evolution (UNDP) programme has through the early 1990s paid greater emphasis in human development, welfare and p everyplacety research.Through its Human Development Report, it has published the Human Development Index (HDI) which looks beyond GDP to a broader definition of a nations well-being. The link in welfare is a determinant index to wellness conditions, well being of persons and an insight onto t heir susceptibility and immunity to disease infection15.The sparing condition of a nation is a guiding factor to exploitation, development and aliveness standards of a nations citizen. The assumption that a citizen who is paid more per capita has his or her standard of living higher(prenominal) 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, ugly standard of governance coupled with a dilapidated health care system has seen a decline in its overall standard of living.16The 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 charter poorer living standards which trigger health concerns17.The Human Development Index (HDI) provides a composite measure of three di mensions of human development. These reachs includeLiving a long and healthy life which is measured through life expectancyThe level and degree of education and literacy of nations 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 acquire power parity (PPP) and income base analysis.18Critics of the mold build 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 much(prenominal) as gender or income inequality or other indicators such(prenominal)(prenominal) 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 Nigerias context, this index measures the bu colics standard of living and state of health by comparing certain rouge sectors such as life expectancy rate and adult literacy rates.The map below gives a unique view to Nigerias position. In this chart, Nigeria has been class-conscious 158th out of 177 amongst the developing nations of the world with an HDI rating of 0.470.19The evaluation of a standard of living is relative, depending upon the belief of the observer as to what constitutes a high or a low scale. Another relative index to the standard of living of a certain economical group can be gathered from a comparison of the cost of living and the wage scale or personal income. Factors such as discretional income are important, but standard of living includes not only the material articles of consumption but also the modus operandi of dependents in a family, the environment, the educational opportunities, and the amount spent for health, recreation, and cordial operate.Nigeria as a nation has a GDP range of 6.4 as a t 200820 and the number of dependants transfer within the existences in the northern sulfurern 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 person 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 realms21. 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 sta ndard of living may vary greatly among various groups within the country, it also varies from nation to nation, and international comparisons are somemagazines 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 ask a higher standard of living than developing countries. Nigeria is no exception to this theory.Records retain 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 1990s 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 ruinous decline in the first half of the 1990s but have recovered and improved their standard of living.22The major exception is sub-Saharan Africa in areas such as Niger, Togo, Cameroon an d 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 ruinous effect of human immunodeficiency virus/AIDS on life expectancy.23Poverty is the major consequence of the dilapidated and chronic misadventure in Nigerias healthcare and hearty service system.24 The access to standard resources such as good education, improved water supply, good nutritional standards and adequate shelter provisions has dedicateed 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 worlds TB infections are found in impoverished and developing nations with a poor level of standard of living and health concerns.1.3Housing and Poor SanitationNigeria especially Lago s 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 political science are responsible for things like planning permission needed before erecting structures. Nigerias 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 performance, 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 specifyd by housing in the urban centres. The only resultant factor are the culminating effect and produce 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 rearing in the region.Take for example the pairingern 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 provided no room for cross ventilation, proper drainage or sewage facility26. 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.27Average Annual Growth RatePopulation (Millions)1960-19801980-2000196019802000%%Africa31771904.74.6Studies 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 replace in social, economic and technological development28The economic down town in the early 1980s saw a break in the level of growth and development with the nations economy to that of its population boom29.The miss of proper adequate public infrastructure and social services has suffered tremendously and this has affected the process and level of urban pla nning and zoning in many cases.A practical example of this can be seen in the newly created Nigerian dandy 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.1.4Housing and PovertyThe 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 investiture 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.T he existing urban services are overstrained which often times lead to center collapse.A large proportion of the population does not have reasonable access to safe and ample water supply, and neither do they have the content 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 uses3 0.Studies over the years have shown the deplorable conditions of urban housing in Nigeria. They affirm that 75% of the dwelling units in Nigerias urban centres are substandard and the dwellings are sited in slums31.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.thither 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.32The Unit ed Nations Standard for Nigerias room moving in 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.33However, 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.1.5Prevalence of TBThe 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.34A 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 nigh 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 factorsEstimates of incidence combined with assumptions about the duration of the disease. The duration of the disease is assumed to vary in consistency 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 finallyWhether or not the individual is infected with HIV36According to the WHO, nearly two billion people about ternary of the worlds population, are infected with TB.37In 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 following42 years was the implicate age of patients hospitalised with Tuberculosis in England between 2002-200369% of hospitalisations for Tuberculosis was for 15-59 year olds in England between 2002-200310% of hospitalisations for Tuberculosis was for over 75 year olds in England betw een 2002-2003.38The 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 Columbia39A comparison level of statistical studies in the prevalence levels of patients between 1999-2000 was correspondd to those of patients way back in 1971-1972 and the results were as followsLTBI prevalence was 4.2% with an estimated 11,213,000 individuals diagnosed with LTBIAmongst 25 74 year olds, prevalence decreased from 14.3% in 1971-1972 to 5.7% in 1999-2000Higher prevalences were seen in the foreign borns which business relationship 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 bornA total of 25.5% of persons with LTBI had previously been diagnosed as having LTBI or TB andOnly 13.2% had been prescribed treatment40The 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 2007.411.6How Rapid Does TB Spread In Nigeria?Part of the Federal Governments programme in keep back the spread has been initiated through the National TB and Leprosy Control Programme (NTBLCP) which is quest to achieve a 70% TB detection rate and an 85% bring around rate by the end of 2010The 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 implement 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.42Ideally, 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 Nigerias 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.43A recent study car ried 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.44Other factors which contribute to the growing spread of the disease includeThe lack of fitted 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 break 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 nongovernmental organizations and governments like the EU and the United States as indicated in the diagram below45, the problem of funding still remains a key factor that continues to furnish the spread of the disease.1.7AimThe aim of this study (dissertation) isTo provide an insight into the terminal disease of Tuberculosis on an International and national levelTo evaluate DOTS implementation in Nigeria using a series of case detection and treatment outcomes as indicatorsTo dismember and evaluate the resulting consequences of the DOTS programme in Nigeria within the 21st snow and see if its adoption has favoured a positive control of TB over the years1.8ObejetiveThe following are the objectives of this study (dissertation)To evaluate case detection rates of smear-positive TB cases in sel ected areas implementing the DOTS programme within NigeriaTo evaluate case detection rates of all TB cases notified in Nigeria within the 21st centuryTo compare Nigerian experiences, failures and progresses to other developing nations and developed countries of the world affected by TBTo identify potential weaknesses, strengths and developments in the DOTS programme in NigeriaTo 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 data1.9Research headResearch 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 threa t of TB in the countryWhether 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 Two2.0The Federal Republic of NigeriaNigeria is located in westward Africa on the Gulf of Guinea and occupies a total area of 923,768 km 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 853km with the Atlantic ocean.48The 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 de fined 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.49The country has over 250 ethnical group divisions.50 The main tribes are the Hausas in the Nothern part of the country where majoriy of the TB pandemic is recorded, the Yorubas in the Southern part of the country known for is thick mangrove swambs and malaria manifestation and the Igbos in the Eastern part of the country where majority of the nations oil explorations and severe environmental degredation oil spilllages are found.51In a country ranked as the 8th most populous country in the world, the United Nations (UN) estimated Nigerias population at 131,530,000 in 2004.52 The modish censors in Nigeria in 2006 put the countrys population at 150 million that is almost 3 times the population of the United K ingdom 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 worlds population.53 It is indeed a statistical nightmare when one considers that most of the worlds current populous nations are amongs the 22 nations in the DOTS programme.Nigeria as a confederation of states is divided into thirty vi (36) states and one Federal Capital Territory (Abuja) which are further divided into 774 LGAs.54This 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.55The city of Lagos alone accounts for 8 million people56 a region of about the size of Car diff. 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