Nigeria’s battles for equity in health, with Delft

Among the top 5 highest TB-burden countries, Nigeria is estimated to have more than 450,000 TB patients, of which 69 thousand are children. A major health crisis, about 13 thousand are estimated to be missing persons with TB.

The highest TB-burden country in Africa, Nigeria is actively working towards providing equity in health.

The Nigeria National Tuberculosis Program and various in-country stakeholders aim to provide healthcare facilities in the remotest locations. They have been actively utilising mobile TB clinics, portable digital X-ray systems, mobile digital X-ray systems and computer-aided detection for tuberculosis software (CAD4TB).

Since 2017, the KNCV Tuberculosis Foundation in Nigeria has been using OneStopTB Mobile Clinics under the ChallengeTB Program. What started with designating one mobile clinic for Nasarawa State at the beginning of the year, led to procuring another one for Ogun State by the end of the year. Called “Wellness on Wheels,” each mobile clinic is equipped with a multi-functional EasyDR, CAD4TB software and a lab compartment for Xpert testing. Bringing free TB testing to the communities leads to quick diagnosis and immediate healthcare treatment.

Recently, in 2021, Delft Imaging supported the Lagos State Ministry of Health in a TB project. To bridge the gap of inadequate logistics, and ultimately bring diagnosis to their doorsteps, 21 digital X-ray installations were made. This included 8 semi-mobile containerized X-ray systems, 10 room installations and 3 mobile TB screening vans. We delivered digital X-ray systems, including the EasyDR, MAC and Dragon light. All systems also received our CAD4TB software and user training.

In 2022, Delft Imaging delivered 20 portable Delft Light backpack X-ray systems to Nigeria, to be used by the KNCV Foundation in Nigeria. Each of the 20 Delft Light X-ray systems, utilized the CAD4TB software and the project came with the relevant installation, training and maintenance services.

Later in that same year – in 2022, Delft Imaging delivered 4 portable Delft Light backpack X-ray systems to the Heartland Alliance in Nigeria.

Finally, in 2022, Delft Imaging delivered 12 multi-functional, stationary EasyDR X-ray systems to the National Agency for the Control of Aids (NACA). Each EasyDR system came with the CAD4TB artificial intelligence software, and with onsite training and installation.

In total, the installed base of Delft Imaging solutions in Nigeria covers 51 portable X-ray systems, 20 stationary X-ray systems (also including mobile TB screening clinics) and 71 sites using the CAD4TB artificial intelligence software.

In order to ensure an effective service and support infrastructure in Nigeria, Delft Imaging works closely with its local in-country partner for rapid onsite support whenever needed.

Making a difference

To eradicate TB, it is critical to ensure TB screening in marginalized and remote sections of the nation. In 2019, the OneStopTB Clinics (called Wow trucks in Nigeria)enrolled more than 45000 people from rural and suburban community settings. These include motor parks, markets, health facilities and mosques in 16 local government areas within the Kano State. In addition to 920 new cases, 3,380 clients were presumptive of TB. While 31 cases were drug-resistant TB, 889 were drug-susceptible TB with a linkage to treatment rate of 97 %.

KNCV Nigeria used the Delft Light for active TB case findings in communities living in the hard-to-reach Delta Region. Within four months, more than 6000 adults and children (ages 4+) were enrolled. Of the 6218 people whom Delft Light, with CAD4TB, screened, 778 presumptive TB and 757 cases were found. These were then further evaluated by Xperts. The program found 70 cases diagnosed with TB. A study found that Number Needed to Screen (NNS) with this approach was more effective than the intervention with the Wow mobile clinics, particularly among the hard-to-reach populations in rural areas.

In the 2022 Union Conference on Lung Health, the KNCV Foundation in Nigeria extensively shared the results of their projects:

Their studies discussed the importance of Wellness on Wheels mobile TB clinics (WoW) and Delft Light played in the increased use of digital X-ray with CAD for active TB case-finding. While their screening efficiency was found similar, their impact, however, was different. The approach with Delft Light led to a higher clinical diagnosis and the WoW clinic had more impactful advocacy.

One of their studies compared various TB case-finding interventions and assessed their numbers needed to screen (%NNS) and test (%NNT). It was found that the portable digital X-ray with AI and a real-time referring/reporting digital platform has shown the best yields in a resource-limited setting.

Another study compared various TB case-finding approaches. It concluded that TB screening using CXR-CAD showed a higher screening yield than the WHO 4-symptom screen. Also, CXR-CAD combined with the WHO 4-symptom screen and GeneXpert as a single diagnostic algorithm yield TB far superior to CXR and GeneXpert alone.

A study exploring the use of artificial intelligence software-aided chest X-ray screening for community active case-finding in Kano, Nigeria, showed the added value of using CXR screening with CAD compared to WHO symptom screen for an efficient community active TB case-finding intervention in Kano state, Nigeria.

Studying the interim result of AI-powered portable CXR in boosting TB case-finding in Katsina State, Nigeria, it was found that the use of Delft Light with CAD4TB at prisons and marginalized communities led to increased TB case notifications. It also doubled case contribution at prisons.

A comparison of yield from symptomatic W4SS screening and mass mobile X-ray in schoolchildren in Lagos, Nigeria concluded that active case-finding based on CXR with CAD was preferable as the yield was better than 4-symptom screening.

Similarly, a study exploring the potential of existing artificial intelligence to improve TB case-finding at the Nigeria Correctional Centre Lafia, Nasarawa State, north- central Nigeria, concludes that the use of digital X-rays with CAD4TB to improve TB screening of most at-risk populations can be efficient in finding missing TB cases, especially in high TB burden countries.