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.Key words: Tuberculosis, Epidemiology, control, DOTS, case finding, Nigeri

Profile, Outcomes, and Determinants of Unsuccessful Tuberculosis Treatment Outcomes among HIV-Infected Tuberculosis Patients in a Nigerian State

Background. Few studies have evaluated the rate of tuberculosis (TB)/human immunodeficiency virus (HIV) coinfection and the determinants of its treatment outcomes in Africa. We aimed to determine the predictors of unsuccessful treatment outcomes in HIV-infected tuberculosis patients in Nigeria. Methods. A retrospective cohort study design was used to assess adult TB/HIV patients who registered for TB treatment in two health facilities in Ebonyi State, Southeast Nigeria, between January 2011 and December 2012. Predictors of unsuccessful treatment outcomes were determined using multivariable logistic regression analysis. Results. Of 1668 TB patients, 342 (20.5%) were HIV coinfected. Of these, 195 (57%) had smear-negative pulmonary TB and 11 (3.2%) had extrapulmonary TB. Overall, 225 (65.8%) patients achieved successful outcomes, while 117 (34.2%) had unsuccessful outcomes. The unsuccessful treatment outcomes were due to “default” (9.9%), “death” (19%), “treatment failure” (1.5%), and “transferring out” (3.8%). Independent determinants for unsuccessful outcomes were receiving care at a public facility and noninitiation of antiretroviral therapy. Conclusion. There is need for the reevaluation of the quality of public sector treatment services provided for TB/HIV patients as well as further expansion of TB/HIV collaborative activities in rural areas, and interventions to reduce mortality and default rates among TB/HIV patients are urgently needed in Nigeria

Profile and determinants of treatment failure among smear-positive pulmonary tuberculosis patients in Ebonyi, Southeastern Nigeria

Background: Early identification of determinants of tuberculosis (TB) treatment failure is urgently needed in resource-limited settings. This study describes the profile and determinants of TB treatment failure in a high-incidence setting where patients were managed at a TB control program with significant resource limitations. Methods: This was a retrospective case-control study carried out in one tertiary and one secondary hospital in Southeastern Nigeria. Cases were adult (≥15 years) TB patients with a positive sputum smear after 5 months of treatment (treatment failure). Controls were adult TB patients whose sputum smear was positive at the beginning of the treatment but who were smear-negative in the last month of treatment and on at least one previous occasion (cured). Cases were compared with controls to assess determinants of treatment failure. Results: Of the 1668 TB patients registered during the study period, 985 (59%) had smear-positive pulmonary TB. Of these, 694 (70.5%) were aged ≤40 years, 602 (61.1%) were males, 707 (71.8%) were rural residents, and 898 (91.2%) received care at the private facility. The prevalence of treatment failure was 2.5%. Significant determinants of treatment failure were: older age (>40 years) (P< 0.001), male gender (P = 0.04), previous treatment for TB (P = 0.045), and positive sputum smears after two month of anti-tuberculosis treatment (0.001). Conclusion: This study showed that the treatment failure rate among smear-positive TB patients is low in Nigeria. Education and improved clinical and laboratory interventions for the identified at-risk groups may reduce TB treatment failure in resource-limited settings

The high cost of free tuberculosis services: patient and household costs associated with tuberculosis care in Ebonyi State, Nigeria.

OBJECTIVE: Poverty is both a cause and consequence of tuberculosis. The objective of this study is to quantify patient/household costs for an episode of tuberculosis (TB), its relationships with household impoverishment, and the strategies used to cope with the costs by TB patients in a resource-limited high TB/HIV setting. METHODS: A cross-sectional study was conducted in three rural hospitals in southeast Nigeria. Consecutive adults with newly diagnosed pulmonary TB were interviewed to determine the costs each incurred in their care-seeking pathway using a standardised questionnaire. We defined direct costs as out-of-pocket payments, and indirect costs as lost income. RESULTS: Of 452 patients enrolled, majority were male 55% (249), and rural residents 79% (356), with a mean age of 34 (± 11.6) years. Median direct pre-diagnosis/diagnosis cost was $49 per patient. Median direct treatment cost was$36 per patient. Indirect pre-diagnostic and treatment costs were $416, or 79$528. The median total cost of TB care per household was $592; corresponding to 37% of median annual household income pre-TB. Most patients reported having to borrow money 212(47%), sell assets 42(9%), or both 144(32%) to cope with the cost of care. Following an episode of TB, household income reduced increasing the proportion of households classified as poor from 54% to 79%. Before TB illness, independent predictors of household poverty were; rural residence (adjusted odds ratio [aOR] 2.8), HIV-positive status (aOR 4.8), and care-seeking at a private facility (aOR 5.1). After TB care, independent determinants of household poverty were; younger age (≤ 35 years; aOR 2.4), male gender (aOR 2.1), and HIV-positive status (aOR 2.5). CONCLUSION: Patient and household costs for TB care are potentially catastrophic even where services are provided free-of-charge. There is an urgent need to implement strategies for TB care that are affordable for the poor

Prevalence of drug-resistant tuberculosis in Nigeria: A systematic review and meta-analysis

<div><p>Background</p><p>Drug-resistant tuberculosis (TB) undermines control efforts and its burden is poorly understood in resource-limited settings. We performed a systematic review and meta-analysis to provide an up-to-date summary of the extent of drug-resistant TB in Nigeria.</p><p>Methods</p><p>We searched PubMed, Scopus, Embase, HINARI, AJOL, the Cochrane library, Web of Science, and Google Scholar for reports published before January 31 2017, that included any resistance, mono-resistance or multidrug resistance to anti-TB drugs in Nigeria. Summary estimates were calculated using random effects models.</p><p>Results</p><p>We identified 34 anti-TB drug resistance surveys with 8002 adult TB patients consisting of 2982 new and 5020 previously-treated cases. The prevalence rate of any drug resistance among new TB cases was 32.0% (95% CI 24.0–40.0%; 734/2892) and among previously-treated cases, the rate was 53.0% (95% CI 35.0–71.0%; 1467/5020). Furthermore, multidrug resistance among new and previously-treated cases was 6.0% (95% CI 4.0–8.0%;161/2502)and 32.0% (95%CI 20.0–44.0; 357/949), respectively. There was significant heterogeneity between the studies (p<0.001, I² tests). The prevalence of drug-resistant TB varied according to methods of drug susceptibility testing and geographic region of Nigeria.</p><p>Conclusion</p><p>The burden of drug-resistant TB in Nigeria is high. We recommend that a national anti-TB drug resistance survey be carried out, and strategies for case detection and programmatic management of drug-resistant TB in Nigeria need to be strengthened.</p></div

Map of Nigeria indicating the geopolitical zones of the country.

<p>[Northern region: North-west, North-central, North-east; Southern region: South-west, South-east, South-south].</p

Funnel plot of the meta-analysis on prevalence of: a) any drug resistance, b) multidrug resistance among previously-treated TB patients, Nigeria.

<p>Funnel plot of the meta-analysis on prevalence of: a) any drug resistance, b) multidrug resistance among previously-treated TB patients, Nigeria.</p

Flow chart depicting the study selection process.

<p>(*Records excluded due to lack of relevance).</p

Included studies after full-text evaluation.

<p>Included studies after full-text evaluation.</p