Lagos steps up search for uncounted, untreated TB patients

Finding “missing cases” of tuberculosis, still one of the world’s greatest killers, is key to interrupting transmission and halting the disease. Lagos State in Nigeria is rolling out new strategies.

A patient standing in front of an xray machine. Credit: Chioma Obinna


Lagos has stepped up its search for 'missing cases' of tuberculosis, said Dr Olusola Sokoya, Deputy Director  Pandrogramme Manager at the Lagos State Ministry of Health's Tuberculosis, Leprosy and Buruli Ulcer Control Programme.

Lagos accounts for 11% of Nigeria's burden of tuberculosis (TB), while Nigeria is home to 4.4% of TB patients worldwide, according to the Global TB Report. That statistic places Nigeria sixth in a list of countries by volume of TB in cases. Strikingly, unlike several other high-burden nations, Nigeria recorded more notifications for TB diagnoses in 2020 and 2021 than in 2019.

Sokoya, speaking for Lagos state, suggests that's not necessarily alarming news: with new diagnosis strategies coming on line in the last five years, Lagos has consistently increased its tally of cases, meaning, crucially, that the number of patients in treatment is growing, he explains.

“Billions of issues could cause people to contract TB in adulthood, so creating booster doses like was done for COVID vaccines will also help in improving BCG effectiveness in children and adults."

– Dr Iorhen Akase, immunologist at the Lagos University Teaching Hospital

"While we have failed to meet the target of detecting over 50,000 cases annually, in 2022, we recorded a total of 17,280 case for the first time following our aggressive strategies.

"Between January and March this year, we have detected and enrolled on treatment 4,621 persons. In 2019, we were only able to detect 11,723 cases, in 2020; it went down again with 10,150; and in 2021 13,499."

Finding hidden patients

Lagos's population is huge and mobile – a challenge for public health visibility. But the state and its partners have had success in creating effective diagnostic strategies.

Treatment and diagnosis for TB are free. The state government, with support from Global Fund, have procured three mobile vans and 18 X-ray machines for 18 state facilities to facilitate TB diagnosis. "We also engaged the services of 23 tuberculosis and leprosy supervisors, who coordinate activities at the local government levels," Sokoya said. Leprosy and tuberculosis are caused by related mycobacteria.

Apart from acquiring chest X-rays and GeneXpert machines – specialist tools for rapid TB diagnosis –  for some of its treatment centres, the state has beefed up its ranks of screening officers in both private and government hospitals.

The GeneXpert machine is a specialist tool for rapid TB diagnosis. Credit: Chioma Obinna
The GeneXpert machine is a specialist tool for rapid TB diagnosis.
Credit: Chioma Obinna

"We conduct routine screening outreaches for TB in communities with our partners like the Institute of Human Virology, Nigeria, (IHVN) and Damian Foundation Belgium in the communities," Sokoya said.

"With more than 1280 Directly Observed Treatment (DOT) centres scattered across the 20 Local Government Areas of Lagos, over 50,000 persons are on treatment," Sokoya says. "Once a patient is screened and confirmed positive, the patient is referred to any of our DOT clinics closer to them."

To ensure support and treatment for identified patients, the State Contact Tracers follow up on patients in the communities.

For Dr Babajide Kadiri, Lagos State Team Lead at IHVN, a Non-Governmental Organisation (NGO) in Lagos, there has been significant improvement in case detection and treatment compared to a few years back.

"When we started, our annual TB detection was within the range of 2,000 to 3,000, but three years into the project we are identifying close to 5,000 in just a quarter.

"Though there have been challenges, one of the things we have realised from our experience is that there is very low level of awareness about TB in Lagos communities, even among health workers."

Kadiri notes that despite the importance of early detection in tuberculosis management, patients still live in denial.

Upward spirals

Dr Chukwuma Anyaike, a consultant public health doctor says, early detection helps in cutting the chain of transmission.

Anyaike, who is also National Coordinator, NTBLCP, states: "One un-intervened case of TB can infect not less than 15 people in a year – hence the need for early diagnosis and treatment. Tuberculosis runs through several vicious circles," he explains. "if you get it and if you don't treat it, it can clear a whole household. Key drivers in Nigeria are undernutrition and HIV."

Demand for a new TB vaccine

"Many cases of TB are missed across the world and it is one of the killer diseases globally. Unfortunately, no adult TB vaccine is available apart from BCG that protects only children from severe TB and has no protection for adults," says Anyaike.

"After 15 years, BCG's effects wear off, and the person becomes at risk of the disease. This is the major limitation of BCG," Anyaike explains.

He says the Global TB report showed that only about one in three people with drug-resistant TB – a rising threat – accessed treatment in 2021. Getting a new tuberculosis vaccine will be a gamechanger for ending TB globally, particularly for countries like Nigeria with a huge burden.

An immunologist at the Lagos University Teaching Hospital, Dr Iorhen Akase, says that though BCG has been around for years, not much progress has so far been made to improve the vaccine.

"Billions of issues could cause people to contract TB in adulthood, so creating booster doses like was done for COVID vaccines will also help in improving BCG effectiveness in children and adults. More people are living longer, so we are going to have a larger community of people that are going to have chronic organ infections. An effective adult TB vaccine will prevent illness, cost of treatment and deaths."

Economic benefits of TB vaccines

Though efforts are ongoing for candidate vaccines, he acknowledges that producing new vaccines involves a lot of funds – but that the economic benefits outweigh the cost.

A modelling study published in PLOS Medicine projected that an effective new TB vaccine could offer large potential health and economic benefits. The researchers estimated that the introduction of an adolescent/adult TB vaccine could produce US$ 283 billion to US$ 474 billion in health and economic benefits by 2050, with those benefits concentrated in the WHO African and South-East Asian regions.