Perceived ease of use of Truenat among laboratory staff as a new diagnostic tool for TB in Nigeria: Result of a pilot roll-out.

In January 2020, WHO released a rapid communication on use of molecular assays as initial tests for diagnosis of tuberculosis, recommending Truenat as a replacement for smear microscopy in TB diagnosis. This study was designed to assess perceived ease of use of Truenat among Laboratory staff as a new diagnostic tool for TB in Nigeria. This study used a cross-sectional design. All trained Laboratory personnel operating the Truenat Duo equipment in 38 Truenat sites in the country were included. Information was obtained using a pre-tested self-administered questionnaire. Ease of use of Truenat was assessed using twenty-three variables on a five-point Likert scale of 1-5. The variables were analyzed quantitatively and qualitatively. Good Ease of use of Truenat was determined by proportion of respondents who answered ≥70% of the variables in the positive. All 50 Truenat Laboratory staff participated in the study. (Response rate 100%). Majority, (58%) were male. The median estimated number of tests before Laboratory staff became proficient with Truenat machine was 9 (IQR, 4-20), median number of tests to be analyzed within eight working hours was 10, (IQR = 8-15) and median time to conduct a Truelab MTBPlus test from start to finish was 60 minutes (IQR = 60-80). The commonest operational challenge that required Molbio service support was Trueprep errors/blockage, 47.4%. Overall, mean ease of use score was 4.0±0.4. Majority, (76%) had Good Ease of use of Truenat. No factor significantly influenced Ease of use of Truenat. Truenat machine is easy to use for a trained laboratory staff with minimal technical support and hence could be rolled out easily and successfully by various National TB Programs. Considering the high Trueprep challenges reported, there is need for further studies into the common errors/challenges, the contexts surrounding them and the programmatic intervention to address the high rate of Trueprep equipment faults.

Challenges of Screening and Investigations of Contacts of Patients with Tuberculosis in Oyo and Osun States, Nigeria.

Tuberculosis (TB) remains a significant public health challenge in Nigeria, with high rates of transmission and low case detection rates. This paper presents the challenges of screening and investigation of contacts of patients with TB in Oyo and Osun State, Nigeria. This descriptive-qualitative study was conducted in eight Local Government Areas with high TB burdens. Twenty-four focus group discussions and 30 key informant interviews were conducted among TB patients, household TB contacts, and government TB staff, among others. Respondents ages ranged from 17-85 years with a mean of 42.08 ± 14.9 years, and (4.0%) had a postgraduate degree. This study identified that the majority of TB contacts who tested negative for TB were unwilling to be placed on TB preventive therapy because of the belief that only a sick person should take drugs. Also, hostility from the TB contacts to the contact tracers during the house-to-house screening of presumptive TB cases due to community stigma associated with TB was another existing gap reported in TB contact investigations. The findings emphasise the importance of tailored approaches in TB prevention and control, addressing challenges in testing and contact investigations; this necessitates investments in community engagement strategies to enhance the cooperation of TB contacts.

Effectiveness of Using AI-Driven Hotspot Mapping for Active Case Finding of Tuberculosis in Southwestern Nigeria.

Background: Nigeria is among the top five countries that have the highest gap between people reported as diagnosed and estimated to have developed tuberculosis (TB). To bridge this gap, there is a need for innovative approaches to identify geographical areas at high risk of TB transmission and targeted active case finding (ACF) interventions. Leveraging community-level data together with granular sociodemographic contextual information can unmask local hotspots that could be otherwise missed. This work evaluated whether this approach helps to reach communities with higher numbers of undiagnosed TB. Methodology: A retrospective analysis of the data generated from an ACF intervention program in four southwestern states in Nigeria was conducted. Wards (the smallest administrative level in Nigeria) were further subdivided into smaller population clusters. ACF sites and their respective TB screening outputs were mapped to these population clusters. This data were then combined with open-source high-resolution contextual data to train a Bayesian inference model. The model predicted TB positivity rates on the community level (population cluster level), and these were visualised on a customised geoportal for use by the local teams to identify communities at high risk of TB transmission and plan ACF interventions. The TB positivity yield (proportion) observed at model-predicted hotspots was compared with the yield obtained at other sites identified based on aggregated notification data. Results: The yield in population clusters that were predicted to have high TB positivity rates by the model was at least 1.75 times higher (p-value < 0.001) than the yield in other locations in all four states. Conclusions: The community-level Bayesian predictive model has the potential to guide ACF implementers to high-TB-positivity areas for finding undiagnosed TB in the communities, thus improving the efficiency of interventions.

Partnering with the private laboratories to strengthen TB diagnostics in Nigeria.

Despite being curable and preventable, tuberculosis (TB) affected 10 million people worldwide in 2020. In the seven highest TB burden countries, private providers account for more than two-thirds of initial care seeking. Closing gaps and finding the "missing people" with TB requires engagement of the private sector for better diagnostics and treatment. This review explores the efforts of a public-private partnership to enhance TB diagnostics in Nigeria, covering logistics and the distribution of GeneXpert machines and other diagnostic tools. Over three years, the Nigerian "hub and spoke" model led to a 28-fold increase in referrals of people with presumed TB in private diagnostic facilities. Various stakeholders' perspectives are also included, providing insight into opportunities and challenges of working with the private sector in this effort. As countries tackle the setbacks brought by COVID-19 and move towards reaching the End TB targets, partnerships such as these can strengthen the foundations of health systems.

Completion of 6-mo isoniazid preventive treatment among eligible under six children: A cross-sectional study, Lagos, Nigeria.

BACKGROUND: Nigeria is one of the thirty high burden countries with significant contribution to the global childhood tuberculosis epidemic. Tuberculosis annual risk for children could be as high as 4% particularly in high tuberculosis (TB) prevalent communities. Isoniazid (INH) Preventive Therapy has been shown to prevent TB incidence but data on its implementation among children are scarce. AIM: To determine the completion of INH among under six children that were exposed to adults with smear positive pulmonary TB in Lagos, Nigeria. METHODS: This was a hospital-based retrospective cross-sectional review of 265 medical records of eligible children < 6 years old enrolled for INH across 32 private hospitals in Lagos, Nigeria. The study took place between July and September 2020. Data was collected on independent variables (age, gender, type of facility, TB screening, dose and weight) and outcome variables (INH outcome and proportion lost to follow up across months 1-6 of INH treatment). RESULTS: About 53.8% of the participants were female, 95.4% were screened for TB and none was diagnosed of having TB. The participants' age ranged from 1 to 72 mo with a mean of 36.01 ± 19.67 mo, and 40.2% were between the ages of 1-24 mo. Only 155 (59.2%) of the 262 participants initiated on INH completed the six-month treatment. Cumulatively, 107 (41.0%) children were lost to follow-up at the end of the sixth month. Of the cumulative 107 loss to follow-up while on INH, largest drop-offs were reported at the end of month 2, 52 (49%) followed by 20 (19%), 17 (16%), 11 (10.2%) and 7 (6.5%) at months 3, 4, 5 and 6 respectively. The analysis showed that there was no significant association between age, gender, type of facility and completion of INH treatment (P > 0.005). CONCLUSION: This study demonstrated suboptimal INH completion rate among children with only 6 out of 10 children initiated on INH who completed a 6-mo treatment in Lagos, Nigeria. The huge drop-offs in the first 2 mo of INH calls for innovative strategies such as the use of 60-d INH calendar that would facilitate reminder and early engagement of children on INH and their caregivers in care and across the entire period of treatment.

Ease and equity of access to free DR-TB services in Nigeria- a qualitative analysis of policies, structures and processes.

INTRODUCTION: Persistent low rates of case notification and treatment coverage reflect that accessing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in Nigeria remains a challenge, even though it is provided free of charge to patients. Equity in health access requires availability of comparable, appropriate services to all, based on needs, and irrespective of socio-demographic characteristics. Our study aimed to identify the reasons for Nigeria's low rates of case-finding and treatment for DR-TB. To achieve this, we analyzed elements that facilitate or hinder equitable access for different groups of patients within the current health system to support DR-TB management in Nigeria. METHODS: We conducted documentary review of guidelines and workers manuals, as well as 57 qualitative interviews, including 10 focus group discussions, with a total of 127 participants, in Nigeria. Between August and November 2017, we interviewed patients who were on treatment, their treatment supporter, and providers in Ogun and Plateau States, as well as program managers in Benue and Abuja. We adapted and used Levesque's patient-centered access to care framework to analyze DR-TB policy documents and interview data. RESULTS: Thematic analysis revealed inequitable access to DR-TB care for some patient socio-demographic groups. While patients were mostly treated equally at the facility level, some patients experienced more difficulty accessing care based on their gender, age, occupation, educational level and religion. Health system factors including positive provider attitudes and financial support provided to the patients facilitated equity and ease of access. However, limited coverage and the absence of patients' access rights protection and considerations in the treatment guidelines and workers manuals likely hampered access. CONCLUSION: In the context of Nigeria's low case-finding and treatment coverage, applying an equity of access framework was necessary to highlight gaps in care. Differing social contexts of patients adversely affected their access to DR-TB care. We identified several strengths in DR-TB care delivery, including the current financial support that should be sustained. Our findings highlight the need for government's commitment and continued interventions.

Factors influencing diagnosis and treatment initiation for multidrug-resistant/rifampicin-resistant tuberculosis in six sub-Saharan African countries: a mixed-methods systematic review.

BACKGROUND: Drug-resistant tuberculosis burdens fragile health systems in sub-Saharan Africa (SSA), complicated by high prevalence of HIV. Several African countries reported large gaps between estimated incidence and diagnosed or treated cases. Our review aimed to identify barriers and facilitators influencing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in SSA, which is necessary to develop effective strategies to find the missing incident cases and improve quality of care. METHODS: Using an integrative design, we reviewed and narratively synthesised qualitative, quantitative and mixed-methods studies from nine electronic databases: Medline, Global Health, CINAHL, EMBASE, Scopus, Web of Science, International Journal of Tuberculosis and Lung Disease, PubMed and Google Scholar (January 2006 to June 2019). RESULTS: Of 3181 original studies identified, 55 full texts were screened, and 29 retained. The studies included were from 6 countries, mostly South Africa. Barriers and facilitators to DR-TB care were identified at the health system and patient levels. Predominant health system barriers were laboratory operational issues, provider knowledge and attitudes and information management. Facilitators included GeneXpert MTB/RIF (Xpert) diagnosis and decentralisation of services. At the patient level, predominant barriers were patients being lost to follow-up or dying due to lengthy diagnostic and treatment delays, negative public sector care perceptions, family, work or school commitments and using private sector care. Some patient-level facilitators were HIV positivity and having more symptoms. CONCLUSION: Case detection and treatment for DR -TB in SSA currently relies on individual patients presenting voluntarily to the hospital for care. Specific interventions targeting identified barriers may improve rates and timeliness of detection and treatment.

Rates and timeliness of treatment initiation among drug-resistant tuberculosis patients in Nigeria- A retrospective cohort study.

BACKGROUND: There were an estimated 580,000 new cases of multidrug/rifampicin resistant TB (DR-TB) in 2015, and only 20% were initiated on treatment. This study explored health system and patient factors associated with initiation and timeliness of treatment among DR-TB patients in Nigeria, ranked 4th globally for estimated TB cases in 2015. METHODS: A retrospective cohort study using 2015 diagnosis and treatment data from the Nigerian TB program electronic records examined "treatment ever received" (yes/no) and "treatment within 30 days" (yes/no). We compared health system and patient characteristics using binomial logistic regression, while controlling for confounders. RESULTS: Of 996 patients diagnosed nationwide in 2015 (aged 0-87 years, median 34), 47.8% were never treated. Of those treated (n = 520), 51.2% were treated within the 30 days prescribed in the National treatment guideline. Healthcare facility locations were significantly associated with ever receiving treatment and timely treatment. Predictors of timely treatment at the national level also included level of care and patient treatment history. The South-West zone, where DR-TB programs started, showed overall better access to DR-TB healthcare. CONCLUSIONS: Healthcare facility geographic locations were significantly associated with treatment initiation and timeliness. Significant regional differences in access to DR-TB care in Nigeria persist, reflecting uneven contexts for national DR-TB treatment rollout.

Doing no harm? Adverse events in a nation-wide cohort of patients with multidrug-resistant tuberculosis in Nigeria.

BACKGROUND: Adverse events (AEs) of second line anti-tuberculosis drugs (SLDs) are relatively well documented. However, the actual burden has rarely been described in detail in programmatic settings. We investigated the occurrence of these events in the national cohort of multidrug-resistant tuberculosis (MDR-TB) patients in Nigeria. METHOD: This was a retrospective, observational cohort study, using pharmacovigilance data systematically collected at all MDR-TB treatment centers in Nigeria. Characteristics of AEs during the intensive phase treatment were documented, and risk factors for development of AEs were assessed. RESULTS: Four hundred and sixty patients were included in the analysis: 62% were male; median age was 33 years [Interquartile Range (IQR):28-42] and median weight was 51 kg (IQR: 45-59). Two hundred and three (44%) patients experienced AEs; four died of conditions associated with SLD AEs. Gastro-intestinal (n = 100), neurological (n = 75), ototoxic (n = 72) and psychiatric (n = 60) AEs were the most commonly reported, whereas ototoxic and psychiatric AEs were the most debilitating. Majority of AEs developed after 1-2 months of therapy, and resolved in less than a month after treatment. Some treatment centers were twice as likely to report AEs compared with others, highlighting significant inconsistencies in reporting at different treatment centers. Patients with a higher body weight had an increased risk of experiencing AEs. No differences were observed in risk of AEs between HIV-infected and uninfected patients. Similarly, age was not significantly associated with AEs. CONCLUSION: Patients in the Nigerian MDR-TB cohort experienced a wide range of AEs, some of which were disabling and fatal. Early identification and prompt management as well as standardized reporting of AEs at all levels of healthcare, including the community is urgently needed. Safer regimens for drug-resistant TB with the shortest duration are advocated.