Chapter One

1.0 Introduction to TB:

Characteristics of Tuberculosis:

Tuberculosis is a disease caused by the bacteria known as Mycobacterium tuberculosis.[1] Mycobacterium tuberculosis was identified in 1882 by Robert Koch.[2] It is an acid-fast bacillus and obligate aerobe which grows in about 15 to 30 days at a temperature of 35 to 37 degrees centigrade in an enriched media with a moderately acid base medium.

It has no natural reservoir and its antigenic properties are similar to the leprosy bacillus, the Bacille Calmette-Guerin (BCG) and other typical types of mycobacterium[3].

M. tuberculosis is pathogenic and virulent in nature. Its ability to cause disease depends on the susceptibility of the host as well as the aggressiveness of the invading organism[4] . An electron scan of the bacterium is highlighted below[5]:

Considered one of the most dreaded diseases of the 19th and 20th centuries, TB was the 8th leading cause of death in children between the ages of 1 to 4 years old during the early 1920’s especially in the developed countries of the world like the United States and Britain. As the general standards of living improved in the industrialised nations of the world so too did the decline in TB related incidences.

TB is often classed by the “infection of one of the two variants of the tubercle bacillus which is known to commonly affect man. They are Mycobacerium tuberculosis and bovis”[6].

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 milk are rare and few and far between[7].

TB can take an “active and an inactive” state of infection. The Word Health Organisation (WHO) describes an active case of TB as “a symptomatic disease due to infection with Mycobacterium tuberculosis”[8]. TB cases are generally classified as either pulmonary or extra-pulmonary.

Patients with pulmonary TB are further sub-divided into “smear-positive” and smear-negative cases[9]. Smear-positive cases are the most important sub-groups for control programmes as they are the source of infection. The WHO has defined a smear-positive patient as:

A patient with at least two sputum specimens positive for acid-fast bacilli (AFB) by microscopy

A 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 defined by the WHO as:

· A 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 chemotherapy

· A patient with a least one sputum specimen negative for AFB, which is culture-positive for M. Tuberculosis; and finally

Extra-pulmonary tuberculosis is defined by the WHO as:

· A 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 chemotherapy[10]

1.10 Mode of Transmission:

The transmission of Tuberculosis is done mainly through “droplet infection and droplet nuclei” which is said to be generated when a patient with tuberculosis coughs[11]. 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.

1.11 Signs & Symptoms:

The element of signs and symptoms in Tuberculosis is often misleading in the sense that the human body may harbour the bacterium that causes tuberculosis, and the immune system in the body suppresses the resultant effect 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 TB”

Latent TB is a condition where the patient has a TB infection but 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.[12]

The state of active TB develops some clear signs and symptoms in its diagnosis and they include:

Chills and cold spells

Fatigue

Fever

Loss of Appetite

Night Sweats

Unexplained weight loss[13]

Medical evidence has shown that there are varying degrees of Tuberculosis depending on which part of the human body it affects. Tuberculosis often attacks the lungs and its signs and symptoms include:

· Coughing that laughs for three weeks or more

· Coughing up blood

· Chest pain or pain resulting from breathing or coughing[14]

Tuberculosis 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 patient’s urine whilst Tuberculosis of the spine shows cases of back pain.

1.12 Incubation Periods

source - http://www.aarogya.com/index.php?option=com_content&task=view&id=834&Itemid=853

1.2 Public Health Importance

Standard of Living & State of Health In Nigeria

The United Nations Human Development (UNDP) programme has through the early 1990's paid greater emphasis in human development, welfare and poverty research. Through its Human Development Report, it has published the Human Development Index (HDI) which looks beyond GDP to a broader definition of a nation’s well-being. The link in welfare is a determinant index to health conditions, well being of persons and an insight onto their susceptibility and immunity to disease infection[15].

The economic condition of a nation is a guiding factor to growth, development and living standards of a nation’s citizen. The assumption that a citizen who is paid more per capita has his or her standard of living higher 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, poor standard of governance coupled with a dilapidated health care system has seen a decline in its overall standard of living.[16]

The 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 have poorer living standards which trigger health concerns[17].

The Human Development Index (HDI) provides a composite measure of three dimensions of human development. These areas include:

· Living a long and healthy life which is measured through life expectancy

· The level and degree of education and literacy of nation’s 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 purchasing power parity (PPP) and income base analysis.[18]

Critics of the process have 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 such as gender or income inequality or other indicators such 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 Nigeria's context, this index measures the country's standard of living and state of health by comparing certain key sectors such as life expectancy rates and adult literacy rates. The chart below gives a unique view to Nigeria's position. In this chart, Nigeria has been ranked 158th out of 177 amongst the developing nations of the world with an HDI rating of 0.470.[19]

The evaluation of a standard of living is relative, depending upon the judgment of the observer as to what constitutes a high or a low scale. Another relative index to the standard of living of a certain economic group can be gathered from a comparison of the cost of living and the wage scale or personal income. Factors such as discretionary income are important, but standard of living includes not only the material articles of consumption but also the number of dependents in a family, the environment, the educational opportunities, and the amount spent for health, recreation, and social services.

Nigeria as a nation has a GDP range of 6.4& as at 2008[20] and the number of dependants vary within the populations in the Northern & Southern 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 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 regions[21]. 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 standard of living may vary greatly among various groups within the country, it also varies from nation to nation, and international comparisons are sometimes 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 have a higher standard of living than developing countries. Nigeria is no exception to this theory. 

Records have 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 1990's 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 catastrophic decline in the first half of the 1990s but have recovered and improved their standard of living.[22]

The major exception is sub-Saharan Africa in areas such as Niger, Togo, Cameroon and 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 catastrophic effect of HIV/AIDS on life expectancy.[23]

Poverty is the major consequence of the dilapidated and chronic failure in Nigeria’s healthcare and social service system.[24] The access to standard resources such as good education, improved water supply, good nutritional standards and adequate shelter provisions has rendered 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 world’s TB infections are found in impoverished and developing nations with a poor level of standard of living and health concerns. 

1.3 Housing and Poor Sanitation

Nigeria; especially Lagos 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 authorities are responsible for things like planning permission needed before erecting structures. Nigeria's 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 implementation, 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 characterized by housing in the urban centres. The only resultant factor are the culminating effect and growth 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 rampant in the region.

Take for example the Northern 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 barely no room for cross ventilation, proper drainage or sewage facility[26]. 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.[27]

Average Annual Growth Rate

Population (Millions)

1960-1980

1980-2000

1960

1980

2000

%

%

Africa

31

77

190

4.7

4.6

Studies 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 change in social, economic and technological development[28]

The economic down town in the early 1980's saw a break in the level of growth and development with the nation’s economy to that of its population boom[29].

The lack of proper & adequate public infrastructure and social services has suffered tremendously and this has affected the process and level of urban planning and zoning in many cases. A practical example of this can be seen in the newly created Nigerian capital - 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. 

1.4 Housing and Poverty:

The 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 investment 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.

 The existing urban services are overstrained which often times lead to total collapse. A large proportion of the population does not have reasonable access to safe and ample water supply, and neither do they have the means 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 uses[30].

Studies over the years have shown the deplorable conditions of urban housing in Nigeria. They affirm that 75% of the dwelling units in Nigeria’s urban centres are substandard and the dwellings are sited in slums[31]. 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.

There 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.[32] 

The United Nations Standard for Nigeria’s room occupancy 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.[33] 

However, 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.

1.5 Prevalence of TB:

The 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.[34]

A 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 next 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 factors:

Estimates of incidence combined with assumptions about the duration of the disease. 

The duration of the disease is assumed to vary in accordance 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 finally

Whether or not the individual is infected with HIV[36]

According to the WHO, nearly two billion people; about one-third of the world’s population, are infected with TB.[37]

In 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 following:

· 42 years was the mean age of patients hospitalised with Tuberculosis in England between 2002-2003

· 69% of hospitalisations for Tuberculosis was for 15-59 year olds in England between 2002-2003

· 10% of hospitalisations for Tuberculosis was for over 75 year olds in England between 2002-2003.[38]

The 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 Columbia[39]

A comparison level of statistical studies in the prevalence levels of patients between 1999-2000 was compared to those of patient’s way back in 1971-1972 and the results were as follows:

LTBI prevalence was 4.2% with an estimated 11,213,000 individuals diagnosed with LTBI

Amongst 25 – 74 year olds, prevalence decreased from 14.3% in 1971-1972 to 5.7% in 1999-2000

Higher prevalence’s were seen in the foreign borns which accounting 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 born

A total of 25.5% of persons with LTBI had previously been diagnosed as having LTBI or TB; and

Only 13.2% had been prescribed treatment[40]

The 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.[41]

1.6 How Rapid Does TB Spread In Nigeria?:

Part of the Federal Governments programme in curbing the spread has been initiated through the National TB and Leprosy Control Programme (NTBLCP) which is seeking to achieve a 70% TB detection rate and an 85% cure rate by the end of 2010

The 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 implemented 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.[42]

Ideally, 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 Nigeria’s 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.[43]

A recent study carried 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.[44] Other factors which contribute to the growing spread of the disease include:

The lack of sufficient 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 undermine 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 NGO’s and governments like the EU and the United States; as indicated in the diagram below[45], the problem of funding still remains a key factor that continues to fuel the spread of the disease.

1.7 Aim:

The aim of this study (dissertation) is:

· To provide an insight into the terminal disease of Tuberculosis on an International and national level

· To evaluate DOTS implementation in Nigeria using a series of case detection and treatment outcomes as indicators

· To analyse and evaluate the resulting consequences of the DOTS programme in Nigeria within the 21st century and see if its adoption has favoured a positive control of TB over the years

1.8 Obejetive:

The following are the objectives of this study (dissertation):

· To evaluate case detection rates of smear-positive TB cases in selected areas implementing the DOTS programme within Nigeria

· To evaluate case detection rates of all TB cases notified in Nigeria within the 21st century

· To compare Nigerian experiences, failures and progresses to other developing nations and developed countries of the world affected by TB

· To identify potential weaknesses, strengths and developments in the DOTS programme in Nigeria

· To 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 data

1.9 Research Question:

Research 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 threat of TB in the country

Whether 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 Two

2.0 The Federal Republic of Nigeria:

Nigeria is located in Western Africa on the Gulf of Guinea and occupies a total area of 923,768 km² 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 853 km with the Atlantic ocean.[48]

The 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 defined 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.[49]

The country has over 250 ethnic group divisions.[50] The main tribes are the Hausa’s in the Nothern part of the country where majoriy of the TB pandemic is recorded, the Yoruba’s in the Southern part of the country known for is thick mangrove swambs and malaria manifestation and the Igbo’s in the Eastern part of the country where majority of the nations oil explorations and severe environmental degredation & oil spilllages are found.[51]

In a country ranked as the 8th most populous country in the world, the United Nations (UN) estimated Nigeria’s population at 131,530,000 in 2004.[52] The latest censors in Nigeria in 2006 put the countrys population at 150 million; that is almost 3 times the population of the United Kingdom 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 world’s population.[53] It is indeed a statistical nightmare when one considers that most of the world’s current populous nations are amongs the 22 nations in the DOTS programme.

Nigeria as a confederation of states is divided into thirty six (36) states and one Federal Capital Territory (Abuja) which are further divided into 774 LGA’s.[54] This 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.[55] The city of Lagos alone accounts for 8 million people[56]; a region of about the size of Cardiff. 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 location is higligted below[57].

Another key segment worth mentioning is the health sector in Nigeria. It is a known fact corroborated by the UN’s list of disfunctional national heathcare systems that over the past 4 decades Nigeria’s healthcare and general living conditions are poor, delapidated, ill funded and neglected since its independence from the British government in 1960. This is not categorically due to inability or lack of financing in a nation that is ranked as the 7th largest oil producing country in the world[58], but merely as a result of lack of proper planning & execution, misrule, mismanagement and corruption over the past 40 years.

The life expectancy rate in Nigeria is put at 47 years for both males and females and just half the population has access to potable and appropriate sanitation. Infant mortality rate is set at 97.1 deaths per 1000 living births with the only plausable progress being the HIV/AIDS rate in Nigeria which is recorded as being lower compared to other African nations such as Kenya, Zimbabwe and South Africa which are in double digits.[59] 

In 1995 the estimated TB cases was put at 220,000 cases. Today the figure is put at over 449,558 as at a 2006 survey done by USAID.[60] This just adds to the evidence of the growing problem in disease malcontrol highligted by poor hygiene, poor medical facilities and lack of good awareness and educational strategic policies which has seen the steady rise in other infectious outbreaks such as polio, cholera, malaria and sleeping sickness.

The Nigerian healthcare system is continuously faced with shortages of doctors due to the simple fact that many highly skilled Nigerian doctors have quiet understandably opted for better standards of living and opportunities in the developed world. It is estimated that in 1995 alone, over 21,000 Nigerian doctors were practicing in the United States of America (USA) alone.[61] This figure accounts for the current volume of qualified medical doctors in the whole country. On average this is just over 700 doctors per state and approximately one doctor to each LGA. This figures are a ridicule to a developing countries basic fundamental right and a case sudy to disaster and intrigue in the fight adopted by the DOTS programme in curbing the TB saga.

There is still a long way to go in curbing such health hazards and improving the chances of an exceedingly significant TB programme which needs political, economic and social will-power from the government of Nigeria to see through this disease which is currently ill-understood and not respected.

So what really is Tuberculosis and what is its impact in Nigeria?

2.1 TB In Nigeria:

Nigeria as a nation has had its own spell of disease epidemics and pandemics. With a well documented spell of malaria, cholera, meningitis and polio, its efforts in combating, curbing and procuring vaccination strategies and control measures have been mediocre to say the least.

The first TB clinic in Nigeria was opened in 1942 during the colonial period in Lagos.[62] WHO records confirm that during the period of 1955 to 1958 in Ibadan, Oyo State, the prevalence rate of TB was showing a level of increase from 0.03 to 0.12 per 1000 population.[63] Estimates published by the World Bank’s WDR (World Development Report) 40 years on showed an alarming increase in its incidence ratings to 222 cases per 100,000 population.[64]

The DOTS strategy for TB control was formally adopted by the Nigerian Federal Ministry of Health (FMOH) in 1993[65] and has seen a keen improvement in the resultant effects from donor support and National subsidy encouraged through free treatments, support with anti-TB drugs, laboratory reagents and awareness programmes. 

By the early 90’s, the National Tuberculosis and Leprosy Control Programme; otherwise known as (NTBLCP) was established by the Federal Ministry of Health (FMOH) in 1988 and formerly kicked of with the execution of its mandate in 1991. The programme cleverly adopts the governments 3 tier system and drafts in National, State and Local Government Co-ordinators, Health officers and Support Staffs to cover all of the 744 LGA’s.[66]

Apart from the DOTS programme currently in force in Nigeria, the Stop TB Partnership strategy instigated by the WHO, drafts in the idea of tackling special problems like multi drug resistant TB; otherwise known as MDR TB.[67] It also involves the integration of HIV related services with TB, engaging all stakeholders involved in the development and execution of this programme and carrying out relevant research to ensure that tuberculosis is tackled decisively within the Nigerian communities. But has this worked over time?

By the turn of the century, Nigeria was heavily involved with UN, WHO, CDC and every other internationally backed healthcare programme sponsored by governments of the developed world. In April 2009, Nigeria’s current Health Minister; Mr Babatunde Osotimehin was reported to have confirmed that Nigeria is ranked 5th on the WHO’s list of the 22 countries with the highest TB burdens worldwide.[68] These 22 countries collectively account for 80% of the global TB burden with the disease seeing an increase in Nigeria from 31,264 cases in 2004 to an outstanding 90,307 cases in 2008.[69]

The problem according to Wale Akeredolu; a Lagos Island Government Medical Officer, lies in two categories:

Inadequate awareness of the disease; and Reluctance by citizens affected by TB to seek treatment even where there is an awareness in sight.[70]

The failure and low trend of success in attributed to government bureaucracy coupled with the slow drive of awareness and initiative that is hampered by cultural, social and taboo related vices. These factors have made the average citizen either too frightened to come up and receive free treatment or too ill informed to carry out the basic health and sanitary culture needed to maintain clean environments and a healthier lifestyle.

2.11 Rates and Number of Cases:

The exact burden of TB in Nigeria is generally unknown due to the inadequacy and non-reliance of disease surveillance in the country. The burden of TB is therefore estimated indirectly using “epidemiological parameters” such as the Annual Risk of Tuberculosis Infection (ARTI), estimated incidence of smear-positive pulmonary TB, case notifications and notification rates[71]. The other parameters used include estimated coverage of the population with Nigeria’s healthcare services, the estimated case-fatality rates for smear positives and other forms and trends of Tuberculosis.

In 2004 for example, the WHO estimated Nigeria’s TB incidence rate in all forms of TB at 290 per 100,000 population within that year. The trend in incidence ratio was fixed at 2.6% per annum and the prevalence ratio was put at 531 cases per 100,000 population.[72] These figures compare with countries like Pakistan and Bangladesh and put Nigeria amongst the countries with the highest “incidence ratio” of TB in the world.

Within the same year, the mortality ratio was recorded at 82 deaths per 100,000 population. The heightened degree in mortality rate can be linked to the synergy between TB and HIV levels in Nigeria. This is evident in the statistics recorded again in 2004 which put the prevalence of HIV in adult TB patients at 27% for those aged 15 to 49 years.[73] 

New cases recorded in 2004 as a result of MDR-TB was recorded at 1.7% with a sharp increase prior to this on previously treated TB cases of multi drug resistant TB (MDR-TB) put at 7.6%.[74] 

Nigeria has since 1995 been recording a steady increase in notification rates. Due to insufficient and unreliable statistics it is yet unclear whether this level of increase is due to the awareness and publicity of the DOTS programme in Nigeria or simply due to the increase in incidence ratio to HIV. In a period of 10 years since 1995, Nigeria has seen an increase of over 120% in the notification rates of TB related syndromes.

The increase is also evident in age demographics. For instance, the highest levels of SS+ cases are recorded in both men and women between the age brackets of 25-35 years and astonishingly a sharp increase of similar magnitude in patients aged 65 and above. The figure below provided by the WHO and IUATLD programmes gives a graphical representation of the above statistics.[75]

Nigeria’s current Health Minister; Prof. Babatunde Osotimehin revealed that the number of TB cases notified in the country increased from 31,264 in 2002 to 90,307 in 2008. Within this period more than 450,000 TB cases have been successfully treated free of charge in the past 5 years in Nigeria.

According to the Minister, the rates and numbers of TB burden in Nigeria is compounded by the high HIV/AIDS prevalence of 4.6% recorded in 2007. Consequently, the FMOH has developed a strategy to maximise collaboration between HIV and TB programmes in Nigeria and has instituted a policy that all TB suspects and patients should be screened for HIV while all HIV positive patients should also be screened for TB. As a result of this policy, about 58, 942 TB patients (65.2% of the registered TB patients in 2008) were screened for HIV last year, out of which 14,698(24.94%) were found to be HIV positive.[76] 

2.12 TB Centres and Influence of Who on TB in Nigeria

Nigeria, being the most populous nation in Africa does have a great burden on itself regarding the amount of TB centres needed for its 772 local government regions. Prior to 1988 only a few states had a relatively well organised TB unit[77]

The centres were plagued with problems such as untrained personnel in charge of clinics and rendered healthcare services. The methodology adopted was one of “isolation of the infected patient” from the community for a long period[78]. The methods of case finding adopted by health workers and the administration of anti-TB drugs were not up to standard or the recommendation of the WHO and IUATLD. The risks therefore were that doctors were prescribing wrong medication based on wrong diagnostic methods and in some other cases due to the unavailability of drugs in certain centres, patients were either turned back or given alternative medicine.

It wasn’t until after 1988 that the government with the aid of WHO and the DOTS programme did healthcare in this sector began taking on a positive start. In 1991 the Federal Ministry of Health (FMOH); then in Lagos, formulated an official TB control policy consisting of a programme manual with goals and objectives, a fully kitted training programme, a plan for supervision and a development plan.

This development plan has over the years seen hospitals, facilities and TB centres move from just 3 centres in the mid 70’s to several hundreds in the early 90’s.

The Nigerian Health Minister confirmed that TB incidences were treated in all 36 states of he Federation with an average of 25 centres per state. An example of this can be seen in Zamfara State in Northern Nigeria which has 66 TB centres in the region. The state representative; Dr Ibrahim Bature confirmed that in 2008 it averaged 25 reports per month of TB related infections[79].

The government’s subsequent health policies backed by NGO’s, WHO and key stakeholders saw the change and redevelopment of Infectious Disease Hospitals (IDH) and TB clinics being built into society. The General Hospitals in the country such as “Murtala Mohammed Hospital” in Kano State, The University Hospital’s in Ife and Ibadan and he Lagos State University Teaching Hospital in Lagos have all been equipped with necessary facilities either donated by international donors, independent sponsors, NGO’s or government intervention.

A recent visit by the Global Alliance for TB Drug Development (TB Alliance) was made to the University College Hospital of Ibadan in September, 2007. The association gave a “satisfactory & favourable site rating” to what it saw as adequate clinical sites and associated Mycobacteriology laboratories needed to conduct clinical studies on anti TB drugs in human subjects.[80]

This is seen as a positive step Nigeria’s TB programme since it is a known fact that TB related research activity is very low in the region. Where funding is available, majority of it comes from individual grants from local research institutions; which includes Nigerian universities and also foreign donors and NGO’s. For example, the recently awarded “Round 5 Global Funds” for ATM was used in Nigeria to scale-up DOTS expansion but this left very little funding for research. Despite this, Nigeria has seen research on TB in such institutes as: 

NIMR, Lagos

The TB training school in Zaria, Kaduna State,

University College Hospital, Ibadan, Oyo State.

The National Institute for Pharmaceutical Research & Development (NIPRD) in Abuja in conjunction with Dr Clifton E Barry of National Institute of Allergy and Infectious Diseases, National Institute of Health, USA.

The challenges of TB related research in Nigeria can be summarised in these words.

Availability of standard research facilities such as proper infrastructure to house equipments, high grade standard equipments, hardware, kits etc.

Capacity to train health personnel, physicians, researches, lab scientists, nurses etc

Continued Financial backing of the programme and adequate support in maintaining facilities, remuneration of staff and recognition of work done

Implementation and maintenance of good clinical practice, good laboratory practice and respect on ethics of research in human subjects.[81]

2.13 What is DOTS?

The term “DOTS” stands for Directly-Observed Treatment Short course. It is a comprehensive and internationally recommended strategy endorsed by the World Health Organization (WHO) and International Union Against Tuberculosis and Lung Diseases (IUATLD) to detect and cure TB patients.[82]

2.14 Origin of DOTS and why it is adhered to:

The DOTS programme has been identified by the World Bank as one of the most cost effective health strategies available. The economic realities of a killer disease in Tuberculosis signifies the unique position the DOTS programme has to play especially in the developing economies of the world when the questions of affordability, reliability and effectiveness all play a part in the realities of life and the survival of the human race and those in desperate need of a cure.

2.15 Aims and Objectives of DOTS:

The aims and objectives of the DOTS strategy are designed to decrease the risk of infection, reduce morbidity and the transmission of the infection and prevent TB deaths. The achievements of these objectives are initiated through:

(a) identifying TB related cases in communities around the world; especially in developing countries; and

(b) treating TB cases by directly observing the medication intake of the patient over a relative period of between six to eight months. This is essential in order to ensure that medication is taken in he right combination and appropriate dosage in an effort to prevent the development of MDR-TB (Multi drug resistant Tuberculosis)[83]

The DOTS operational goals are geared towards detecting at least 70% of the new smear-positive TB cases and curing at least 85% of these detected cases. The end goal is that through these detection methods about 80% of deaths attributed to TB worldwide will have been successfully prevented.[84]

The WHO has always advocated that for the DOTS strategy to be effective and successful, five key elements are essential in its implementation. They are:

(1) Sustained Political and Financial Commitment:

TB can be cured and the epidemic reversed if adequate resources and administrative support for TB control are provided. Invariably this would enhance the opportunity for countries with a higher level of TB occurrences to make the TB policies part of their national health system.

(2) Diagnosis by Quality Ensured Sputum-Spear Microscopy:

This entails aspects such as detection amongst patients found to have symptoms of TB especially those with prolonged cough. An even heightened concern is given to case detection among HIV infected people or other similar high risk scenarios.

(3) Standardised Short-course Anti-TB Treatment (SCC) Given Under Direct and Supportive Observation (DOT):

This is a case management strategy that involves the direct observation of treatment. This segment helps to ensure that the right drugs are administered at the right time and for the full duration of the treatment.

(4) A Regular, Uninterrupted Supply of High Quality Anti-TB Drugs:

This segment ensures that there is a credible national TB programme in place that satisfies demand with the supply of high quality drugs secured through a satisfactory drug procurement and distribution system.

(5) Standardised Recording and Reporting:

This final segment enables the assessment of each and every patient as well as the assessment of the overall programme performance[85]

2.16 Search Strategies

To be filed in once research work and thesis write up is completed

2.17 Literature Review

· Data Extraction

· Appraisal of Study

· Baseline Data Extraction

· Findings Extracted

To be filed in once research work and thesis write up is completed

[1] Walton J., Barondess J.A. and Lock S., The Oxford Medical Companion, Oxford University Press, London, 1994.

[2] See Nobelprice.org via website link entitled “Robert Koch and Tuberculosis” at http://nobelprize.org/educational_games/medicine/tuberculosis/readmore.html

[3] Pagel W., Simmonds F.A.H., MacDonald N., “Pulmonary Tuberculosis”, Oxford University Press, London 1994.

[4] Grange J.M., Macobacteria and Human Disease, 2nd Edition, Arnold, London, 1996.

[5] Diagram on TB can be found at Todar’s Online Textbook on Bacteriology available online at: http://www.textbookofbacteriology.net/tuberculosis.html

[6] For further reading see Walton J., Barondess J.A. and Lock S., The Oxford Medical Companion, Oxford University Press, London, 1994.

[7] NTBLCP (1991), Workers Manual. Federal Ministry of Health Lagos.

[8] See World Health Organisation (1993). Treatment of Tuberculosis. Guidelines for National Programme, Geneva.

[9] Ibid.

[10] For further research see S.K. Sharma & A Mohan, Indian Journal on Medical Research, 120 on October 2004 also available online at: http://icmr.nic.in/ijmr/2004/1008.pdf

[11] See Australia’s Victorian Health Information Centre on Tuberculosis available online at: http://www.health.vic.gov.au/ideas/bluebook/myco_tb

[12] See Article from CDC entitled: TB Elimination – The Difference Between Latent TB Infection and Active TB Disease, February 2005 also available online at: http://www.temple.edu/ovpr/ehrs/docs/LatentTBandActiveTBFactSheet.pdf

[13] For further reading see link on MedTV available online at: http://tuberculosis.emedtv.com/latent-tuberculosis/latent-versus-active-tuberculosis.html

[14] Ibid.

[15] See Human Development Reports on the UNDP website available online at: http://hdr.undp.org/en/countries/

[16] For further reference see A. Abba, The Nigerian Economic Crisis; Causes and Solutions, Published by The Academic Staff Union of the Universities of Nigeria, 2005

[17] See UNDP: Nigeria – 2007/2008 Human Development Report, The HDI – Going Beyond Income available online at http://hdrstats.undp.org/countries/country_fact_sheets/cty_fs_NGA.html

[18] Ibid.

[19] Ibid.

[20] For further analysis of the countries GDP values see Mundi Index: Nigeria GDP – Real Growth Rate available online at: http://www.indexmundi.com/nigeria/gdp_real_growth_rate.html

[21] See further research on “Health Workers Renewing Fight Against Polio” available online at: http://www.pbs.org/newshour/bb/africa/jan-june09/nigeria_04-13.html

[22] See Russian Demographics; Wikipedia Analysis, available online at: http://en.wikipedia.org/wiki/Demographics_of_Russia

[23] See Medical Article by Mark Cichocki R.N., “The Deadly Intersection Between TB & HIV”, 2007 also available online at http://aids.about.com/od/opportunisticinfections/a/tbhiv.htm

[24] For further reference see text authority by Sofo C.A., Ali-Akpajiak and Tony Pyke, “Measuring Poverty in Nigeria” Oxfam Publ at pg. 8/65, 2003 also available online at: http://books.google.co.uk/books?id=4scgLlqWHWEC&source=gbs_navlinks_s

[25] See UNDP: Nigeria – 2007/2008 Human Development Report, The HDI – Going Beyond Income available online at http://hdrstats.undp.org/countries/country_fact_sheets/cty_fs_NGA.html

[26] See Rotary International Journal Publication entitled “Fulfilling Our Promise” by Norman R Veliquette, 2004

[27] See Article by Olotuah A.O. and Adesiji O.S., “Housing Poverty, Slum Formation and Deviant Behaviour”, 2005. Article is also available online at: http://209.85.229.132/search?q=cache:5DqImlRIWlQJ:www.york.ac.uk/inst/chp/hsa/autumn05/papers/OLOTUAH1.doc+salau,+1992&cd=3&hl=en&ct=clnk&gl=uk

[28] See text authority by: Mabogunje, Akin L., “Urbanisation in Nigeria”, University of London Publ., 1968

[29] See Text Authority by Salau A.T., “Urbanisation, Urban Poverty and Housing Inadequacy”, 1992

[30] Full insight on this point can be seen at Journal & article presentation made by Professor Akin L Mabogunje, “Global Poverty Research Agenda – The African Case”, Abuja, Nigeria, 2005.

[31] Ibid.

[32] Ibid.

[33] Article by Olotuah A.O. and Adesiji O.S., “Housing Poverty, Slum Formation and Deviant Behaviour”, 2005

[34] See WHO Website on “Prevalence on TB” also available online at: http://www.who.int/whosis/indicators/compendium/2008/2ptt/en/index.html

[35] Article on “The STOP TB Strategy – Building on and Enhancing DOTS to Meet the TB-Related Millennium Development Goals” hosted by the WHO and presented in 2006. Available online at: http://www.stoptb.org/resource_center/assets/documents/The_Stop_TB_Strategy_Final.pdf

[36] See WHO: Prevalence of Tuberculosis (Per 100000 Population) available online at: http://www.who.int/whosis/indicators/compendium/2008/2ptt/en/index.html

[37] See NIAID (National Institute of Allergy and Infectious Disease) on Tuberculosis available online at: http://www3.niaid.nih.gov/topics/tuberculosis/Understanding/overview.htm

[38] Department of Heath Statistic records for the United Kingdom available online at: http://www.dh.gov.uk/en/Publichealth/Communicablediseases/Tuberculosis/DH_278

[39] See statistic records available online at cureresearch.com at: http://www.cureresearch.com/t/tuberculosis/prevalence.htm

[40] See American Journal on Respiratory and Critical Care Medicine, Vol. 177 pp. 344-355, 2008 also available online at: http://ajrccm.atsjournals.org/cgi/content/short/177/3/348

[41] See Henry J. Kaiser Family Foundation website on US Global Health Policy available online at: http://www.globalhealthfacts.org/topic.jsp?i=12

[42] See Kaiser Network.org – The Henry J Kaiser Network Foundation on Tuberculosis - Nigeria Implements DOS at Antiretroviral Treatment Centres Nationwide, 11th July, 2006 also available online at: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=38419

[43] See Article written by Ogechi Eronini entitled “TB – A Leading Cause of Death Amongst People Leaving With AIDS”, 2007 aso available online at: http://www.panosaids.org/Left_read.asp?leftStoryId=123&leftSectionId=2

[44] Xinhua News Agency – Nigeria: Poverty, Obsolete Equipment Responsible for TB Spread in Nigeria, March, 2007 also available online at: http://www.aegis.com/news/ads/2007/AD070632.html

[46] See analysis of the Geography, Subdivision and Demographics of Nigeria in the Wikipedia printout available online at: http://en.wikipedia.org/wiki/Nigeria See also publication and Broadcast of the BBC on “What do you think about Nigeria”, BBC. 2006-06-16. http://news.bbc.co.uk/2/hi/africa/5072244.stm. Retrieved on 2008-08-05

[47] Ibid.

[48]Ibid

[49] Ibid

[50] Ibid. For further reference on this see Geographica: The complete Atlas of the world, "Nigeria", (Random House, 2002).

[51] Ibid. For further reference on Nigeria and Oil Spillage and Environmental Degradation see National Geographic, Nigerian Oil, Publication made in August 2009 and available online at: http://ngm.nationalgeographic.com/2007/02/nigerian-oil/oneill-text

[52] See analysis of the Geography, Subdivision and Demographics of Nigeria in the Wikipedia printout available online at: http://en.wikipedia.org/wiki/Nigeria

[53] Ibid

[54] Ibid

[55] Ibid

[56] Ibid

[57] See Wikipedia search on Nigeria available online at: http://en.wikipedia.org/wiki/Nigeria

[58] See List of TOP 10 Oil Producing Countries of the World at http://internationaltrade.suite101.com/article.cfm/top_ten_oil_countries For further reading see The Economist, Shutting the Stable Door – OPEC and Oil Prices, September, 1990

[59] See International Journal of Tuberculosis and Lung Disease, IUATLD Article on “Treatment Regimens in HIV-Infected Tuberculosis Patients – An Official Statement from the IUATLD, 2: 175-8 of 1998. See also WHO Website on Nigeria and HIV at http://www.who.int/countries/nga/areas/hiv/en/index.html

[60] See Global Tuberculosis Control: Surveillance, planning, financing: WHO Report 2008. For figurative analysis and survey see USAID Website on Nigeria and Infectious Diseases available online at http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/africa/nigeria_profile.html

[61] See Buse K, Walt G, and Mays N., Making Health Policy, Published by Open University Press, 2008 at pg. 140. See Also Wikipedia Printout on Healthcare in Nigeria available online at: http://en.wikipedia.org/wiki/Health_care_in_Nigeria

[62] For further reference see Unpublished reports by the NTBLCP on “TB in Nigeria”, 1998 and see also NTBLCP Workers Manual in he Ministry of Health, Lagos, 1991. For further reading see the USAID link on TB in Nigeria at: http://www.usaid.gov/ng/hiv_aids_r.htm and Arukwe E., Nigeria Newsday, TB and Its Scourge on Nigeria’s Population, 2007 available online at: http://www.nasarawastate.org/newsday/news/nasara07/NewArticle207.html

[63] Kochi A., Tuberculosis Control – Is DOTS the Health Breakthrough of the 1990’s?, World Health Forum, 18:225-47 , 1997

[64] Ibid.

[65] Kochi A., Tuberculosis Control – Is DOTS the Health Breakthrough of the 1990’s?, World Health Forum, 18:225-47 , 1997

[66] For further reference see Federal Ministry of Health Lagos, Workers Manual by the NTBLCP, 1991

[67] For further research on this see Wikipedia Printout on Multi Drug Resistant TB available online at: http://en.wikipedia.org/wiki/Multi-drug-resistant_tuberculosis

[68] See WHO Webpage on TB in Nigeria available online at: http://www.who.int/countries/nga/en/ 

[69] Ibid.

[70] See Global Health Reporting.Org, Weekly TB/Malaria Report, April, 2009 available online at: http://www.globalhealthreporting.org/article.asp?DR_ID=58098

[71] See WHO official website at: http://www.who.int/whosis/indicators/compendium/2008/3itt/en/index.html

[72] Ibid.

[73] Ibid.

[74] See Country Profile available online at: http://www.afro.who.int/tb/country-profiles/nig.pdf

[75] Ibid.

[76] Ibid.

[77] NTBLCP, 1991

[78] Ibid.

[79] See This Day Newspaper, “Nigeria 220 Tuberculosis Cases”, September 2008 available online at: http://allafrica.com/stories/200809090344.html

[80] See Presentation by Dr Aderemi O Kehinde, “Tuberculosis Drug Research in Nigeria – Challenges and Prospects”, 2005

[82] See Indian Journal of Tuberculosis, A Report on the 34th IUATLD World Conference on World Health, Paris, 2003 at 51:97-98. Also available online at http://medind.nic.in/ibr/t04/i2/ibrt04i2p97.pdf

[83] See article on STOP TB Working Group on DOTS – Plus for MDR-TB Strategy Plan 2006 to 2015 available online at http://www.finddiagnostics.org/export/sites/default/media/news/pdf/Stop_TB_Working_Group_on_DOTS_Final.pdf

[85] See World Health Organisation – Regional Office for the Western Pacific, “What is DOTS?”, available on the WHO website at: http://www.wpro.who.int/sites/stb/dots_definition.htm