Q & A With the Executive Director DR. BETHRAND ODUME

1.Which initiatives, programs, or collaborations would you say made a notable impact on TB prevention, diagnosis, or treatment this year?

This year, two impactful interventions have significantly contributed to advancing TB prevention, diagnosis, and treatment. The first intervention is the use of the portable digital x-ray (PDX) with an Artificial Intelligence (CAD4TB AI) software for targeted TB case finding. Deployed directly to remote communities and hard to reach areas, this technology has not only reduced the cost of x-rays for TB screening /diagnosis but also minimized transportation time and expenses incurred by patients thus significantly enhancing access to TB services.

The second is the XMAP, a mobile application deployed by KNCV Nigeria with Instant Health Services that is revolutionizing digital chest x-ray reporting and result transmission. This innovation enables seamless communication between radiographers conducting CXR screening in remote communities and radiologists/clinicians. Especially in hard-to-reach areas, where CXR screening is utilized for on-the-spot pre-diagnostic screening of most at risk populations (MARPS), the XMAP facilitates prompt interpretation of CXR results, optimizing clinical diagnosis and ensuring swift linkage to care and treatment for presumptive TB cases.

2. Among the challenges faced by KNCV Nigeria in addressing TB in 2023, which will you say presented the most learning points?

The TB notification gap has been a persistent challenge in Nigeria, and the TB LON regions 1 & 2 project is being implemented to primarily address this across 14 states. One of the implementing states is Anambra, in the south-south region of the country. The strategic placement of a TB LAMP diagnostic platform at PHC Omor in Ayamelum LGA in Anambra state has significantly contributed to learning points. Previously, patients faced a considerable challenge as they were referred to GH Umuere in Anambra East LGA, a journey of about 1 hour and 45 minutes on challenging terrain.

The project identified PHC Omor as a site with untapped potential for case finding but lacking in TB testing capacity. In Q1 2023, the facility reported no presumptive TB cases. However, after thorough engagement and staff re-sensitization, 84 presumptive TB cases were identified in April and May 2023. Following the placement of a TB LAMP platform in June 2023, the facility, in the same month, identified 192 presumptive TB cases, confirming 26 TB cases. This experience showcases a critical learning point that TB cases often exist in areas without adequate TB testing services. To address this, bringing TB testing services closer to distant communities, coupled with a strategic site selection process, is vital to ensuring optimal performance and to mitigate leakages from referrals and challenges associated with transportation.

3. In the course of programme implementation for 2023, what gap presented an opportunity for intervention to end TB?

During the implementation of the program in 2023, a notable gap that presented a significant opportunity for TB intervention was identified through the periodic congregation at NYSC orientation camps. Recognizing the potential to actively screen seemingly healthy adults in these communities, the TB LON 1&2 team, guided by USAID Nigeria, employed various strategies, including WoW & WoK-driven diagnostic platforms, to execute a comprehensive TB screening campaign across the 14 supported states, specifically targeting the Batch B NYSC stream camp locations for 2023.

This initiative proved impactful, with 96% of the 7,638 individuals in attendance being screened, resulting in the identification of 449 presumptive TB cases (presumptive yield of 6%). Through this effort, 17 TB clients were diagnosed, including 56% bacteriologically confirmed cases and 1 DR-TB case. All diagnosed TB clients have been successfully linked to treatment. The key lesson learned is that TB can manifest even among the young, educated, and seemingly healthy individuals in their prime, such as members of the NYSC corps, challenging conventional determinants of TB. Moreover, the persistent gap in low TB awareness highlights the need for intensified efforts in mitigation, emphasizing the importance of routinizing TB screening across various congregate settings to effectively break the chain of transmission.

4. How differently did KNCV Nigeria engage with local communities and stakeholders to raise awareness about TB, improve access to healthcare, and reduce stigma associated with the disease?

We worked collaboratively with Breakthrough Action Nigeria (BAN) in the states we are collocated alongside the State TB programs to engage community leaders buy in. Our efforts at increasing community awareness and TB service demand creation continued across the 14 supported states, with the second largest contribution of persons sensitized and screened for TB (3,519,155) across all interventions. With a presumptive yield of 7.5% in FY23, almost all presumptive TB accessed diagnostic services (95.6%). Over the quarters, the project observed a progressive trend in TB yield from 3.4% in Q1 to 5.2% in Q4 (avg for FY23 is 4.3%). Enrolment on treatment of the 10,620 TB patients identified stands at 98.0%. Consistently, community screening has been the 3rd highest TB case contributing intervention through all the quarters.

5. Can you share examples of community-led initiatives or partnerships that had a positive impact on TB control efforts?

The story of 4-year old Ubong Obasi, a TB survivor in Etinan Akwa Ibom state is a perfect depiction of the positive impact of community led initiatives. Ekereobong Ikobo is a community healthcare worker acting in charge of the facility at the Primary Health Care Center in Etinan Local Government Area in Akwa Ibom State. A few months ago, upon returning from work on Tuesday, November 1st, 2022, she noticed her 4-year-old son, Ubong Obasi had a cough. Initially, she thought it was a common cough, but it continued for three days. I became concerned, three days later, I arrived home from work and my children informed me that some representatives from KNCV Nigeria visited our community and collected stool samples for TB testing. Hearing the news was relieving and reassuring as I intended to take my children to the hospital to have their samples tested to determine the appropriate treatment approach, she says.

She eagerly awaited the test results which arrived, and the results indicated that Ubong had tested positive for TB. Subsequently, they were referred to the general hospital in Etina for treatment. Her role as a healthcare provider enabled Ekeerobong to administer the necessary medication diligently, adhering to the prescribed dosage based on age. About two weeks later, the cough started to ssubside. This was the moment I truly realized the gravity of the situation — my child indeed had Tuberculosis, a fact I didn’t notice due to the absence of clear symptoms. Unlike the typical indicators such as weight loss, my child exhibited only a slight reduction in appetite, she says.

A contact investigation was conducted by the KNCV Team Fortunately the rest of the household tested negative, and TB Preventive Therapy (TPT) medication was administered to all members of her household. Ubong has completed his treatment and is in good health. Ekereobong is grateful for the support and guidance provided by the KNCV Nigeria Cluster Coordinator Ofonime Nsito throughout this period. Since then, I have adopted a vigilant approach toward anyone exhibiting even the slightest cough. I promptly collect samples and forwarded them for testing”.

KNCV Nigeria House-to-house TB screening is usually done by two Community Healthcare Workers (CHWs). These CHWs are usually familiar and known in the Community where house-to-house is done. They usually have an identifier (reflective jacket used in Akwa Ibom) and the jacket is branded to address stigma and discrimination. Patients are screened symptomatically for TB, presumptive TB are identified, and samples are collected on the spot and shipped to the testing labs or referred to have x-rays.

This model of Community Active Case Finding is peculiar because it takes less time to plan and is cheaper to implement. However, the number of persons screened might be lower when compared to mass community TB screening.

6. How did the ongoing COVID-19 pandemic affect TB control efforts by KNCV in Nigeria in 2023?

To ensure acceptance and address the challenges posed by COVID-19 vaccine hesitancy, KNCV Nigeria with funding from USAID strategically integrated the vaccination program within the KNCV Nigeria TB LON community outreach TB Active Cases Finding (ACF) intervention while also leveraging on our structure in the supported public and private health facilities.

7.What measures were taken to mitigate this impact?

The COVID-19 Vaccination Acceleration project has an overall goal of promoting COVID-19 vaccine access, acceptability, and uptake, while strengthening adverse drug reaction feedback and timely response, by leveraging on the ongoing USAID-funded Tuberculosis Local Organizing Network (TB LON) 1 & 2 project structures.

8. How important were the partnerships or collaborations that KNCV Nigeria fostered or strengthened in 2023 to advance the TB fight?

Collaboration and coordination with other stakeholders are key to finding the missing TB cases in Nigeria. KNCV Nigeria has always participated in Zonal and Annual review meetings organized by the NTBLCP. We also participated multiple times in a NTBLCP ACSM Sub-committee national TB testing week planning meeting, together with numerous other IPs & stakeholders to plan towards the National Testing week in August 2023.

9. What are the key priorities or focus areas for KNCV Nigeria in 2024 to accelerate progress towards the goal of ending TB by 2030?

KNCV Nigeria will continue to strengthen a mixed model of community and facility based, health systems strengthening strategies and digital solutions to find TB cases. The key priorities will include Improving access to high quality person-cantered, TB, DR-TB and TB/HIV services; Strengthen TB service delivery platforms; Reduce TB transmission and disease progression and Apply innovation and accelerate research in TB with improved impact on program implementation.

10. What role will KNCV Nigeria play in advocating for policy changes or initiatives at national or regional levels to strengthen TB control programs?

KNCV Nigeria, a member of STOP TB Partnership Nigeria will ensure to promote and support the prevention and control of TB and other diseases of public health concern in Nigeria through the implementation of innovative and evidence informed disease control strategies and advocate for funding support across all levels of Government.

11. Are there strategic advocacy plans aimed at increasing support or funding for TB-related activities from the Government and private sector?

KNCV Nigeria has facilitated and coordinated efforts for Domestic Resources Mobilization through the following approaches:

• Advocacy visits to state leaderships (Hon commissioners of health, Permanent secretaries MoH, Directors of finance) and organized private sectors (OPS) for increased financial support for a sustainable TB response
• Stakeholder engagements by the SPOs to health financing ministries for the integration of TB care and other services into the state health insurance scheme (SHIS).
• Ensuring the State Health Insurance Scheme (SHIS) Bills are passed into law; Staff of SHIS Agency appointed; SHIS Operational guideline in place
• Working with the state health insurance agencies to integrate TB from diagnosis to treatment into the basic minimum health package
• Monitoring enrolment of beneficiaries ensuring enrolees can access care under SHIS, without difficulty
• Working through the Technical working group (TWG) to ensure the budgeted government funds are released and the expenditure of such released funds tracked.
• Instituting systems for expenditure tracking of public financing of TB in the various states.

12. What accountability measures are in place to ensure that the organization remains on track with its objectives and commitments?

The KNCV Nigeria board of directors plays a major role in ensuring the organization remains on track with its objectives. There is also a bi-weekly meeting with our Funders USAID to track the project implementation progress. The organization submits monthly, quarterly, and annual program and finance reports to USAID.