Nigeria’s battles for equity in health, with Delft

About

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. It brings free TB testing to communities, leading to quick diagnosis and immediate healthcare treatment. The project was also covered by the news channel Newspost in Nigeria.

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 containerised X-ray systems, 10 room installations and 3 mobile TB screening vans. We delivered digital X-ray systems, including the EasyDR, MAC and Delft Light. All systems also received our CAD4TB software and user training.

In 2021, another 5 OneStopTB clinics were delivered to Kaduna State, including the multi-functional EasyDR X-ray system and the CAD4TB artificial intelligence software.

Moreover, additional Delft Light portable X-ray systems and CAD4TB were delivered to Nigeria as part of the Introducing New Tools Project, also called iNTP. The project, supported by USAID and the Stop TB Partnership, aims to roll out cutting-edge innovations in diagnostics, treatments, and digital health technologies to strengthen TB care in high-burden countries. 7 Delft Light portable X-ray systems with CAD4TB were delivered to the KNCV Foundation in Nigeria, and 3 Delft Light portable X-ray systems with CAD4TB were delivered to the Institute of Human Virology in Nigeria (IHVN)

In 2022, we delivered 20 portable Delft Light backpack X-ray systems to Nigeria for use 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, we delivered 4 portable Delft Light backpack X-ray systems, and followed it up by 3 more, to the Heartland Alliance in Nigeria.

In addition, in 2022, we 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 2024, Nigeria procured over 200 additional Delft Lights, with CAD4TB, for the National Tuberculosis, Leprosy & Buruli-Ulcert Control Programme.

The installed base of Delft Imaging solutions in Nigeria covers 38 portable X-ray systems, 18 mobile X-ray systems, 10 mobile OneStopTB clinics, 22 stationary EasyDR X-ray systems, and 78 sites with CAD4TB, AI software.

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.

Client Stories

For more information about how the Delft Light portable X-ray and CAD4TB solutions are used in Nigeria, please view the story of “Finding the Missing TB Cases Using DX with AI” The KNCV Nigeria Experience,’ as presented by Dr. Odume Bethrand, Executive Director of the KNCV Foundation in Nigeria. The story with presented during the Delft Q2 webinar of 2022. Dr. Bethrand also presented on “Using CAD in Bi-Directional Screening” during the Delft Q2 Webinar 2021.

During the webinar, Dr. Odume noted: “Since 2018, KNCV Nigeria has pioneered the chest X-ray with CAD4TB in Nigeria with the ‘Wellness on Wheels’ Trucks. It has been pivotal in our targeted TB case finding and advocacy, especially within rural communities and hard-to-reach locations.

Thanks to the introduction and pilot of the Delft Light Backpack, we are scaling up digital X-ray with AI for TB case finding. The pilot helped us generated local evidence and experience, which informed country-wide scale-up by other TB partners with the National TB Program to help bridge the gap in TB case-finding in Nigeria, Digital X-ray with AI has shown efficiency in TB case finding as the number needed to screen and the test ad reduced significantly.” The story of the iNTP porject using the delft Light X-ray and CAD4TB artificial intelligence software was also covered in a video made by Delft Imaging in collaboration with the KNCV Foundation in Nigeria.

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.

Delft Light in use, KNCV Nigeria

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.

A 2023 Stop TB Partnership Report detailed the implementation of Delft Light and CAD4TB software in Nigeria. As part of the introducing New Tools Project (iNTP), supported by USAID, Institute of Human Virology Nigeria (IHVN) and KNCV deployed 10 Delft Light with CAD4TB software across eight states, facilitating TB screening in remote areas and among high-risk populations. It has significantly improved case detection rates, with over 130,000 individuals been screened so far, of which 10% were detected with abnormal CXR, and 3,200+ diagnosed with TB through this intervention.

KNCV’s Executive Director, Dr. Bethrand Odume, also spoke about CAD4TB in an interview in 2023. He spoke how portable x-ray systems with CAD4TB has not only contributed to advancing TB screening, but has also reduced the cost of x-rays, minimised transportation time and expenses incurred by patients, thus significantly enhancing access to TB services.

In the beginning of 2024, a study evaluated the Wellness on Wheels for TB improves efficiency, yield, and outcomes in Nigeria. The mobile TB clinic combines digital chest radiography with computer-aided automated detection (CAD) and chronic cough screening to identify presumptive TB cases among high-risk populations in communities, health facilities, and prisons.

The study lauded the “Wellness on Wheels” (WoW) for its efficiency and the effectiveness of its team, noting significant operational improvements and high engagement from all involved. Specifically, it mentions the evolution of operations in real-time to address issues, and incremental improvements in client volumes, target group inclusion, on-site testing, TB treatment initiation, and TB treatment success. These findings suggested that “the return on investment from CAD may be doubled by following up clients with high CAD scores and/or provision of an early intervention regimen or vaccine.”

Case Study

Delve into these impactful case studies throughout the years:

2021

2022

2023