Challenges of Tuberculosis Control in Lagos State, Nigeria: A Qualitative Study of Health-Care Providers' Perspectives.

BACKGROUND: Tuberculosis (TB) burden in Nigeria is a reflection of the challenges of TB control strategy in the country. This study explored the challenges encountered by the health workers in public and private TB treatment centers in Lagos, Nigeria. METHODS: In-depth interviews were held with 34 health workers providing TB services in private and public health facilities and the Lagos state Program Officer between October 1, 2016 and January 31, 2017. The transcripts were read severally and coded for qualitative data analysis. Themes were developed from coding. RESULTS: Insufficient or lack of funds to track patients lost to follow-up, conduct home visits, collect drugs from the central stores, and shortage of laboratory reagents were some of the logistical challenges encountered by the health workers. There was shortage of health workers and some were yet to be trained resulting in work overload. This was situation aggravated by the frequent redeployment and health worker attrition in the public and private sector respectively. CONCLUSION: The government need be proactive and show leadership by finding lasting solutions to the logistical and human resource challenges facing the LAgos State TB and Leprosy Program.

Community health care workers in pursuit of TB: Discourses and dilemmas.

Community-led tuberculosis (TB) active case finding is widely promoted, heavily funded, but many efforts fail to meet expectations. The underlying reasons why TB symptom screening programs underperform are poorly understood. This study examines Nigerian stakeholders' insights to characterize the mechanisms, enabling structures and influences that lead programs to succeed or fail. Eight focus group discussions were held with Community Health Workers (CWs) from four models of community-based TB screening and referral. In-depth interviews were conducted with 2 State TB program managers, 8 Community based organizations (CBOs), and 6 state TB and Leprosy Local Government supervisors. Transcripts were coded using Framework Analysis to assess how divergent understandings of CWs' roles, expectations, as well as design, political and structural factors contributed to the observed underperformance. Altruism, religious faith, passion, and commitment to the health and well-being of their communities were reasons CWs gave for starting TB symptom screening and referral. Yet politicized or donor-driven CWs' selection processes at times yielded implementers without a firm grounding in TB or the social, cultural, and physical terrain. CWs encountered suspicion, stigma, and hostility in both health facilities and communities. As the interface between the TB program and communities, CWs often bore the brunt of frustrations with inadequate TB services and CBO/iNGO collaboration. Some CWs expended their own social and financial capital to cover gaps in the active case finding (ACF) programs and public health services or curtailed their screening activities. Effective community-led TB active case finding is challenging to design, implement and sustain. Contrary to conventional wisdom, CWs did not experience it as inherently empowering. Sustainable, supportive models that combine meaningful engagement for communities with effective program stewardship and governance are needed. Crucially effective and successful implementation of community-based TB screening and referral requires a functional public health system to which to refer.

Evaluation of outcomes of tuberculosis management in private for profit and private-not-for profit directly observed treatment short course facilities in Lagos State, Nigeria.

BACKGROUND: The engagement of private practitioners in the public-private mix of tuberculosis (TB) management started in 2007 in Lagos State Nigeria. This study compared the treatment outcomes of patients managed at private for profit (PFP) and private not for profit (PNFP) directly observed treatment short course (DOTS) facilities. METHODS: A retrospective review of treatment cards of TB patients managed between January 1, 2012, and June 30, 2012, in seven PFP and four PNFP DOTS facilities that served as treatment and microscopy center under the Lagos State TB and Leprosy Control Programme (LSTBLCP) at least 2 years before data collection was conducted. RESULTS: A total of 372 treatment cards of TB patients were reviewed, of which 132 (35.5%) and 240 (64.5%) were from PFP and PNFP DOTS facilities, respectively. Treatment success rate was higher among patients managed at PFP (89.4%) DOTS facilities than PNFP (81.3%) DOTS facilities (P = 0.04). The proportion of patients lost to follow-up (12.5% vs. 8.3%), dead (3.3% vs. 1.5%) and treatment failure (2.5% vs. 0.8%) was higher among patients managed at PNFP DOTS facilities (P > 0.05). The odds that patients treated at PFP DOTS facilities had treatment success were about four times higher than PNFP DOTS facilities when other variables have been controlled for (P < 0.05). CONCLUSION: There is need by the LSTBLCP to engage more private practitioners to increase case detection and improve treatment outcomes of TB patients.

Treatment Outcomes of Childhood TB in Lagos, Nigeria.

BACKGROUND: : Treatment outcomes of tuberculosis (TB) in children are rarely evaluated by most national TB programmes in sub-Saharan Africa. This study evaluated the treatment outcomes of children treated for TB in Lagos State, Nigeria. METHODS: A retrospective review of programme data of the Lagos state TB and the Leprosy control programme in Nigeria from 1 January 2012 to 31 December 2012. Treatment outcomes were categorized according to the national TB guidelines. RESULTS: A total of 535 cases of childhood TB were notified in 2012, representing 6.3% of the total TB cases notified in Lagos state in 2012. The prevalence of TB/HIV co-infection was 29%. The treatment success rate was 79.2% in TB/HIV-negative children compared with 73.4% in TB/HIV-positive children (p = 0.1268). Children <1 year had the worst treatment outcomes (p < 0.001). CONCLUSION: There is a need to intensify effort at improving notification and treatment outcomes in children.

Trend of childhood TB case notification in Lagos, Nigeria, 2011-2014.

BACKGROUND: Childhood tuberculosis (TB) has been neglected by national TB programs in sub-Saharan Africa because of the emphasis on adult smear-positive TB cases. About 80,000 HIV children die from TB, and over 550,000 childhood TB cases occur annually, representing 6% of the global TB burden, making TB an important cause of morbidity and mortality in children. Thus, this study assessed the trend of childhood TB cases notified in Lagos, Nigeria from 2011 to 2014. METHODS: Retrospective data review of childhood TB cases notified to the Lagos State TB and Leprosy Control Programme (LSTBLCP) between January 1, 2011 and December 31, 2014. RESULTS: A total of 2396 children were treated for all forms of TB representing 6.8% of the total 35,305 TB cases notified during the study period. This constituted 1102 (46%) males and 1294 (54%) females. There was a progressive increase in the proportion of children treated for TB from 495 (5.9%) in 2011, 539 (6.4%) in 2012, 682 (7.2%) in 2013 and 680 (7.6%) in 2014. Of the total childhood TB cases notified, 16.3-20% were new sputum pulmonary smear positive; 68.2-74.6% were new sputum pulmonary smear negative; while extra-pulmonary TB accounted for 6.7-10.6%. The case notification rate (CNR) of childhood TB per 100,000 increased from 13.4 in 2011, 14.3 in 2012, 17.7 in 2013 and 17.2 in 2014. CONCLUSION: There was an increase in the case notification rate of TB among children between 2011 and 2014. Efforts should be made to sustain this increasing trend.