Profile and determinants of unsuccessful tuberculosis outcome in rural Nigeria:Implications for tuberculosis control

AIM: To determine the treatment outcomes and predictors for unsuccessful tuberculosis(TB) outcomes in rural Nigeria.METHODS: Adult rural TB patients treated during 2011 and 2012 in two healthcare facilities(one urban public and one rural private) were identified from the TB treatment registers and retrospectively reviewed. Tuberculosis treatment outcomes were assessed according to World Health Organisation guidelines. Determinants of unsuccessful treatment outcomes were identified using a multivariable logistic regression analysis.RESULTS: Between January 2011 to December 2012, 1180 rural TB patients started treatment, of whom 494(41.9%) were female. The treatment success rate was 893(75.7%), while the rates of death, loss-tofollow-up, and treatment failure were 129(10.9%), 100(8.5%), and 18(1.5%) respectively. In the final multivariable logistic regression model, the odds of unsuccessful treatment outcome were higher among patients who received care at the urban public facility(a OR = 2.9, 95%CI: 1.9-4.4), smear-negative(1.3,1.0-1.8) and extrapulmonary(2.7, 1.3-5.6) TB patients, human immunodeficiency virus(HIV) co-infected(2.1, 1.5-3.0), and patient who received the longer(8-mo) anti-TB regimen(1.3, 1.1-1.8).CONCLUSION: Treatment success among rural TB patient in Nigeria is low. High risk groups should be targeted for closer monitoring, socio-economic support, and expansion of TB/HIV activities.

Risk factors of treatment default and death among tuberculosis patients in a resource-limited setting

Objective:To evaluate the rates,timing and determinants of default and death among adult tuberculosis patients in Nigeria.Methods:Routine surveillance data were used.A retrospective cohort study of adult tuberculosis patients treated during 2011 and 2012 in two large health facilities in Ebonyi State.Nigeria was conducted.Multivariable logistic regression analyses were used to tdentify independent predictors for treatment default and death.Results:Of 1668 treated patients,the default rate was 157(9.4%),whilst 165(9.9%) died.Also,35.7%(56) of the treatment defaults and 151(91.5%) of deaths occurred during the intensive phase of treatment.Risk of default increased with increasing age(adjusted odds ratio(aOR) 1.2;95%confidence interval(CI)1.1-1.9).smear-negative TB case(aOR 2.3:CI 1.5-3.6).extrapulmonary TB case(aOR 2.7:CI 1.3-5.2).and patients who received the longer treatment regimen(aOR 1,6;1.1-2.2).Risk of death was highest in extrapulmonary TB(aOR 3.0:CI 1.4-6.1) and smear-negative TB cases(aOR 2.4:CI1.7-3.51.rural residents(aOR 1.7:CI 1.2-2.6),HIV co-infected(aOR 2.5:CI 1.7-3.6),not receiving antiretroviral therapy(aOR 1.6:CI 1.1-2.9),and not receiving cotrimoxazole prophylaxis(aOR 1.7:CI 1.2—2.6).Conclusions:Targeted interventions to improve treatment adherence for patients with the highest risk of default or death are urgently needed.This needs to he urgently addressed by the National Tuberculosis Programme.

A Case Study of Multi Drug-Resistant Tuberculosis (MDR-TB), HIV and Diabetes Mellitus (Dm) Comorbidity: Triple Pathology;Challenges and Prospects

Tuberculosis (TB), diabetes mellitus and HIV co-morbidity is a rare and interrelated health condition with associated high morbidity and mortality especially in developing countries with high prevalence of TB. It has become an emerging concern to epidemiologists and TB control programs due to complexities in its control and management. Managing MDR-TB, DM and HIV comorbidity is challenging, with risk of unfavorable outcome;consequently, close monitoring is necessary. Individuals with weak immunity resulting from diseases such as uncontrolled Diabetes Mellitus (DM) and HIV have a higher risk of developing TB or progression from latent to active TB. We present a 65-year old known diabetic patient who presented to Royal Cross Hospital Ugwueke Abia State, Nigeria with a one-year history of recurrent productive cough with associated night sweats, low grade fever and marked weight loss. A diagnosis of drug-resistant TB with DM/HIV co-morbidity was made and co-managed by experts from the respective clinics and the State TB control program. The patient was declared cured (7 months consecutive negative cultures each taken 30 days apart) after completing 20 months of conventional MDR-TB treatment. The patient showed remarkable clinical improvement including weight gain, good diabetic control and significant increase in CD4 (700 cells). Managing MDR-TB patients with diabetes and HIV is challenging, however, appropriate treatment, psychosocial support, adequate blood sugar control as well as monthly monitoring of patients with requisite investigations are vital in achieving good treatment outcome.

Implementation of the Active TB Case Finding in Nigeria;Processes, Lessons Learnt and Recommendations

Introduction: Tuberculosis remains a major public health issue in Nigeria with the country ranking seventh among the 30 high TB burden countries. Nigeria is among the three countries that account for half of the 4.3 million “missing” TB cases globally. One untreated TB case is able to infect about 10 - 20 people annually. Hence, it is pertinent that TB is controlled effectively through the use of active case finding strategies to find the missing TB cases. Objective: This article highlights the best practices and key lessons learnt during the implementation of the active house to house TB case finding strategy in Nigeria. Lessons Learnt and Recommendations: Strategic community engagement, massive awareness creation using mass media and local means of communication, mapping of locations where registered TB cases live, to inform home visits for contact tracing and strengthening of laboratory systems, are viable mechanisms to improve TB case finding. Conclusion: Active TB case finding interventions should be implemented in the context of a strengthened diagnostics system, strategic community engagement and media involvement.

Prevalence of Adverse Drug Reactions to Second Line Anti Tuberculosis Drugs in Nigeria: A Cross-Sectional Study

Introduction: Multidrug resistant tuberculosis (MDR-TB) is treated with second line antituberculosis drugs. These drugs are notorious for inflicting serious adverse drug reactions (ADRs), which many studies have shown causes a wide range of economic and health problems including death. Aim: The study examined the prevalence of ADRs, associated risk factors, socio-demographic association and outcomes among patients treated for MDR-TB at a comprehensive tuberculosis treatment center in Nigeria. Method: The study was conducted at the Government Chest Hospital, Jericho, Ibadan. We applied a retrospective assessment of patient treatment data and ADRs reports stored at the study site from March 2013 and February 2016. Subsequently, a prospective study of ADRs was conducted on patients admitted into the same hospital. Causality relationship between the drugs and the reported ADRs was determined with a specially validated tool. The outcomes assessed include recovery from the ADRs, death and permanent deafness from the ADRs. Extracted data were analyzed using SPSS version 22.0. Risk Ratio was calculated for the influence of risk factors for adverse drug reactions. Logistic regression was performed to test for the strength of relationships between risk factors and incidence of ADRs among patients. Result: Almost all the participants in this study reported adverse drug reaction [99% (118/119)]. However, ototoxicity was the most prevalent ADR (35.3%), followed by electrolyte imbalance (12.6%), gastrointestinal track (10.1%) and psychiatric disorders (10.1%). Being older than 35 years and HIV negative or having a healthy BMI were not significant risk factors for developing ADRs. Duration of ADR above one month was significantly associated with the outcome of ADR. Conclusion: Ototoxicity, electrolyte imbalance, psychiatric disorders and gastrointestinal tract problems were the most frequently reported ADRs. Healthcare providers, government and donor agencies supporting the treatment should ensure that hearing aids and other forms of support are readily made available for the affected patients.

Household catastrophic payments for tuberculosis care in Nigeria: incidence, determinants, and policy implications for universal health coverage

Background:Studies on costs incurred by patients for tuberculosis(TB)care are limited as these costs are reported as averages,and the economic impact of the costs is estimated based on average patient/household incomes.Average expenditures do not represent the poor because they spend less on treatment compared to other economic groups.Thus,the extent to which TB expenditures risk sending households into,or further into,poverty and its determinants,is unknown.We assessed the incidence and determinants of household catastrophic payments for TB care in rural Nigeria.Methods:Data used were obtained from a survey of 452 pulmonary TB patients sampled from three rural health facilities in Ebonyi State,Nigeria.Using household direct costs and income data,we analyzed the incidence of household catastrophic payments using,as thresholds,the traditional>10%of household income and the≥40%of non-food income,as recommended by the World Health Organization.We used logistic regression analysis to identify the determinants of catastrophic payments.Results:Average direct household costs for TB were US$157 or 14%of average annual incomes.The incidence catastrophic payment was 44%;with 69%and 15%of the poorest and richest household income-quartiles experiencing catastrophic activity,respectively.Independent determinants of catastrophic payments were:age>40 years(adjusted odds ratio[aOR]3.9;95%confidence interval[CI],2.0,7.8),male gender(aOR 3.0;CI 1.8,5.2),urban residence(aOR 3.8;CI 1.9,7.7),formal education(aOR 4.7;CI 2.5,8.9),care at a private facility(aOR 2.9;1.5,5.9),poor household(aOR 6.7;CI 3.7,12),household where the patient is the primary earner(aOR 3.8;CI 2.2,6.6]),and HIV co-infection(aOR 3.1;CI 1.7,5.6).Conclusions:Current cost-lowering strategies are not enough to prevent households from incurring catastrophic out-of-pocket payments for TB care.Financial and social protection interventions are needed for identified at-risk groups,and community-level interventions may reduce inefficiencies in the care-seeking pathway.These observations should inform post-2015 TB strategies and influence policy-making on health services that are meant to be free of charge.