Assessment of TB underreporting by level of reporting system in Lagos, Nigeria

BACKGROUND: Nigeria has an estimated TB prevalence of 219 per 100,000 population. In 2019, Nigeria diagnosed and notified 27% of the WHO-estimated cases of all forms of TB and contributed 11% of the missing TB cases globally.OBJECTIVE: To assess TB underreporting by type and level of health facility (HF), and associated factors in Lagos State, Nigeria.METHODOLOGY: Quantitative secondary data analysis of TB cases was conducted in 2015. χ2 test was used to assess the association between treatment initiation, TB underreporting, local government area (LGA) and HF characteristics.RESULTS: Overall, 2,064 persons with bacteriologically confirmed TB (15.5%) were not matched to patients in sampled TB registers. Treatment status was unknown for 86 cases (IQR 55–97) per LGA. LGAs with higher case-loads had higher proportions of cases with unknown TB status. Discrepant reporting of treated TB was also common (60% HFs). Primary-level TB treatment facilities and unengaged private facilities were less likely to notify.CONCLUSION: There was TB under-reporting across all types and levels of HFs and LGAs. There is a need to revise or strengthen the process of supervision and data quality assurance system at all levels

Introducing bedaquiline: experiences from the Challenge TB Project

BACKGROUND: Drug-resistant tuberculosis (DR-TB) remains a global public health crisis. In 2013, the World Health Organization recommended the introduction of bedaquiline (BDQ) for eligible DR-TB patients.METHODS: We conducted a retrospective review and analyses of project reports from 2016 to mid-2019 on the processes, activities implemented, available results on enrolment and interim treatment outcomes, across the 23 Challenge TB (CTB) supported countries.RESULTS: Initial introduction of BDQ-containing regimens in the 23 CTB-supported countries took on average 2 years, with subsequent nation-wide scale-up achieved in Ethiopia and Kyrgyzstan within a short time period. Successful implementation required critical interventions including advocacy, revision of policies and guidelines, capacity building of health care workers, and strengthening of laboratory networks. The number of countries providing BDQ increased from 9 to 23; 9398 patients were enrolled on bedaquiline containing regimens; 71% were culture-negative after 6 months of treatment; and the number of countries reporting serious adverse events increased (from 5 to 18). Major challenges included limited in-country coordination with drug regulatory agencies, unrealistic quantification and drug ordering, weak laboratory networks and reporting systems for drug safety.CONCLUSION: BDQ introduction required a systematic and programmatic approach. The initial time investment helped achieve initial introduction and scale-up of coverage, ownership and sustainability by National TB Programmes.

Unsuccessful Xpert® MTB/RIF results: the Nigerian experience

Setting: Nigeria, a high tuberculosis (TB) burden country. Objective: To study the rate, distribution and causes of unsuccessful Xpert^® MTB/RIF test outcomes, with the aim of identifying key areas that need to be strengthened for optimal performance of the assay. Design: This was a retrospective analysis of data uploaded between January and December 2015 from Xpert facilities to the central server using GXAlert. Result: Of 52 219 test results uploaded from 176 Xpert machines, 22.5% were positive for Mycobacterium tuberculosis, 10.8% of which were rifampicin-resistant; 4.7% of the total number of results were invalid, 4.2% had error results and 2.1% no result outcomes. Technical errors were most frequent (69%); these were non-seasonal and occurred in all geopolitical regions and at all health facility levels. Temperature-related errors were more prevalent in the North-West Region, with peaks in April to June. Peak periods for temperature and machine malfunction errors coincided with the periods of low utilisation of the assay. Conclusion: The key challenge affecting performance was poor adherence to standard operating procedures. Periodic refresher training courses, regular supervision, preventive maintenance of Xpert machines and proper storage of cartridges are strategies that could improve Xpert performance.

Economic support intervention improves tuberculosis treatment outcomes in rural Nigeria

SETTING

A secondary care hospital in rural Nigeria.

OBJECTIVE

To investigate the feasibility of providing financial incentives to tuberculosis (TB) patients under routine conditions, and to determine their impact on TB treatment outcomes in a low-resource setting.

DESIGN

A prospective, non-randomised intervention study.

RESULTS

A total of 294 TB patients (respectively 173 and 121 in the control and intervention periods of 3 months' duration each) were registered in the study. The patients did not differ in terms of their demographic or clinical characteristics (P not significant). The treatment success rate was 104/121 (86.0%) during the intervention, and 123/173 (71.1%) during the control period (P = 0.003). The proportion of patients who were lost to follow-up significantly decreased during the intervention period (20.2% vs. 5.0%, P <0.001). There were no differences in deaths (P = 0.8) or treatment failure rates (P = 0.5) in the intervention and control periods. There was also no difference in the rate of sputum smear conversion after the intensive phase of treatment (88.1% vs. 91.5%, P = 0.5). Independent determinants of treatment success were female sex (adjusted odds ratio [aOR] 1.9), human immunodeficiency virus negativity (aOR 2.5) and receiving financial incentives (aOR 2.3).

CONCLUSIONS

Financial incentives proved to be effective in improving treatment success and reducing loss to follow-up among poor TB patients in Nigeria.

Community referral for presumptive TB in Nigeria: a comparison of four models of active case finding

Background

Engagement of communities and civil society organizations is a critical part of the Post-2015 End TB Strategy. Since 2007, many models of community referral have been implemented to boost TB case detection in Nigeria. Yet clear insights into the comparative TB yield from particular approaches have been limited.

Methods

We compared four models of active case finding in three Nigerian states. Data on presumptive TB case referral by community workers (CWs), TB diagnoses among referred clients, active case finding model characteristics, and CWs compensation details for 2012 were obtained from implementers and CWs via interviews and log book review. Self-reported performance data were triangulated against routine surveillance data to assess concordance. Analysis focused on assessing the predictors of presumptive TB referral.

Results

CWs referred 4–22 % of presumptive TB clients tested, and 4–24 % of the total TB cases detected. The annual median referral per CW ranged widely among the models from 1 to 48 clients, with an overall average of 13.4 referrals per CW. The highest median referrals (48 per CW/yr) and mean TB diagnoses (7.1/yr) per CW (H =70.850, p < 0.001) was obtained by the model with training supervision, and $80/quarterly payments (Comprehensive Quotas-Oriented model). The model with irregularly supervised, trained, and compensated CWs contributed the least to TB case detection with a median of 13 referrals per CW/yr and mean of 0.53 TB diagnoses per CW/yr. Hours spent weekly on presumptive TB referral made the strongest unique contribution (Beta = 0.514, p < 0.001) to explaining presumptive TB referral after controlling for other variables.

Conclusion

All community based TB case-finding projects studied referred a relative low number of symptomatic individuals. The study shows that incentivized referral, appropriate selection of CWs, supportive supervision, leveraged treatment support roles, and a responsive TB program to receive clients for testing were the key drivers of community TB case finding.

Tuberculosis among nomads in Adamawa, Nigeria: outcomes from two years of active case finding

BACKGROUND

Nomadic populations are often isolated and have difficulty accessing health care, leading to increased morbidity and mortality. Although Nigeria has one of the highest tuberculosis (TB) burdens in Africa, case detection rates remain relatively low.

METHODS

Active case finding for TB among nomadic populations was implemented over a 2-year period in Adamawa State. A total of 378 community screening days were organised with local leaders; community volunteers provided treatment support. Xpert(®) MTB/RIF was available for nomads with negative smear results.

RESULTS

Through active case finding, 96 376 nomads were verbally screened, yielding 1310 bacteriologically positive patients. The number of patients submitting sputum for smear microscopy statewide increased by 112% compared with the 2 years before the intervention. New smear-positive notifications increased by 49.5%, while notifications of all forms of TB increased by 24.5% compared with expected notifications based on historical trends. Nomads accounted for respectively 31.4% and 26.0% of all smear-positive and all forms TB notifications. Pre-treatment loss to follow-up and treatment outcomes were similar among nomads and non-nomads.

DISCUSSION

Nomads in Nigeria have high TB rates, and active case-finding approaches may be useful in identifying and successfully treating them. Large-scale interventions in vulnerable populations can improve TB case detection.

HIV-TB co-infection in children: associated factors and access to HIV services in Lagos, Nigeria

BACKGROUND

Human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading causes of death from infectious disease worldwide. The World Health Organization estimates that the prevalence of HIV among children with TB in moderate to high prevalence countries ranges between 10% and 60%. This study aimed to determine the access to HIV services of HIV-TB co-infected children.

METHODS

A retrospective review of data of children diagnosed with TB in Lagos State, Nigeria from 1 January 2012 to 31 December 2013.

RESULTS

A total of 1199 children aged between 0 and 14 years were diagnosed with TB. Of 1095 (91.3%) who underwent testing for HIV, 320 (29.2%) were HIV seropositive. The male-to-female ratio of HIV-TB positive outcomes was 1:0.9. Of the 320 HIV-TB co-infected children, 57 (17.8%) were aged <1 year, 86 (26.9%) 1-4 years and 186 (58.1%) 5-14 years; 186/320 (58.1%) began cotrimoxazole preventive therapy (CPT), and 151 (47.2%) were put on antiretroviral treatment (ART). ART uptake was not significantly higher in facilities where HIV-TB services were co-located (P > 0.05).

CONCLUSION

The uptake of CPT and ART was low. There is a need to intensify efforts to improve access to HIV services in Lagos State, Nigeria.

Estimating the cost of TB and its social impact on TB patients and their households

Illness often poses a significant financial burden on individuals and their households, and tuberculosis (TB) is no exception. Although TB treatment is free in Nigeria, patients are likely to incur costs due to multiple visits during treatment. The purpose of this study was 1) to examine the health-seeking behaviour of TB patients and the costs borne by TB patients in Nigeria, and 2) to assess the social impact of TB disease on TB patients and their families/households. Of 260 TB patients surveyed, the majority (74.7%) were aged between 20 and 49 years. TB patients expended an average of US$52.02 (N = 8323.58, at the rate of US$1 = N = 160) per person on all visits associated with diagnosis and receipt of diagnostic test results. Overall, households experienced a shortfall of about US$57.30 (N = 9174.72) or 24.9% of income loss due to TB illness. Further analysis revealed that 9.7% of TB patients relied on children of school age or below to finance the costs of TB illness.

TUBERCULOSIS CONTROL IN SECURITY CHALLENGED STATES OF NORTH-EAST NIGERIA. ARE THERE SIGNIFICANT IMPACT?

BACKGROUND

Nigeria in the past few years is faced with various security challenges in different parts of the country. The most severe in the last three years has been the crisis in northern Nigeria and specifically the north-eastern States, where three of the States have been under emergency rule for a year. Health care delivery system is usually one of the major casualties in a security challenged environment leading to unavailability or low utilization of services.The aim of this paper is to share the experience of TB services in states under emergency rule.

METHODOLOGY

A retrospective review of program data (reportable indicators for TB case finding,TB/HIV and treatment outcome for periods of eight years (2006-2013) comparing national data with north-east and the three states most affected by security challenges (Borno, Adamawa & Yobe).

RESULTS

A national positive trend on case notification for all forms of TB and smear positive, with a declined in 2011 but generally the case notification has remain low (59/100,000 in 2013 compared to estimated prevalence of 338/100,000). North east data is a negative trend for case notification and this is worse for 2 states (Borno and Yobe) while Adamawa shows and increase CNR from 2012 because of TB Reach active case, finding. Treatment success rate has a positive trend both national, north east states and in the 3 challenged states (TSR above 84%). TB/HIV indicators for north east are 81%, 75%, and 58% for HCT CPT and ART respectively, these figures has serious fluctuations within and among the three security challenged states with Borno most affected.

CONCLUSIONS

Insecurity can pose a challenge for TB control activities especially case finding, therefore the need for innovative approaches for case finding in areas of insecurity. Chronic infectious diseases like TB and HIV should be incorporated into emergency responses offered by organisations and agencies for internally displaced persons.