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With      the information you gathered for your Research Paper, you will now create      an intriguing visual presentation and present it to the class.
Presentation      should include 10 slides-Background (1 slide), literature review (1      slide), program goal and objectives (1 slide), Program (5 slides),      recommendation (1 slide) and conclusion (1 slide).
Your      presentation should be between 5-7 minutes long; practice it several times      beforehand! Running head: MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 1

Multi-drug Resistant Tuberculosis in the Eastern Region, Nigeria

Oluwatobi Susan Akinsanya

0189927

PH690-101

Global Health

Submitted to:

Dr. Aditi Puri

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 2

Abstract

In the world today, there are several global health issues ranging from epidemic, endemic,

to a pandemic. These health issues are caused by numerous factors such as unclean and unsafe

water, environmental pollution, poverty. This paper focuses on the prevalence of MDR-TB in

Eastern Region, Nigeria. The causes and symptoms of Tuberculosis were established as the root

cause of MDR-TB. MDR-TB- known as multi-drug resistant TB is a strain of Tuberculosis that is

resistant against TB anti-biotics (rifampicin and isoniazid). Surveillance diagnoses were carried

out on previously treated and suspected TB patients to established growth of the disease and how

to fight it. Past studies were reviewed with emphasis on MDR-TB to gather information on the

epidemiology of the disease. In addition, proven program utilized in the past were evaluated to

determine if there were any successful interventions to reduce TB transmission. Moreover, this

paper recommends program incorporated into SMART objectives to reduce the prevalence of TB

in the stated region. These proposed programs worked collaboratively with the previous programs

put in place by WHO to create a lasting solution.

The recommendations proposed in this paper built on the disparities existing in past programs to

proffer an advanced study in the fight against TB. The recommendations of this paper with the

collaborative work of WHO suggested that testing and contact tracing should be increased by 40%.

In addition, surveillance data should be increased by 60% and shared with the public to educate

and increase awareness of the disease.

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 3

Multi-drug Resistant Tuberculosis in the Eastern Region, Nigeria

Nigeria, also known as the giant of Africa, is one of the most renowned countries in Africa.

It is renowned for its fast pace of civilization and the emerging growth of its citizens across the

globe. It has over 200 ethnic groups with diversity in cultural and religious beliefs. Nigeria is

blessed with numerous natural resources ranging from cash crops, fossil fuels, rubber, cocoa, gold

to mention but a few (Mohammad et al., 2017). However, regardless of the abundance of these

resources, Nigeria is lying fallow in abject poverty which is a ripple effect of a failed government

and a collapsed economy. This impoverishment has given rise to tons of health issues which

include various communicable and non-communicable diseases. The World Health Organization

reported that Nigeria amongst other developing countries have skyrocketed death records from

these health problems. For instance, the death rate caused by malaria in Nigeria was 146 in 100,000

population while Tuberculosis was reported to have caused 311 deaths in 100,000 population. This

made Nigeria one of the nations in the world with the highest burden in Tuberculosis (WHO, 2011).

As a result of this data, Tuberculosis is considered a highly deadly disease ravaging the nation due

to its fast rate of spread.

The emergence of Tuberculosis can be dated far back to over 4000 years and has been a

menace to mankind. It is a highly chronic disease caused by a bacterium called “bacillus

mycobacterium tuberculosis” (Zaman, 2010). It can be easily passed from person to person

through the air, making the lungs its first point of target. Its symptoms depend on where this

bacterium is growing in the body. Albeit, its major symptoms include chronic cough, excessive

weight loss, severe pains in the chest region (Zaman, 2010). This disease is one of the leading

causes of high rate of morbidity and mortality in several developing countries including Nigeria.

Over the years, most developed countries have recorded a plummet in the growth of this disease,

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 4

however, it is still ravaging in several developing countries. Statistics reported that 86% of the

global Tuberculosis cases were prevalent in Asia and Africa (WHO, 2011). In response to this,

Tuberculosis was declared the first global pandemic by World Health Organization.

In most studies, the causes of Tuberculosis have been associated with poverty, which made

it a major public health problem in Nigeria. It was established that Tuberculosis grows faster in

low-income communities with people living in overcrowded slums which surges the rate of spread.

Also, poverty induces malnutrition that alters the immune system to fight against diseases as this.

Additionally, the prevalence of Human Immunodeficiency Virus (HIV) constituted 50% increase

in the spread of T. B, of which Nigeria has over 3.4 million HIV-infected persons (Mohammad et

al., 2017). Moreover, there has been constant neglect of the public health system by the Nigerian

government leading to the increased presence of Tuberculosis in the country.

In the 20th century, patients treated with anti-tuberculosis medications are beginning to

show symptoms of a new strain of the disease. Data has it that over 3-5% of patients diagnosed

have exhibited this new strain of Tuberculosis and a higher proportion of this percentage are from

patients who have been previously treated from Tuberculosis (Sharma & Mohan, 2004). This was

evident that the previous programs designed to completely expunge Tuberculosis was a failure.

The emergence of this new strain has led to the increment of the spread of TB and mitigated every

effort to completely halt its existence. This new strain of Tuberculosis is called Multi-Drug

Resistant Tuberculosis.

Multi-drug resistant tuberculosis (MDR-TB)

The emergence of MDR-TB can be traced back to over 20 years (Gandhi et al., 2010). Its

name was derived because of its resistance to anti-tuberculosis treatment. This new strain emerged

because of an inadequate program designed to cure drug-susceptible Tuberculosis, whose ripple

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 5

effect led to the emergence of MDR-TB. In addition, this new strain is new and bizarre to most

countries, thus several countries are slow in their response to fighting MDR-TB (Gandhi et al.,

2010). MDR-TB can be treated with the same diagnostic programs designed to cure Tuberculosis.

Although, its treatment is far more arduous, and its treatment failure and mortality rate are

exceedingly high as compared to the drug-susceptible Tuberculosis. This is the case with MDR-

TB in developed countries, especially in Nigeria. The continued neglect of providing adequate

health programs to its public health system has influenced the rampage of MDR-TB specifically

in the South-Eastern region of the country. With over 460,000 new cases of MDR-TB occurring

annually in Nigeria, approximately 40% of these cases are from the South-Eastern region

(Mohammad et al., 2017).

Literature Review

Epidemiology of MDR-TB

An epidemiology study conducted by Girum et al., (2018) in Ethiopia established the

narratives on the emergence of MDR-TB as a global health issue in developing countries. It was

stated that with an increment in the prevalence and complexities in the treatment of this disease, it

has become a burgeoning challenge to the country. In addition, most developed countries do not

understand the epidemiology of this disease. Thus, to implement a quality and adequate approach

to combat this disease is futile. Prior to this study, little research has been done to create an

understanding of this disease, but they reached an unconcise conclusion. The authors conducted a

systematic review on the epidemiology of this disease by conducting a meta-analysis on previous

studies to derive a conclusive finding. The author used studies published between 1997 and 2017.

This search was done using 5 literature databases and a systematic cleaning, sorting, and analysis

of the studies were conducted using a statistical database (STATA 11). The total combination of

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 6

these studies focusing on the prevalence, growth rate, and outcomes was established using the

random-effects model. In addition, the heterogeneity of the studies was evaluated by the I2 and

research biases were sorted through the funnel plot. After sorting, 34 studies out of 280 were

collected for further analysis. It was established that these studies enrolled a total of about 7461

TB & MDR-TB patients. A total of 2.18% of newly diagnosed patients and 21.07% of previously

treated TB patients had MDR-TB with a general prevalence of over 7.24%. Thus, it was

determined that patients with a history of previous treatment of TB is one of the key factors of the

prevalence of MDR-TB. Also, contact history with the infected and lack of adherence to

medication is another factor of prevalence. In addition, these studies also established that 12.25%

of MDR-TB patients died during the treatment procedures. The increased complications from

medications’ side effects as previously mentioned in the studies were the major factor for the deaths

in several other patients.

In conclusion, the prevalence reported in this meta-analysis was far higher than previous

studies. Albeit the treatment outcomes derived in this study were similar to previous reports. This

implies that there has been no improvement in the treatment outcomes since 1997 until the ’20s

which is a great concern. The complications that arose as a result of the medications’ side effects

and the HIV history were also added factors. To adequately treat MDR-TB, a well assessed, quality

health care treatment must be utilized to treat TB which is the foundation of MDR-TB. Also,

continuous surveillance and evaluation of previously treated TB patients should be conducted to

promote early detection of MDR-TB. Furthermore, contact tracing of these cases should be made

paramount to curb more deaths from this disease.

Multi-Drug Resistant Tuberculosis in South East, Nigeria

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 7

A study conducted by Ahiarakwem et al (2020) was established to promptly detect MDR-

TB amongst patients in a region of high prevalence of TB and HIV (South East, Nigeria). This

study established that HIV patients infected with MDR-TB have a higher susceptibility to mortality

as compared to Non-HIV-MDR infected patients. In addition, it was also indicated that patients

previously treated with rifampicin and isoniazid are also highly susceptible to MDR-TB. MDR-

TB can be passed from person to person due to inadequate adherence to anti-TB antibiotics, contact

transmission coupled with HIV/AIDS. It was stated that MDR-TB can be detected early by

conducting molecular testing where mycobacterium tuberculosis is cultured with patient’s sputum.

On the 30th of September 2013, the patients of chest clinics in 3 hospitals in Imo States were used

to conduct this study. The hospitals included Imo State University Teaching Hospital, Umuna-

Orlu; Saint Damian’s Hospital, Okporo; Holy Rosary Hospital, Emekuku. These hospitals are the

major TB healthcare providers in the state. Before conducting the study, a consent form was signed

by these patients to avoid violating the privacy rights of these patients. Seven hundred and forty

patients were enrolled for the laboratory investigation using a multi-center cross-sectional study.

Samples of sputum were collected from all patients who were in these categories (previously

treated TB patients, suspected TB patients, and newly diagnosed TB patients). The ratio of male

to female patients collected were 2:4:1. All these patients attended any of the three chest clinics in

the previously stated settings and these samples of sputum were analyzed acid-fast bacilli (AFB).

A sample size of 111 positive AFB was reported. Patients were also tested for HIV and a standard

interview questionnaire was done to collect the socio-demographics of each patient. From the 740

sputum samples analyzed, 111 were AFB positive, out of these AFB positive samples, 65 indicated

culture-positive organisms. They were called the isolates. These 65 isolates were further examined

using the SB BIOLINE test and it was confirmed to be MDR-TB. The drug resistance to isoniazid

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 8

and rifampicin was observed in these 65 isolates and 3.1% of these samples indicated the

prevalence of MDR-TB. 7.7% of the sample tested positive for HIV but no significant relationship

was established between the HIV patients and MDR-TB. The proportion of males with MDR-TB

to females was 46% to 19%. There was no concrete evidence establishing any relationship between

the MDR-TB patients and their gender. Ultimately, from the 111 AFB positive samples, 97.3%

continued with the treatment while 90.1% also maintained their anti-TB medications without

interruption. Conclusively, this study showed a low prevalence of MDR-TB in this setting. This is

because the hospitals used in the study were major TB health care providers in the state. In addition,

they have harnessed all efforts in providing a stolid and adequate TB treatment procedures. It is

recommended that a larger population size should be utilized with a constant surveillance on these

patients. Also, early detection testing and contact tracing would help salvage the menace caused

by MDR in the region.

Major Health Problems in Nigeria

According to Mohammad et al (2017), the study conducted focused primarily on the causes

of the major public health problems in Nigeria. It was established that many of these problems

arose because of inadequate health care programs in place to tackle the disease. The narrative is

that many of the diseases are poverty-related targeting the urban slums that lack the basic social

amenities. In addition, the major public health problems in Nigeria are communicable and non-

communicable diseases and TB is not an exemption.

However, Nigeria has been working towards its sustainable development goals. Some of

which was to eradicate public health problems through adequate and quality healthcare. This study

addresses these goals with emphasis to fighting these diseases and creating a lasting solution to

the health problems in Nigeria. The study collected data from literature databases and web engines,

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 9

of the Nigerian Ministry of Health between January 2016- July 2016. Furthermore, primary data

were collected using databases from international health organizations to trace new development

related to public health issues in Nigeria. The results from this study addressed numerous health

issues and the percentage burden of each disease on the country.

Statistics reported that 18.8% of the Nigerian populace as of 2017 died from either Malaria

or TB. It was believed that these deaths could have been avoided if there were adequate resources

in the health system. In its efforts to accomplish its sustainable development goals, this study

recommended the government of Nigeria to work collaboratively with NGOs and Donor agencies.

Ultimately, the government should be vigilant to their duties by providing access to basic social

amenities to the Nigerian populace.

Surveillance of anti-tuberculosis drug resistance in the world: an updated analysis, 2007-2010

The authors Zignol et al (2011) conducted an analysis of the trends, growth, and treatment

outcomes of MDR from 1994-2010. This study focused also on the surveillance data on the

treatment of TB and MDR-TB to evaluate the effectiveness of the previous program interventions.

This is because surveillance data is keystone to MDR-TB program intervention. Thus, this study

created an analysis to accurately monitor, and design patients’ treatment in accordance with the

growth of the disease. On this premise, data from MDR-TB patients previously treated were

collected from countries reported to the World Health Organization and analyzed. These data were

collected through surveys of MDR-TB patients and a sample from this data were tested. In addition,

an association between MDR-TB and HIV/AIDS was established through logistic regression.

Furthermore, the global project on data surveillance was analyzed from 127 countries; 63 countries

was used as sample due to drug susceptibility of the patients in each of the country. This

surveillance data indicated an increase of about 3.4% in MDR-TB and a 19.8% increase in T.B

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 10

cases globally. It was also established that the association between HIV/AIDS and MDR-TB has

an odd ratio of 1.4 and a CI between 0.7-3.0. The highest global surge of MDR-TB was reported

between 2009 and 2010. Although the trends in MDR-TB are vague, but with quality surveillance

rate, data outcomes can be easily predicted, and treatment outcomes anticipated.

Multi-drug and rifampicin tuberculosis (MDR-TB): global response

In this study, Falzon et al (2017) established that TB strains with MDR and as a result,

MDR requires more complex treatment and procedure as opposed to drug-susceptible TB. This

study aims to indicate if the sustainable development goals of WHO towards the END TB global

strategy was effective. The method utilized by World Health Organization was to generate global

indicators for MDR-TB responses. These indicators included testing coverage, early case detection,

the inception of treatments, and treatment outcomes based on the surveillance data reported.

Although, the treatment of MDR-TB takes between 18-24 months with less rate of positive

outcomes. The complications that arise from the treatment of MDR-TB led to high rate of mortality

as it is less efficacious as compared to drug-susceptible TB. Thus, using the surveillance data

reported by different countries, the effectiveness of the END TB strategy can be measured globally.

Statistically, in 2015, 580,000 incidents of MDR-TB and 250,000 deaths were projected to occur

globally. The testing coverage was able to reach 30% of the TB patients that were notified of which

24% were new cases and 53% were previously treated patients. It was also reported in the same

year that 132,000 cases were diagnosed, and 125,000 cases were undergoing treatment which

comprised of 22% of the estimated eligible cases. In addition, the rate of treatment was 52% overall

of all MDR-TB cases whose treatment has commenced since 2013. This treatment rate was

reported from countries within the 30 high MDR-TB burdens, with testing rates ranging from 39%

to 84%. The testing and treatment of MDR-TB have increased significantly since 2009 but early

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 11

case detection and treatment success has been declining in recent times. MDR-TB testing is short

of the estimated 100% target, thus continuous diagnosing and early detection will be crucial.

Moreover, WHO reformed its policies on rapid molecular testing and composition of new regimen

to fight the disease. This would enhance early detection of cases which would inform access to

quality and effective treatment.

Conclusively, these literatures were able to establish that TB is the parental cause of MDR. This

implies that any patient previously treated of TB or suspected TB patient have a high tendency to

have MDR-TB. The relationship between HIV and MDR-TB was established but was not proven

to be the cause of MDR-TB. In addition, the prevalence of MDR-TB mortality rate was linked to

the complications of the drugs side effect. Ultimately, treating MDR-TB can be very arduous and

success rate slim. However, with an early detection and continuous surveillance of formerly treated

TB patients, the rate of MDR-TB can be curbed.

Proven Programs

The development of MDR-TB has contributed enormously to the spread of TB in Nigeria.

Since the emergence of Tuberculosis, there have being several research interventions around the

globe to curb the spread. The World Health Organization posited a high-quality DOTS expansion

(direct observed therapy short course) as part of the global intervention strategy to tackle T.B

(Zaman, 2010). Another intervention is the STOP TB Partnership Nigeria. This program was a

collaborative effort of the Nigerian government and WHO global TB team to fight the disease and

stop the development of MDR- TB. In addition, the Nigerian Ministry of Health also partnered

with United States Agency for International Development (USAID) to implement a comprehensive

approach towards the STOP TB program in fighting the disease. The approaches utilized by the

STOP TB program in collaboration with WHO are as follows:

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 12

• As recommended by the CDC (Center for Disease Control and Prevention) to

mitigate the spread of Tuberculosis; improving diagnosis, contact tracing and a

directly observed therapy strategy became an essential part of the program.

• Introduction of activities to reduce the spread of Tuberculosis especially in hot

zones: Activities such as campaigns to create awareness, educating the public,

identifying infected persons and reducing exposure (Mohammad et al., 2017).

• Immediate quarantining of infected persons and evacuation of non-infected persons

from hot zone areas.

• Enacting healthcare policies and regulation that addresses effective treatment of

patients with quality anti-tuberculosis medications.

• Free access to TB medications to all TB and MDR-TB patients.

• Engagement of all health care providers in local communities.

• Enabling and promoting of research to reduce rate of mortality (STOP TB, 2019).

This program is still ongoing in Nigeria, however, statistics recorded that between 2000-

2016, over 53 million people were saved through the program (STOP TB, 2020). In addition, as

part of the health target of Sustainable Development goal of 2030, the program sought to expunge

the spread of TB completely and bring an end to the epidemic.

Another successful program intervention against TB and MDR-TB is the DOTS system

which was utilized in Bangladesh and several Asian countries. This program was termed the

breakthrough from TB in many of these countries. It utilizes the directly observed therapy strategy.

It involved a continuous monitoring of patients and ensuring adequate and quality health care

treatment through surveillance data. Statistics reported that over 35 million people has been cured

and 8 million people averted deaths through the DOTS-system (Zaman, 2010).

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 13

Proposed Programs

Although the interventions put in place to tackle the mortality and morbidity rate of MDR-

TB are yielding results, there are certain gaps and discrepancies to be addressed. Testing and

treatment have increased globally from 39% to 84% since 2013, but success rate has declined

exponentially in recent times (Falzon et al, 2017). This is a wake-up call to re-strategize and re-

evaluate the intervention programs. This study would recommend SMART goals and objectives

that are founded on existing programs but improves on the gaps existing in previous programs.

Goal: To reduce the prevalence and mortality rate of MDR-TB in the Eastern region, Nigeria. To

achieve this goal, this paper would establish 3 SMART objectives which are as follows:

Objective 1: To increase access to free TB anti-biotics by 65% by the end of year 2022 through

collaborative efforts using the DOTS-system.

Description: One of the major prerequisites to effectively achieve the goal is to increase access of

free TB medications to all TB and MDR-TB patients in the Eastern region of Nigeria. The region

has the highest number of deaths from TB cases due to the prevalence of HIV/AIDS (Ahiarakwem

et al, 2020). To reduce the rate of deaths in this region, it is crucial that all TB and MDR-TB

patients get access to free medications. Treatment of TB and MDR-TB is very arduous, and several

complications arise due to the complexity of the disease (Girum et al, 2018). As a result, ensuring

easy access to free medications through the DOTS system would reduce TB transmission in this

region. The STOP-TB campaign in collaboration with WHO proposes to reduce the rate of spread

of the disease by 95% as part of the Sustainable Development Goal of 2023 (STOP-TB, 2021).

Thus, it is vital that all patients get access to DOTS to accelerate the achievement of the SDG goal.

In addition, the direct observed therapy short course (DOTS) would be utilized to closely monitor

patients’ response to treatment. Access to medications should be a necessity in every health system,

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 14

however, Nigeria has a dilapidated health system which has led to the untimely demise of several

patients. On this premise, the collaborative efforts of the STOP-TB campaign with the WHO would

help to increase access to free TB anti-biotics by 65%. TB medications would be delivered to the

remotest parts of this region through outreach and establishment of resource centers. These centers

would serve as a medium to extend support to these regions and accentuate the achievement of

this goal.

In addition, these centers would be an extension of the UNAID to ensure that the needed support

is extended to the right quarters without the meddling of corrupt officials in the Nigerian ministry

of health.

Objective 2: To increase testing and contact tracing by 40% in the Eastern region, Nigeria by the

year ending of 2024.

Description: Another objective critical to this goal is to increase testing and contact tracing by

40%. This would increase an early detection of patients with MDR-TB and allow for an intensive

treatment procedure. In addition, it would help reduce the rate of spread within the region as the

persons exposed to this disease would be quarantined for surveillance and monitoring. The STOP

TB program aims to reduce the number of infected persons by 90% (STOP TB, 2020). Thus,

increasing testing and contact tracing would help curb the spread (Falzon et al, 2017). Additionally,

to achieve this goal, funding and collaborative partnerships with international organizations is vital.

This partnership would enable the Nigerian government to establish more testing sites and

equipment needed to accommodate patients and exposed persons. Studies established that a larger

percentage of TB and MDR-TB patients are treated by self-medication (Girum et al, 2018). The

high cost of treating MDR-TB made it difficult for patients to access quality healthcare which

accelerated the mortality and morbidity rate. Increasing capacities of testing sites and contact

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 15

tracing would increase patients’ access to intensive treatment, free medications, and early

surveillance.

If this strategy is put in place, the STOP TB program predicated that the rate of exposure to TB

would reduce by 95% (STOP TB, 2019). Testing and contract tracing are necessities in every health

system to curb an epidemic. It would decrease TB transmission and allow for an intensive

supervision of infected persons. The testing sites would be constructed under the guidelines

provided by WHO to ensure compliance and effective treatment outcomes. Conclusively, this

objective would be achieved through collaborative efforts with the global WHO team on the fight

against TB.

Objective 3: To improve surveillance by 80% on previously treated TB patients to monitor

resistance to treatments and implement public awareness campaigns to stop TB transmission in the

Eastern region of Nigeria by 2022.

Description: According to Zignol et al (2011), surveillance of MDR-TB and TB patients is crucial

to accurately monitor and predict patients’ response to treatment. Surveillance is imperative to

ensure effective treatment outcomes. To achieve the stated goal, increasing the rate of surveillance

by 80% on previously treated TB patients and newly detected MDR-TB patients is important. The

causes of MDR-TB occur mostly in previously treated TB patients, thus detailed monitoring and

surveillance of these patients is crucial to reduce morbidity rates. The data collected from this

surveillance would be used to implement public awareness of the disease such as the use of social

media. In addition, this surveillance data can be used to educate the public on the trends and growth

of the disease. Thus, increasing the surveillance would help curb TB transmission in this region of

the country. Surveillance collected in the past reduced TB transmission in developed countries by

40% between 2006 and 2011 (Zignol et al, 2011). Through collaborative efforts with WHO and

MULTI-DRUG RESISTANT TUBERCULOSIS (MDR-TB) 16

other international health organizations, rate of surveillance can be increased by 80% and

significant changes can be implemented by 2024. The importance of increasing surveillance cannot

be overemphasized. It is vital to creating a lasting solution to the spread of TB and reducing the

mortality …

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