Empowering Nomadic Communities: TB Screening and Care Project in Nigeria

1. TB Screening & Linkage to Care for Nomadic Populations in North-Eastern Nigeria The 49th Union World Conference on Lung Health, The Hague, October 2018 Stephen John, MD, MPH/ICHD (CEO, Janna Health Foundation)

2. Outline • Overview of the Project: • Background • Objectives • Strategies • Key Interventions • Results • Challenges in TB Screening & Linkage to Care • Lesson Learnt • Conclusion

3. Project Location & TB Services • Population: 3.8 m • Land Mass: 42,000 Km2 • Number of BMUs: 21 • Total Health Facilities: 1,040 • Total DOTS Centers: 142 • Coverage: 1/27,000 pop • TB Diagnostic Centers: • GeneXpert: 1 • AFB Microscopy: 44 • Coverage: 1/87,000 pop • Target Population: 0.45 m • Evaluation Population: 3.8 m Map of Nigeria and Adamawa State

4. Background..1 • Over 50m Nomads Globally: • 30m (60%) in Africa • Estimated 9.3m Nomads in Nigeria: • 5.3m are Nomadic Pastoralists • Estimated 450,000 in Adamawa • 4m are Nomadic farmers/fishermen • High Rates of TB among Nomads: • Sahelian Nomads, • Maasai, Fulani & other Nomads in Africa Chabasse et al, 1985, Omar, 1992, Van Cleeff et al, 1995, A. Sheik-Mohammed & J. P. Valema 1999

5. Background…2 • Factors influencing high rates of TB: • Poor access to Health Facilities • Malnutrition • Poor Housing (overcrowding/ventilation) • Consumption of un-pasteurized milk • High rates of Bovine TB • Mobile population • Poor vaccine coverage (BCG) • Low level of formal education/Low awareness on TB • Low Literacy rate of (0.2 – 2%) Imperato, 1975; Ailou, 1992, Omar, 1992, E. F. Ejeh et al, 2013, Adamu et al, 2015; Ige. M. Tilo et al, 2017

6. Objectives • To expand TB services in an innovative and highly collaborativemanner through the involvement of the Nomadic Leaders to ensure communityownershipandsustainability • To determine whether or not the incidence rates of TB among the target population is higher as compared to the evaluation population

7. Key Strategy: Preparatory..1 • Identification, orientation & linkage of “Contact” Person with the TB Programme (State & LGA levels) • Mapping: • Grazing Reserves, Nomadic settlements, Resting Points & Health Facilities (proximal to reserve, route & resting points) • Identification & engagement of Nomadic Community Leaders • Advocacy Meeting with Community Leaders • Identification/Selection of CVs & HCWs

8. Key Strategy: Preparatory..2 • Training/orientation of CVs, HWs & Lab Staff • Develop/pre-test jingles in “Fulfulde”, “Hausa” and English • Re-constitute ACSM Committee • Advocate to line Ministries/Boards: • Ministry of Health, LGAs, Livestock Production & Universal Basic Education Board (UBEB)

9. Engaging the Nomads

10. Interventions • ACSM: • Strategic & sustained advocacy to key stakeholders including result sharing • Broadcast of Radio & TV Jingles • Active TB Case Finding: • Tent-to-tent screening of settlements • Outreach on Market days • Sputum transportation & Diagnosis: • AFB Sputum Microscopy • GeneXpert for SS- presumptives • Linkage to care

11. Impact of ACF on TB Case Notifications: ‘08 –’17 TB REACH Insurgency

12. Impact of ACF onAdamawa’s TB Treatment Outcomes Cured Treatment Completed Died Treatment Failure Loss to Follow-up Transfer Out Despite more people being treated in 2012, outcomes were better than 2011.

13. Challenges in TB Screening/Linkage to Care..1 • No appropriate guidelines/SOPs: • NTP to develop appropriate guidelines for their key populations • Maps of cattle routes: • Need for validation • Engagement process: • Peculiarity of Nomadic Communities • Difficult topography/Hard-to-Reach • Appropriate project vehicles • Strategic decentralization of TB services

14. Cattle Routes

15. Accessing Nomadic Communities

16. Challenges in TB Screening/Linkage to Care..2 • Climatic Condition: • Schedule more activities in the dry season • Childhood TB Diagnosis • Delays in commencement of treatment • Replacement Worker • Migration • Alternative TB Care: • Traditional Healers, PMVs and CPs • Adherence to TB Treatment • Community Leader engagement/involvement • PARE Trained HCWs & Nomadic CVs/TS • Language Barrier!

17. Lesson Learnt • Dealing with a mobile population • TB Screening: Target market days, resting points, cattle routes & grazing reserves • Treatment/adherence: Use Nomadic youth as CVs and sustained engagement of Community Leaders • Communication: LGA TB Supervisors, HCWs, sustained supplies • Use of Veterinary Dispensaries for DOTS • Use of Nomads as CVs • Cross border interventions • Strategic advocacy and result sharing • Ownership & Sustainability

18. Acknowledgements • Adamawa & Taraba State Governments • The 2 State TB Programme Teams • Pastoral Resolve (PARE); Adamawa State • KNCV Nigeria • NTBLCP, Nigeria • Netherlands Leprosy Relief • Members of the Global indigenous STOP TB initiative (GISI) Funders • TB REACH / Stop TB Partnership • Global Affairs Canada

19. Thank You