Background

The Northeast of Nigeria remains the poorest region in the country with the worst development indices across indicators including health. The region has the weakest health system prior to the onset of insurgency led by Boko-Haram. The region is made up of 6 States with a land mass of 280,419 km² (1/3^rd the size of Nigeria) and has the weakest health system prior to the onset of insurgency led by Boko Harram. The evaluation population is made up of 12 LGAs across Adamawa, Gombe and Yobe States with an estimated population of 3,362,345. The population is predominantly young, one of the most marginalized and underdeveloped in Nigeria with a high poverty rate. Subsistent farming and hunting is the main occupation while they share similar socio cultural and religious characteristics. The need for immediate humanitarian response was escalated further with the Nigerian military liberating more areas that were previously under the control of Boko Haram in the insurgency‐hit North‐Eastern region.

Epidemiology

Despite having a TB case detection rate of 17%, Nigeria has one of the largest burdens of both HIV and TB in Africa and is classified as a high TB, HIV, and MDR-TB burden country. The latest prevalence study revealed that the burden of TB is actually 3 times higher than previously estimated. It was found that ~40% of TB patients were asymptomatic and did not seek care hence they were not detected by the passive healthcare system. National TB prevalence is 524/100,000 population based on the survey conducted, which represents a three-fold increase in the WHO estimate for the same year. The projected TB incidence is at 338/100,000 population. At the end of 2015, 2, 362 all forms of TB cases were notified in the evaluation area of which 1,253 were SS⁺/B⁺. The Male:Female ratio among cases notified is 2:1 while the highest notification was in the age group of 35 – 54. Records show that over 95% of TB cases detected were notified. The evaluation area reported a treatment success rate of 89% (range: 85 – 95%). On the average, the HIV prevalence for the 3 States is 3.5%, which is above the National prevalence of 3.2% (NHARS, 2012). There are over 175,000 people living with HIV across the 3 States.

TB Service Delivery Points

There are a total of 91 DOTS centers in the evaluation area of which 64 are primary, 16 are secondary and 3 are tertiary while 9 are privately owned. Similarly, there are 31 AFB sputum microscopy centers in the evaluation area out of which 5 are primary, 15 are secondary, 3 are tertiary and 8 are private. There are also 17 comprehensive ART sites in the area. Some of the DOTS centers in the evaluation area were destroyed by the insurgents and therefore were not mentioned here. All health facilities mentioned also provide basic HIV services (HCT and referrals), however, collaboration and referral linkages are weak. Twelve (12) of the health facilities providing DOTS services in the evaluation area also have functional GeneXpert equipment. 

Internally Displaced Persons

IDPs in Gombe, Adamawa and Yobe States are mainly found in 12 LGAs spread across these 3 States. 87.48% of the IDPs were displaced directly by activities of Boko haram insurgents. Based on IOM assessment, there are 69,444 in Gombe State 159,445 IDPS in Adamawa, and 112, 671 in Yobe State giving a total of 341,761 IDPs across 12 LGAs in the 3 States. They are housed in primary schools, rented buildings and temporary tents while some have integrated into the host communities.  The IDPs are made up of 52.95% female. 6.9% of the IDP Population were above 60 years while Children under 18 constitute 55% of the IDP population with more than half of them under five years old.

The target population is made up of 341,761 IDPs across 12 LGAs in Adamawa, Gombe and Yobe States. On the other hand, the total evaluation population across the 12 LGAs in the 3 States is 3,362,345; therefore the target population is 10.2% of the evaluation population. Although the target population is small, according to a risk group assessment conducted by KNCV, Nigeria, the relative risk of TB among IDPs compared to the general population is 2 while the estimated prevalence of TB among the IDPs is 1004/100,000. This implies that the burden of TB among IDPs in North-eastern Nigeria is high and required urgent attention. Based of the current Prevalence of TB in Nigeria (524/100,000 population), there are 17,618 all forms of TB cases across the 12 LGAs in the 3States while there are 1,790 all forms of TB cases among the IDPs which translates to 10% of the estimated prevalence. However, going by the KNCV risk assessment, the estimated burden of TB among IDPs is twice the above estimation

Given the level of destruction of Health Facilities (HFs) and the devastating impact of insurgency upon the Health System in the region, accessibility to health services remains extremely challenging. There are 26 functional HFs in the target population (IDP Camps and host Communities); 8 of these are located within the premises of the IDP camps and are tents constructed by humanitarian partners. These HFs are spread across 12 BMUs (LGAs) each headed by a formally trained TB supervisors. Through support from these partners and Government, they provide general health services through the temporary engagement of Medical Officers and other health staff from other HFs in the 3 States. However, TB and HIV services are limited while there are no TB diagnostic services in the IDP camps. In the host communities around the IDP camps, there are 14 health facilities providing TB and HIV services; these facilities have formally trained staff on TB and HIV and receive occasional referrals of presumptive TB cases from the HFs in the IDP camps. There are also 9 GeneXpert facilities within the area that will be used for screening presumptive TB cases and NTP plans to expand to 3 more facilities. However, currently referral linkages and TB/HIV collaborative services in the DOTS providing HFs are weak while they are occasionally supervised by trained BMU TB supervisors and data collected and managed according to the NTP guidelines. In addition, the new IDP settlements lack formal health services; Patent Medicine Vendors are utilized to meet their health needs.

Problem Statement:

The Northeast region is the most marginalized and underdeveloped region in Nigeria with the worst health indices. The recent mayhem unleashed by the Boko-Haram terror group in the region has worsened this situation and created the largest cohorts of Internally Displaced Persons (IDPs) in Africa. According to IOM (Round 10 Report, June, 2016), 56% of the IDPs are children, 53% are Females while 6.9% are above 6o years. Most of the IDPs are hosted in several camps and host communities with inadequate basic amenities and poor sanitary conditions. Malnutrition especially among children is rampant and has been reported in the IDP camps. The IDPs are often overcrowded in their tents with poor ventilation thereby posing a risk for the transmission of TB infection. Due to the arrivals of IDPs weekly in thousands from the neighboring States and the Cameroons, existing Health Facilities within the camps and host communities are overstretched. Government with support from humanitarian partners set up health service tents within the IDP Camps, however, TB and HIV services are only provided to limited extent with poor referral linkages by untrained Health Workers on TB to the few existing DOTS service providing facilities in the host communities. Therefore, due to lack of capacity on TB control by existing health workers in the camp, these health-service “tents’ tents within the IDP camps are not able to detect existing TB cases among the IDPs. Although other humanitarian partners flooded the IDP camps and host communities, the range of services provided are mainly psycho-social counseling, food security, education, hygiene, ante-natal care and sanitation; there is no partner providing TB and HIV services while the presence of the State TB Programme in the IDP camp is minimal.

The level of awareness on TB and HIV among IDPs is low while preventive services for the 2 diseases are virtually non-existent in the camps. The knowledge of available service delivery points for TB and HIV is also limited among the IDPs thereby leading to delays in accessing TB services and diagnosis. There are also incidences of violence against women including rape in some of the IDP camps thereby promoting the spread of HIV. Furthermore, pregnant women attending ante-natal clinics in the IDP camps lack access to PMTCT services thereby resulting to the birth of HIV infected children. It is worthy of note that the NTP’s priority is to increase TB case detection from the current 17%. This intervention would serve as an important opportunity to contribute to increased TB case detection.

Implementation Approach

Active case finding approach will target the Internally Displaced Persons in the 12 LGAs which will entail visits to IDPs within the camps and host communities around the IDP camps. We are going to use GeneXpert for screening all presumptive TB cases among our target population. This is because of its advantage in rapid diagnosis of TB disease and even drug resistance TB. The test simultaneously detects Mycobacterium tuberculosis complex (MTBC) and resistance to rifampin (RIF) in less than 2 hours. The project would work within the existing NTP structure in which existing DOTS and TB diagnostic centers will be utilized in the management of presumptive TB cases identified by this intervention in the IDP camps and host communities. Six (6) domestic Community Based Organizations (2 per State) experienced in TB and HIV control will be engaged to implement the community component of the intervention including awareness creation and community mobilization on TB and HIV. 10 Community Volunteers (CVs) will be identified and engaged in each of the intervention LGAs (40 in each State) by the CBOs and community gate keepers. The CVs will be involved in the identification of presumptive TB cases using a standardized symptom checklist, collect and transport sputa samples to GeneXpert facilities, obtain results and linkage of diagnosed TB cases among IDPs and host communities to DOTS centers for treatment. The CBOs will provide close monitoring of all activities conducted by CVs. The capacity of Health Workers from existing Health Facilities, CVs and CBOs will be strengthened through formal training by the State TB and HIV Programmes to ensure the provision of quality TB and HIV control services. At the onset of the intervention, key stakeholders from the host communities will be engaged in order to buy into the intervention for ownership and sustainability. Patent Medicine Vendors, who are known to provide health services in new IDP settlements, will be identified and engaged in order to identify and refer presumptive TB cases to CVs for further management. The project will ensure that partners providing various services in the IDP camps are mapped and those providing health services relevant to TB and HIV control are identified for collaboration. Data management will be in line with the NTP guidelines in which LGA TB supervisors visit DOTS centers monthly to register new TB cases. This is followed by quarterly programme review meetings of the LGA TB Supervisors with the State TB Programme to collate, analyze and transmit validated TB data to the NTP. At this quarterly meeting, data from this intervention will be segregated by the respective TB supervisors of the intervention LGAs and transmitted to the M & E officer at GomSACA. This will be followed by the collation of segregated data by the M & E officer at GomSACA for final upload/submission to TB Reach on quarterly basis. Similarly, HIV data will be managed according to the National HIV guidelines. Integrated supportive supervision will be intensified to TB and HIV service delivery points within the IDP camps and the host communities by the State TB Programme supervisors and periodically by supervisors from the NTP and GOMSACA. The performance of the CVs will be reviewed quarterly in order to identify non-performing CVs for further action

Expected outcome:

1. Awareness on TB and HIV among IDPs and host communities in Adamawa, Gombe and Yobe States would be improved through active engagement with the CVs and CBOs thereby reducing the level of stigma aginst TB and HIV patients
2. 2,768 SS+ TB cases will be notified by the intervention
3. At least 12,120 (4% of IDPs population) are counselled and tested and all positives referred for ART Treatment
4. Ownership and sustainability of the project will be ensures due to the active involvement of key stakeholders from the host communities
5. There will be improved TB/HIV collaboration at facility and TB programme levels
6. The project is expected to provide a platform for advocacy and to influence policy making on a National scale particularly with regards to proactive TB care and control specifically among IDPs and their host communities
7. Policy on funding and implementation of other health programmes among IDPs and their host communities will be enhanced