A rapid assessment of the impact of the 2020 “ENDSARS” protests and political unrest on weekly TB notification in Southwest Nigeria

INTRODUCTION

Globally, tuberculosis (TB) is a leading cause of mortality, especially in developing countries like Nigeria. In 2020, there was an 7.5% increase in TB-associated mortality from 2019, bringing the number of TB-related deaths to about 1.5 million people.^[1] Nigeria is a high burden country for TB, HIV-associated TB, and drug-resistant TB. In 2019, the total TB incidence was 429,000 cases, with a rate of 219/100,000.^[2] Nigeria is one of the countries with a huge gap between TB case notifications and incidence, leading to a high burden of “missing” TB cases. The COVID-19 pandemic has greatly affected TB surveillance and services worldwide^[3-5] evidenced by an 18% decline in TB case notifications in 2020. In many developing countries like Nigeria, TB notification has been negatively affected by a mix of the COVID pandemic, a high TB burden, and armed conflicts and crisis. Nigeria has been plagued by different political and economic crises such as the “ENDSARS” protest, in recent times.^[6]

Special Anti-Robbery Squad (“SARS”), an acronym for SARS, was a Nigerian Police Force unit established in 1992 to investigate and prosecute violent crimes such as robbery and kidnapping. However, the unit later became a machinery for witch-hunt, torture, and brutality against Nigerian youths, culminating in a nationwide youth protests tagged “ENDSARS,” just as the COVID-19 lockdown was being eased.^[7,8] The protests lasted approximately 3 weeks, with attendant heightened insecurity and curfews in some states – Lagos, the epicenter of the protest, as well as Oyo, Ogun, and Osun states. Infrastructures and equipment in several health care institutions such as hospitals and laboratories were either destroyed or carted away by hoodlums who hijacked the protest.

It is well reported that crises and armed conflicts have a negative impact on TB surveillance and case notifications.^[9,10] In the Northeast region, the Boko Haram crisis has led to a decrease in TB case notifications and surveillance.^[10] We hypothesized that crisis such as the “ENDSARS” protest would have a negative effect on TB surveillance and notification in the affected states. Thus, we aimed to analyze the impact of the protest on weekly TB notification and overall TB cascade performance.

MATERIAL AND METHODS

The Study took place in over 300 health facilities and 103 local government areas (LGA) across Lagos, Oyo, Ogun, and Osun States, all in Southwest Nigeria. Facility clients and community residents were targeted for TB screening in these states. Identified presumptive cases were linked up for further laboratory evaluation and treatment initiation when eligible.

A retrospective review of the weekly TB notification data across Lagos, Ogun, Osun, and Oyo states over 7 weeks between September 21 and October 30, 2020, was carried out. Weekly trends in TB case notification were tracked before and during the “ENDSARS” protests. Weekly TB cascade data (population eligible for screening, screened, presumptive TB cases, evaluated, diagnosed, and notified) were compared between the preceding 3 weeks of the nationwide protest (September 20–October 7) and 3 weeks that followed the onset of the protest (October 11–30, 2020). Data were collected and analyzed using Microsoft Excel 2020. Descriptive statistics such as frequency and percentages were used to present the results.

RESULTS

In [Figure 1], except for Oyo state and clinical TB diagnosis, TB notification declined across the remaining three states and interventions types from 3 weeks before the “ENDSARS” protests to 3 weeks following the onset of the protests. Highest decreases, −27% from 174 to 137, were observed in community interventions, bacteriologically diagnosed declined by −20% from 599 to 481, and in Osun state by −26% from 65 to 48. There was a significant increase in clinical diagnosis, + 58% from 99 in the 3 weeks before to 156 during the 3 weeks of the protest. However, in Oyo state which had the least curfews and breakdown in security, TB cases increased by 23% from 98 before to 121 in the 3 weeks of the protest.

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Figure 1:

% Change in weekly TB Surveillance pre-post END SARS Protest by intervention types, states and types of TB.

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In [Figure 2], the total outpatient department (OPD) visits declined between the preceding weeks 1–3 when compared with weeks 5–7 following the onset of the protest, that is, from 140,886 to 130,788. Similar patterns were observed for TB screening and TB diagnostic evaluation. TB screening declined from a total of 146,955 to 136,348 while the number of TB diagnostic evaluation declined from 6567 to 5624 from the 3 weeks before to the 3 weeks following the ENDSARS protest. TB screening exceeded OPD attendance since screeners routinely screened accompanied relatives of OPD attendees also for TB.

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Figure 2:

Weekly tuberculosis cascade before and after ‘ENDSARS’ protest, Nigeria.

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DISCUSSION

Our findings showed that TB case notification declined across all the four Southwest states during the political unrest in Nigeria. This echoes findings from other conflict settings such as Northeast Nigeria and Sudan.^[10,11] With the activities of insurgents in Northeast Nigeria, a study evaluated 7-year trend in TB notification in Adamawa state and found systematic decline in TB notification since 2013 and this was worse in LGAs affected by and initially captured by insurgents. This study also reported differences in declining trends across gender and age groups.^[10] Many factors could explain the decline in TB case notification in conflict situations. These include breakdown in diagnostic infrastructure from destruction or theft, fear of hospital visits for safety reasons, decreased NGO support for government (training, support staff, etc.), restriction in vital TB, and related services such as contact investigation among others. During the 2020 “ENDSARS” protest in Nigeria, there were reports of destruction of health facilities and abandonment by staff for safety concerns; theft of TB diagnostic GeneXpert machine and sputum samples of TB patients, raising concerns of potential outbreak.^[12] In Syria for instance, 912 health workers were reportedly killed and over 70% of health facilities were targeted between the onset of Syrian conflict in March 2011 and August 2019.^[13,14] Similarly, in the conflict-ridden region of Goma, Democratic Republic of Congo, only 61% of health facilities were available for provision of TB services during conflict.^[15] Shockingly, our study revealed a downward trend in community TB notification during the unrest, underlining the need to strengthen community systems and providers (Patent Proprietary Medicine Vendors, Community pharmacists, and other informal providers) to deliver TB services in crisis when conventional health facility may be difficult to access.

We found significant decline in hospital attendance, TB screening, as well as TB laboratory evaluation which is not uncommon in protracted conflict situations. Interestingly, despite the overall decline in TB notification, clinical TB notification increased during the conflict period. A Syrian study observed earlier that physicians were more likely to rely on non-specific symptoms (cough, weight loss, night sweats, fever, etc.) for the diagnosis of TB in crisis.^[14] Building capacity of physicians for clinical diagnosis of TB will not only help to increase overall TB notification but also be a good preparedness strategy for sustained service delivery in conflicts. One limitation of the study is that unlike most protracted conflict situations reported in the literature, ours was rather an acute conflict and political unrest that lasted for 3 weeks. The selected study states were those where major conflict took place and likely to have major impact on TB and other health services, even though the conflict was of national impact and affected more than four states reported in our study.

CONCLUSION

The study revealed a decline in weekly TB case notification and across the cascade indicators in Southwest Nigeria (with some states being disproportionately affected than others), following a national youth protest. Attacks on health care institutions during crises are a violation of human rights and are against the laws of engagement in armed conflict.^[16-18] Despite national and regional under-performance in clinical TB diagnosis and notification before the conflict, this skill came to the fore in the event of a complex emergency that destroyed some of the existing health infrastructures, underlining the need to sustain this in normalcy. There is an urgent need for national capacity building on TB program preparedness in crises, with emphasis on how national and subnational governments, hospitals, and communities could anticipate and respond effectively, thus maintaining the minimum package of TB care in conflict. There is also a need to build resilient systems and train HCWs on strategies to continue care in areas prone to armed conflict. A reduction in hospital visits is a typical response to crisis, leading to declining in screening and diagnosis of TB. Therefore, patient-centered approaches such as the use of mobile vans and X-rays for community screening need to be scaled up and become part of routine services delivered by the TB program. A strong integration of the TB program with community structures such as Village Health Committee is capable of sustaining TB services in times of crisis. Finally, TB program needs to look beyond the health sector and partnership and coordination with other non-health sector players such as transportation department, police, and criminal justice systems will be invaluable in sustaining TB services in a crisis.