Impact of the Stool-Based Xpert Test on Childhood Tuberculosis Diagnosis in Selected States in Nigeria.

BACKGROUND: In Nigeria, most children with tuberculosis (TB) present at primary health clinics where there are limited personnel skilled in collecting appropriate respiratory specimens from those who cannot produce sputum. KNCV Nigeria, in collaboration with the National Tuberculosis Control Program, implemented a modified simple, one-step (SOS), stool-based Xpert MTB/RIF method for diagnosis of TB in children who cannot expectorate sputum. We evaluated the impact of its implementation on childhood TB diagnosis. METHOD: A cross-sectional study was conducted across 14 selected states using secondary data of children presumed to have TB. Stool was collected from children presumed to have TB and processed using Xpert. RESULT: Out of 52,117 presumptive TB cases, 52% were male and 59.7% were under 5 years old. A total of 2440 (5%) cases were diagnosed with TB, and 2307 (95%) were placed on treatment. Annual TB notifications increased significantly after the introduction of the stool-based Xpert test when compared to those in the pre-implementation period. Increasing contributions from stool testing were observed throughout the implementation period, except in 2020 during the COVID-19 era. Overall, stool Xpert testing improved childhood TB notification in the studied states. Interventions aimed at awareness creation, capacity building, and active case finding improved the performance of the test.

Identifying Hot Spots of Tuberculosis in Nigeria Using an Early Warning Outbreak Recognition System: Retrospective Analysis of Implications for Active Case Finding Interventions.

BACKGROUND: Undiagnosed tuberculosis (TB) cases are the major challenge to TB control in Nigeria. An early warning outbreak recognition system (EWORS) is a system that is primarily used to detect infectious disease outbreaks; this system can be used as a case-based geospatial tool for the real-time identification of hot spot areas with clusters of TB patients. TB screening targeted at such hot spots should yield more TB cases than screening targeted at non-hot spots. OBJECTIVE: We aimed to demonstrate the effectiveness of an EWORS for TB hot spot mapping as a tool for detecting areas with increased TB case yields in high TB-burden states of Nigeria. METHODS: KNCV Tuberculosis Foundation Nigeria deployed an EWORS to 14 high-burden states in Nigeria. The system used an advanced surveillance mechanism to identify TB patients' residences in clusters, enabling it to predict areas with elevated disease spread (ie, hot spots) at the ward level. TB screening outreach using the World Health Organization 4-symptom screening method was conducted in 121 hot spot wards and 213 non-hot spot wards selected from the same communities. Presumptive cases identified were evaluated for TB using the GeneXpert instrument or chest X-ray. Confirmed TB cases from both areas were linked to treatment. Data from the hot spot and non-hot spot wards were analyzed retrospectively for this study. RESULTS: During the 16-month intervention, a total of 1,962,042 persons (n=734,384, 37.4% male, n=1,227,658, 62.6% female) and 2,025,286 persons (n=701,103, 34.6% male, n=1,324,183, 65.4% female) participated in the community TB screening outreaches in the hot spot and non-hot spot areas, respectively. Presumptive cases among all patients screened were 268,264 (N=3,987,328, 6.7%) and confirmed TB cases were 22,618 (N=222,270, 10.1%). The number needed to screen to diagnose a TB case in the hot spot and non-hot spot areas was 146 and 193 per 10,000 people, respectively. CONCLUSIONS: Active TB case finding in EWORS-mapped hot spot areas yielded higher TB cases than the non-hot spot areas in the 14 high-burden states of Nigeria. With the application of EWORS, the precision of diagnosing TB among presumptive cases increased from 0.077 to 0.103, and the number of presumptive cases needed to diagnose a TB case decreased from 14.047 to 10.255 per 10,000 people.

Predictors of COVID-19 Vaccine Acceptance among Healthcare Workers in Nigeria.

Healthcare workers (HCWs) are regarded as role models regarding health-related issues, including vaccination. Therefore, it is essential to identify the predictors for COVID-19 vaccine acceptance among them. A cross-sectional study to assess the risk perception, attitudes and knowledge of HCWs toward COVID-19 vaccination was carried out. A total of 710 responses were received between September 2021 and March 2022, from HCWs in the Northern, Western and Eastern regions of Nigeria. Cross tabulations were performed to determine statistical relations between sociodemographic variables, knowledge, attitudes and risk perceptions concerning COVID-19 vaccine acceptance. Multinomial logistic regression analysis was performed to determine the predictive variables for COVID-19 vaccine acceptance. Statistical analyses were performed and P-values less than 0.05 were considered statistically significant at a CI of 95%. Results showed that 59.3% of the participants were amenable to COVID-19 vaccines. Multinomial regression analysis identified 14 variables at α < 0.05 as predictors for vaccine acceptance. Male HCWs were 2.8 times more likely to accept the vaccine than their female counterparts. HCWs that were knowledgeable of the different kinds of vaccines, were willing to recommend the vaccines to their patients, believed that the timing of COVID-19 vaccination was appropriate and had recent vaccination history within three years were 1.6, 24.9, 4.4 and 3.1 times more likely to take COVID-19 vaccine than those not sure. The study found a relatively high trust (51.3%) in the Nigerian Center for Disease Control (NCDC) for information regarding COVID-19 vaccines. Therefore, the NDCD should disseminate more robust insights regarding the safety profiles of various COVID-19 vaccines.

Assessment of GeneXpert MTB/RIF Performance by Type and Level of Health-Care Facilities in Nigeria.

SETTING: Nigeria adopted GeneXpert MTB Rif as a primary diagnostic tool were available and accessible since 2016. The current geographical coverage of GeneXpert machines by LGAs stands at 48%, with a varied access and utilization. OBJECTIVES: To assess the association between the type and level of health facilities implementing GeneXpert MTB/Rif and performance outcome of the machines in Nigeria. STUDY DESIGN: Retrospective secondary data analysis of GeneXpert performance for 2017 from GXAlert database. The independent variables were type and levels of health care facilities, and dependent variables were GeneXpert performance (utilization, successful test, error rates, MTB detected, and Rifampicin resistance detected). RESULTS: Only 366 health care facilities are currently implementing and reporting GeneXpert performance, the distribution is 86.9% and 13.1% public and private health care facilities respectively, and only 6.3% of the facilities are primary health care. Of 354,321 test conducted in 2017, 91.5% were successful, and among unsuccessful test 6.8% were errors. The yield was 16.8% MTB detected (54,713) among which 6.8% had Rif resistance. The GeneXpert utilization rate was higher among private health care facilities (55.8%) compared to 33.3% among public health care facilities. There was a statistically significant difference in the number of successful test between public and private health facility-based machines as determined by one-way ANOVA (F(1,2) = 21.81, P = 0.02) and between primary, secondary and tertiary level health facility-based machines (F(1,2) = 41.24, P < 0.01). CONCLUSION: Nigeria with very low TB coverage should rapidly scale-up and decentralize GeneXpert services to the private sector.

Proficiency testing for HIV, tuberculosis and malaria diagnosis in clinical laboratories in Nigeria.

BACKGROUND: Proficiency testing (PT) is a means of verifying the reliability of laboratory results, but such programmes are not readily available to laboratories in developing countries. This project provided PT to laboratories in Nigeria. OBJECTIVES: To assess the proficiency of laboratories in the diagnosis of HIV, tuberculosis and malaria. METHODS: This was a prospective study carried out between 2009 and 2011. A structured questionnaire was administered to 106 randomly-selected laboratories. Forty-four indicated their interest in participation and were enrolled. Four rounds of pre-characterised plasma panels for HIV, sputum films for tuberculosis and blood films for malaria were distributed quarterly by courier over the course of one year. The results were returned within two weeks and scores of ≥ 80% were reported as satisfactory. Mentoring was offered after the first and second PT rounds. RESULTS: Average HIV PT scores increased from 74% to 95% from the first round to the third round, but decreased in the fourth round. For diagnosis of tuberculosis, average scores increased from 42% in the first round to 78% in the second round; but a decrease to 34% was observed in the fourth round. Malaria PT performance was 2% at first, but average scores increased between the second and fourth rounds, culminating in a fourth-round score of 39%. Many participants requested training and mentoring. CONCLUSIONS: There were gross deficiencies in the quality of laboratory services rendered across Nigeria. In-country PT programmes, implemented in conjunction with mentoring, will improve coverage and diagnosis of HIV, tuberculosis and malaria.

Improving quality in national reference laboratories: The role of SLMTA and mentorship.

BACKGROUND: The Nigerian Institute of Medical Research houses two reference laboratories: the virology and tuberculosis laboratories. Both were enrolled in the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme. OBJECTIVE: To describe the impact of SLMTA and discuss factors affecting the results, with an emphasis on mentorship. METHODS: The SLMTA programme was implemented from April 2010 through November 2012. Participants attended three workshops and executed quality improvement projects; laboratory auditors evaluated performance using a standard checklist. The virology laboratory did not receive mentorship; however, the tuberculosis laboratory had an international mentor who visited the laboratory four times during the programme, spending two to four weeks embedded within the laboratory during each visit. RESULTS: There was an overall improvement in the performance of both laboratories, with the virology laboratory increasing 13% (from 80% at baseline to 93% at exit audit) and the tuberculosis laboratory increasing 29% (from 66% to 95%). These scores were maintained nine months later at the surveillance audit. CONCLUSION: The SLMTA programme resulted in improved and sustained quality management performance for both laboratories. Mentoring was a possible factor in the substantial improvement made by the tuberculosis laboratory and should be considered in order to augment the training received from the SLMTA workshops.

Genetic determinants of drug-resistant tuberculosis among HIV-infected patients in Nigeria.

Tuberculosis (TB) is the most common opportunistic infection in human immunodeficiency virus (HIV)-infected patients and the emergence of drug-resistant tuberculosis (DR-TB) is a growing problem in resource-limited settings. Adequate infrastructure for testing drug sensitivity and sufficient evidence of first-line resistance are currently unavailable in Nigeria. We collected sputum samples from HIV-infected patients enrolled in the Harvard PEPFAR/APIN Plus program over 12 months at two PEPFAR antiretroviral therapy (ART) clinics in the southwest and north central regions in Nigeria. Smear-positive sputum samples were submitted for GenoType MTBDRplus testing (n = 415); mutations were confirmed through sequencing. Our results show high rates of DR-TB in Nigerian HIV-infected individuals (7.0% for rifampin [RIF] and 9.3% for RIF or isoniazid [INH]). Total RIF resistance indicative of MDR-TB in treatment-naive patients was 5.52%, far exceeding the World Health Organization predictions (0 to 4.3%). RIF resistance was found in 6/213 (2.8%) cases, INH resistance was found in 3/215 (1.4%) cases, and MDR-TB was found in 8/223 (3.6%) cases. We found significantly different amounts of DR-TB by location (18.18% in the south of the country versus 3.91% in the north central region [P < 0.01]). Furthermore, RIF resistance was genetically distinct, suggesting possible location-specific strains are responsible for the transmission of drug resistance (P < 0.04). Finally, GenoType MTBDRplus correctly identified the drug-resistant samples compared to sequencing in 96.8% of cases. We found that total DR-TB in HIV-infection is high and that transmission of drug-resistant TB in HIV-infected patients in Nigeria is higher than predicted.