Building and Strengthening Infection Control Strategies to Prevent Tuberculosis - Nigeria, 2015.

Tuberculosis (TB) is the leading cause of infectious disease mortality worldwide, accounting for more than 1.5 million deaths in 2014, and is the leading cause of death among persons living with human immunodeficiency virus (HIV) infection (1). Nigeria has the fourth highest annual number of TB cases among countries, with an estimated incidence of 322 per 100,000 population (1), and the second highest prevalence of HIV infection, with 3.4 million infected persons (2). In 2014, 100,000 incident TB cases and 78,000 TB deaths occurred among persons living with HIV infection in Nigeria (1). Nosocomial transmission is a significant source of TB infection in resource-limited settings (3), and persons with HIV infection and health care workers are at increased risk for TB infection because of their routine exposure to patients with TB in health care facilities (3-5). A lack of TB infection control in health care settings has resulted in outbreaks of TB and drug-resistant TB among patients and health care workers, leading to excess morbidity and mortality. In March 2015, in collaboration with the Nigeria Ministry of Health (MoH), CDC implemented a pilot initiative, aimed at increasing health care worker knowledge about TB infection control, assessing infection control measures in health facilities, and developing plans to address identified gaps. The approach resulted in substantial improvements in TB infection control practices at seven selected facilities, and scale-up of these measures across other facilities might lead to a reduction in TB transmission in Nigeria and globally.

Reaching the underserved: Active tuberculosis case finding in urban slums in southeastern Nigeria.

BACKGROUND: Nigeria ranks 10th among 22 high TB burden countries with low TB case detection that relies on passive case finding. Although there is increasing body of evidence that active case finding (ACF) has improved TB case finding in urban slums in some parts of the world, this strategy had not been implemented in Nigeria despite the pervasiveness of urban slums in the country. OBJECTIVE: To assess the yield and profile of TB in urban slums in Nigeria through ACF. METHODS: A prospective, implementation study was conducted in three urban slums of southeastern Nigeria. Individuals with TB symptoms were identified through targeted screening using a standardized questionnaire and investigated further for TB. Descriptive and bivariate analyses were performed using SPSS. RESULTS: Among 16,743 individuals screened for TB, 6361 (38.0%) were identified as TB suspects; 5894 suspects were evaluated for TB. TB was diagnosed in 1079 individuals, representing 6.4% of the screened population and 18.3% of those evaluated for TB. Of the 1079 cases found, 97.1% (n=1084) had pulmonary TB (PTB), and majority (65%) had new smear-positive TB. Children (<15years) accounted for 6.7% of the cases. Also, 22.6% (216) of the cases were HIV co-infected, among whom 55.1% (n=119) were females. The average number of individuals needed to screen to find a case of TB was 16. CONCLUSIONS: There is high prevalence of TB in Nigeria slum population. Targeted screening of out-patients, TB contacts, and HIV-infected patients should be optimized for active TB case finding in Nigeria.

Epilepsy prevalence, potential causes and social beliefs in Ebonyi State and Benue State, Nigeria.

Epilepsy is a common neurological disorder in Nigeria. Many individuals are affected in rural areas, although prevalence data is not available. In this study we aimed to establish the prevalence of epilepsy in a rural community in south-east Nigeria, a community suspected for having a high number of people living with epilepsy. We compared this with the prevalence in a nearby semi-urban community in north-central Nigeria. In both communities we identified potential causes of epilepsy and obtained information on the social beliefs regarding epilepsy. We used door-to-door surveys and focus group discussions. The epilepsy prevalence in the rural community was 20.8/1000 [95% confidence interval (CI): 15.7-27.4]. The prevalence in the semi-rural community was lower, namely 4.7/1000 [CI: 3.2-6.9]. The difference in prevalence was highly significant (χ(2)-test, p<0.0001). In both communities most people with epilepsy were in the age range of 7-24 years. Causes that might be contributory to the prevalence of epilepsy in both communities included poor obstetric practices, frequent febrile convulsions, head trauma, meningitis and neurocysticercosis. In both communities we found stigma of people with epilepsy. In conclusion, the epilepsy prevalence in the semi-urban community is similar to that in industrialized countries. In contrast, the rural community has a much higher prevalence. This may require the establishment of specific community-based epilepsy control programs. Community interventions should focus on treatment of acute epilepsy and on stigma reduction.

Trend in case detection rate for all tuberculosis cases notified in Ebonyi, Southeastern Nigeria during 1999-2009.

Unlike previous annual WHO tuberculosis reports that reported case detection rate for only smear-positive tuberculosis cases, the 2010 report presented case detection rate for all tuberculosis cases notified in line with the current Stop TB strategy. To help us understand how tuberculosis control programmes performed in terms of detecting tuberculosis, there is need to document the trend in case detection rate for all tuberculosis cases notified in high burden countries. This evidence is currently lacking from Nigeria. Therefore, this study aimed to assess the trend in case detection rate for all tuberculosis cases notified from Ebonyi state compared to Nigeria national figures. Reports of tuberculosis cases notified between 1999 and 2009 were reviewed from the Ebonyi State Ministry of Health tuberculosis quarterly reports. Tuberculosis case detection rates were computed according to WHO guidelines. 22, 508 patients with all forms of tuberculosis were notified during the study. Case detection rate for all tuberculosis rose from 27% in 1999 to gradually reach a peak of 40% during 2007 to 2008 before a slight decline in 2009 to 38%. However, the national case detection rate for all tuberculosis cases in Nigeria rose from 7% in 1999 and progressively increased to reach a peak of 19% during 2008 and 2009. Since the introduction of DOTS in Ebonyi, the programme has achieved 40% case detection rate for all tuberculosis cases - about 20% better than national figures. However, with the current low case detection rates, alternative mechanisms are needed to achieve the current global stop- TB targets in Nigeria.

From DOTS to the Stop TB Strategy: DOTS coverage and trend of tuberculosis notification in Ebonyi, southeastern Nigeria, 1998-2009.

BACKGROUND: Nigeria ranks fourth among the 22 high tuberculosis (TB) burden countries. The estimated incidence of all TB cases in 2009 was 311/100,000 population. Since the implementation of DOTS in Ebonyi state, southeast Nigeria, the epidemiology of TB in the region has not been documented. Therefore, the objective of this study was to assess the type and case notification dynamics of TB following DOTS expansion and to examine age- and sex-specific trends in TB notification rate. METHODS: A retrospective trend analysis of case notification data from the Ebonyi State Ministry of Health records from 1998 to 2009 was conducted. Patients were diagnosed according to the National TB and Leprosy Control Programme guidelines. Denominators for TB notifications were derived from population census data. RESULTS: Of the 24, 475 cases notified between 1998 and 2009, 66% were smear-positive, 31% smear-negative and 3% had extra-pulmonary tuberculosis. Overall, the proportion of new smear-positive cases notified decreased continuously from 67% to 48% in 2009 while that of smear-negative cases increased from 29% to 40% in 2009. In 2005, 13 (100%) of the local government areas were covered by DOTS. Despite initial increase in case notification with DOTS expansion, the case notification rate had a mean annual decline of 3.1% for all TB cases (falling from 123/100,000 to 77/100,000), and of 5% for smear-positive patients (falling from 80/100,000 to 32/100,000). Smear-positive notification rate in children <14 years was consistently low while 25-34-year-old persons were affected most. However, smear-positive rates among persons aged =65 years did not change. Overall, annual new smear-positive notification rates were persistently lower in females than males. CONCLUSION: TB notification rate shows a decreasing trend in our region with a pool of infectious cases in young-persons. Additional targeted, type and age-/sex- specific interventions for TB control are needed.