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

Quadratic exponential random early detection: a new enhanced random early detection-oriented congestion control algorithm for routers

Network congestion is still a problem on the internet. The random early detection (RED) algorithm being the most notable and widely implemented congestion algorithm in routers faces the problems of queue instability and large delay arising from the presence of an ineffectual singular linear packet dropping function. This research article presents a refinement to RED, named quadratic exponential random early detection (QERED) algorithm, which exploits the advantages of two drop functions, namely quadratic and exponential in order to enhance the performance of RED algorithm. ns-3 simulation studies using various traffic load conditions to assess and benchmark the effectiveness of QERED with two improved variants of RED affirmed that QERED offers a better performance in terms of average queue size and delay metrics at various network scenarios. Fortunately, to replace/upgrade the implementation for RED algorithm with QERED’s in routers will require minimal effort due to the fact that nothing more besides the packet dropping probability profile got to be adjusted

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

BackgroundThere 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.MethodsA 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.ResultsOf 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.ConclusionsHealthcare 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

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

Categorizing of adverse events based on signs and symptoms.

<p>Categorizing of adverse events based on signs and symptoms.</p

Pharmacovigilance Form (Yellow Form).

<p>Pharmacovigilance Form (Yellow Form).</p

Number and severity of adverse events among MDR-TB patients in Nigeria, 2012–2013 (N = 482).

<p>Number and severity of adverse events among MDR-TB patients in Nigeria, 2012–2013 (N = 482).</p

Duration of ADRs among MDR-TB patients admitted to in-patient care, Nigeria, 2012–2013.

<p>Duration of ADRs among MDR-TB patients admitted to in-patient care, Nigeria, 2012–2013.</p

Baseline characteristics of MDR-TB patients admitted to in-patient care, Nigeria, 2012–2013 (N = 482).

<p>Baseline characteristics of MDR-TB patients admitted to in-patient care, Nigeria, 2012–2013 (N = 482).</p

Association between AEs, sex, age and body weight among MDR-TB patients admitted to in-patient care, Nigeria, 2012–2013.

<p>* <i>Adjusted Odds Ratio and p-value (Wald’s test) based on multivariate logistic regression using a stepwise backward elimination approach</i>.</p><p><i>Note</i>: <i>Treatment centers</i>: <i>DL HMH = Dr</i>. <i>Lawrence Henshaw Memorial Hospital</i>, <i>Calabar; GCH = General Chest Hospital</i>, <i>Ibadan; IDH = Infectious Disease Hospital</i>, <i>Kano; JUTH = Jos University Teaching Hospital</i>, <i>Jos; MHY = Mainland Hospital</i>, <i>Yaba; NTBLCT = National Tuberculosis and Leprosy Training Center; UCH = University College Hospital</i>, <i>Ibadan; UPTH = University of Port Harcourt Teaching Hospital; UUTH = University of Uyo Teaching Hospital</i>, <i>Uyo</i>.</p><p>Association between AEs, sex, age and body weight among MDR-TB patients admitted to in-patient care, Nigeria, 2012–2013.</p