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Background: Malaria is still a disease of global public health importance and children under-five years of age are the most vulnerable to the disease. Nigeria adopted the "test and treat" strategy in the national malaria guidelines as one of the ways to control malaria transmission. The level of adherence to the guidelines is an important indicator for the success or failure of the country's roadmap to malaria elimination by 2030. This study aimed to assess the fidelity of implementation of the national guidelines on malaria diagnosis for children under-five years and examine its associated moderating factors in health care facilities in Rivers State, Nigeria. Methods: This was a descriptive, cross-sectional study conducted in Port Harcourt metropolis. Data were collected from 147 public, formal private and informal private health care facilities. The study used a questionnaire developed based on Carroll's Conceptual Framework for Implementation Fidelity. Frequency, mean and median scores for implementation fidelity and its associated factors were calculated. Associations between fidelity and the measured predictors were examined using Mann Whitney U test, Kruskal Wallis test, and multiple linear regression modelling using robust estimation of errors. Regression results are presented in adjusted coefficient (β) and 95% confidence intervals. Results: The median (IQR) score fidelity score for all participants was 65% (43.3, 85). Informal private facilities (proprietary patent medicine vendors) had the lowest fidelity scores (47%) compared to formal private (69%) and public health facilities (79%). Intervention complexity had a statistically significant inverse relationship to implementation fidelity (β = − 1.89 [− 3.42, − 0.34]). Increase in participant responsiveness (β = 8.57 [4.83, 12.32]) and the type of malaria test offered at the facility (e.g., RDT vs. no test, β = 16.90 [6.78, 27.03]; microscopy vs. no test, β = 21.88 [13.60, 30.16]) were positively associated with fidelity score. Conclusions: This study showed that core elements of the "test and treat" strategy, such as testing all suspected cases with approved diagnostic methods before treatment, are still not fully implemented by health facilities. There is a need for strategies to increase fidelity, especially in the informal private health sector, for malaria elimination programme outcomes to be achieved. [ABSTRACT FROM AUTHOR]

Background: Patients with recurrent TB have an increased risk of higher mortality, lower success rate, and a relatively feeble likelihood of treatment completion than those with new-onset TB. This study aimed to assess the epidemiology of recurrent TB in Tanzania; specifically, we aim to determine the prevalence of TB recurrence and factors associated with unfavourable treatment outcomes among patients with recurrent TB in Tanzania from 2018 to 2021. Methods: In this cross-sectional study, we utilized Tanzania's routinely collected national TB program data. The study involved a cohort of TB patients over a fixed treatment period registered in the TB and Leprosy case-based District Health Information System (DHIS2-ETL) database from 2018 to 2021 in Tanzania. We included patients' sociodemographic and clinical factors, facility characteristics, and TB treatment outcomes. We conducted bivariate analysis and multivariable multi-level mixed effects logistic regression of factors associated with TB recurrence and TB treatment outcomes to account for the correlations at the facility level. A purposeful selection method was used; the multivariable model included apriori selected variables (Age, Sex, and HIV status) and variables with a p-value <0.2 on bivariate analysis. The adjusted odds ratio and 95% confidence interval were recorded, and a p-value of less than 0.05 was considered statistically significant. Findings: A total of 319,717 participants were included in the study; the majority were adults aged 25–49 (44.2%, n = 141,193) and above 50 years (31.6%, n = 101,039). About two-thirds were male (60.4%, n = 192,986), and more than one-fifth of participants (22.8%, n = 72,396) were HIV positive. Nearly two in every hundred TB patients had a recurrent TB episode (2.0%, n = 6,723). About 10% of patients with recurrent TB had unfavourable treatment outcomes (9.6%, n = 519). The odds of poor treatment outcomes were two-fold higher for participants receiving treatment at the central (aOR = 2.24; 95% CI 1.33–3.78) and coastal zones (aOR = 2.20; 95% CI 1.40–3.47) than the northern zone. HIV-positive participants had 62% extra odds of unfavourable treatment outcomes compared to their HIV-negative counterparts (aOR = 1.62; 95% CI 1.25–2.11). Bacteriological TB diagnosis (aOR = 1.39; 95% CI 1.02–1.90) was associated with a 39% additional risk of unfavourable treatment outcomes as compared to clinical TB diagnosis. Compared to community-based DOT, patients who received DOT at the facility had 1.39 times the odds of poor treatment outcomes (aOR = 1.39; 95%CI 1.04–1.85). Conclusion: TB recurrence in Tanzania accounts for 2% of all TB cases, and it is associated with poor treatment outcomes. Unfavourable treatment outcomes were recorded in 10% of patients with recurrent TB. Poor TB treatment outcome was associated with HIV-positive status, facility-based DOT, bacteriologically confirmed TB and receiving treatment at the hospital level, differing among regions. We recommend post-treatment follow-up for patients with recurrent TB, especially those coinfected with HIV. We also propose close follow-up for patients treated at the hospital facility level and strengthening primary health facilities in TB detection and management to facilitate early treatment initiation. Author summary: Why was this study done?: TB recurrence contributes to TB burden and incidence globally, especially among high TB burden countries. Patients previously treated for TB have a high likelihood of acquiring a recurrent TB episode. Recurrent TB is associated with lower cure rates and a high risk of TB drug resistance. A recent systematic review reported successful treatment outcomes in only 68.4% of patients previously treated for TB. In Tanzania, it was reported in 2018 that patients who had previously undergone TB treatment had an approximate 89% success rate, with 6.6% of those who had recurrent TB dying during treatment. The necessity for more studies in this specific re-treatment group is driven by the absence of evidence regarding the treatment outcomes for patients with recurrent TB. What did the researchers do and find?: We analysed a national dataset of all patients with TB diagnosis from 2018 to 2021 recorded in the DHIS2-ETL database countrywide. We determined TB treatment outcome as either favourable if the patients were considered cured or completed treatment; or unfavourable if they were lost to follow-up (default), with treatment failure, or died. We established possible determinants for poor treatment outcomes and considered both individual and facility-level effects in the analysis through a multilevel regression model. About 10% of patients with recurrent TB had unfavourable treatment outcomes; death was the most reported poor outcome affecting 6% of recurrent TB patients. Patients coinfected with HIV, those treated under facility-based DOT, and patients who received treatment in Zanzibar, Coastal, and Central geographical zones had higher rates of poor outcomes. Patients with bacteriologically confirmed TB and who were treated at the hospital were more likely to have unfavourable treatment outcomes. What do these findings mean?: There is a need to design and implement interventions that are specifically targeted for managing patients with TB recurrence, especially for HIV coinfected patients. Drug susceptibility testing and close monitoring after treatment completion are crucial to prevent recurrence. Also, ensuring early detection and treatment and promoting short- and long-term improvements in treatment outcomes for these patients. Capacitating and strengthening Primary health care facilities for TB diagnosis and treatment may be a promising approach to promote early TB detection and treatment initiation and subsequently maintain better outcomes for patients with recurrent TB. This should be coupled with close monitoring of patients treated at the hospital level through an appropriate DOT strategy. [ABSTRACT FROM AUTHOR]