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INTRODUCTION: Successful treatment of TB requires high levels of adherence to treatment. This has been found to be below optimal with directly observed therapy (DOT), and digital adherence technologies (DATs) offer a promising approach to non-adherence to medication and improving treatment outcomes. This study explores the perception, acceptability, and challenges of DATs among healthcare workers (HCWs). METHODS: The study was conducted in eight states in Nigeria among Health Care workers involved in treating patients with TB. This was a descriptive cross-sectional study using an open questionnaire and analysed using IBM SPSS v25. RESULTS: Twenty-three HCWs (95.8%) agreed that DATs helped them provide better support and counselling to their patients. All of them would recommend DATs to their patients and found it easy to explain them. Eleven (45.8%) of them were not able to use DATs on a few occasions; their reasons were poor network (n = 9, 37.5%) and (n = 1, 4.2%) power failure. CONCLUSION: DATs help HCWs provide better support and care regarding real-time tracking of their patients’ adherence to treatment and possibly reduction of attrition. This implies that DATs are a suitable alternative to DOT to help HCWs provide the best care and support to their patients towards achieving the End TB targets.

INTRODUCTION: Poor adherence to TB treatment poses a significant public health threat to TB control programmes. The sustainability of directly observed treatment has been questioned because of its non-patient-centred approach and resource-intensive nature, and Digital Adherence Technologies (DATs) provide a suitable alternative. This study assessed the feasibility and acceptability of DATs among patients with TB. METHODS: This descriptive study was conducted in eight states in Nigeria among all patients with drug-susceptible TB. RESULT: A total of 230 patients (89.1%) own a phone that no one else uses, and 18 (7.0%) use a family phone. A higher proportion of 189 (73.3%) have airtime credit and 119 (46.1%) have internet credit on their phone. In addition, 216 (83.7%) stated that the reminders they received on their phone helped them remember to take their medicine. Only 11 (4.3%) patients missed a dose of the TB medicine. Equally, 11 (4.3%) patients had taken their TB medicine without using DAT. Of these, 7 (63.3%) did not use DATs because they forgot to text medication labels, and 3 (27.6%) did so because of poor network. Only four (1.6%) purchased additional items to support the use of DATs. CONCLUSION: DATs are acceptable in a wide variety of settings, even with reported challenges. Implementation efforts should ensure access, address technical challenges, and minimise additional cost to patients.

Abstract Background Engagement of communities and civil society organizations is a critical part of the Post-2015 End TB Strategy. Since 2007, many models of community referral have been implemented to boost TB case detection in Nigeria. Yet clear insights into the comparative TB yield from particular approaches have been limited. Methods We compared four models of active case finding in three Nigerian states. Data on presumptive TB case referral by community workers (CWs), TB diagnoses among referred clients, active case finding model characteristics, and CWs compensation details for 2012 were obtained from implementers and CWs via interviews and log book review. Self-reported performance data were triangulated against routine surveillance data to assess concordance. Analysis focused on assessing the predictors of presumptive TB referral. Results CWs referred 4–22 % of presumptive TB clients tested, and 4–24 % of the total TB cases detected. The annual median referral per CW ranged widely among the models from 1 to 48 clients, with an overall average of 13.4 referrals per CW. The highest median referrals (48 per CW/yr) and mean TB diagnoses (7.1/yr) per CW (H =70.850, p

The presence of water in the skin is crucial for maintaining the properties and functions of the skin, in particular its outermost layer, known as the stratum corneum, which consists of a lipid barrier. External exposures can affect the skin’s hydration levels and in turn, alter its mechanical and physical properties. Monitoring these alterations in the skin’s water content can be applicable in clinical, cosmetic, athletic and personal settings. Many techniques measuring this parameter have been investigated, with electrical-based methods currently being widely used in commercial devices. Furthermore, the exploration of optical techniques to measure hydration is growing due to the outcomes observed through the penetration of light at differing levels. This paper comprehensively reviews such measurement techniques, focusing on recent experimental studies and state-of-the-art devices.

Background: Recently, there has been a marked increase in the incidence of cancer, HIV, and other noncommunicable diseases globally. Thus, the demand for palliative care (PC), including end-of-life care, continues to grow worldwide. Physiotherapy has an important role in PC as it aims to alleviate symptoms and improve quality of life by optimising independent levels of function. Objective: To assess the level of knowledge, awareness and current practice of PC amongst Nigerian physiotherapists in clinical practice. Method: Our study used a cross-sectional descriptive census-based method and recruited practising physiotherapists in Nigeria. An electronic questionnaire was used to collect data over 12 weeks, comprising 36 semistructured questions in four domains: personal information, knowledge, awareness and current practices regarding PC. Data were analysed using a pragmatist paradigm. Results: Of the 426 physiotherapists who participated, 50% (n = 213) had a postgraduate degree, 49.5% (n = 211) had a bachelor’s degree and 0.5% (n = 2) had a Doctor of Physical Therapy degree. The results also indicate that 73.9% (n = 315) of the participants had sufficient knowledge about PC, 80.5% (n = 343) had a sufficient level of awareness about PC and 66.7% (n = 284) were using current clinical practices in the rehabilitation of critically ill patients or those with chronic conditions. Conclusion: It was concluded that most Nigerian physiotherapists had sufficient knowledge and awareness about PC and were involved in the management of patients requiring PC physiotherapy. Clinical implication: It can be understood that a large proportion of Nigerian physiotherapists have clinical experience managing patients requiring PC, despite inadequate formal training in this field.

Introduction: Successful treatment of TB requires high levels of adherence to treatment. This has been found to be below optimal with directly observed therapy (DOT), and digital adherence technologies (DATs) offer a promising approach to non-adherence to medication and improving treatment outcomes. This study explores the perception, acceptability, and challenges of DATs among healthcare workers (HCWs)., Methods: The study was conducted in eight states in Nigeria among Health Care workers involved in treating patients with TB. This was a descriptive cross-sectional study using an open questionnaire and analysed using IBM SPSS v25., Results: Twenty-three HCWs (95.8%) agreed that DATs helped them provide better support and counselling to their patients. All of them would recommend DATs to their patients and found it easy to explain them. Eleven (45.8%) of them were not able to use DATs on a few occasions; their reasons were poor network ( n = 9, 37.5%) and ( n = 1, 4.2%) power failure., Conclusion: DATs help HCWs provide better support and care regarding real-time tracking of their patients' adherence to treatment and possibly reduction of attrition. This implies that DATs are a suitable alternative to DOT to help HCWs provide the best care and support to their patients towards achieving the End TB targets., (© 2024 The Authors.)

Introduction: Poor adherence to TB treatment poses a significant public health threat to TB control programmes. The sustainability of directly observed treatment has been questioned because of its non-patient-centred approach and resource-intensive nature, and Digital Adherence Technologies (DATs) provide a suitable alternative. This study assessed the feasibility and acceptability of DATs among patients with TB., Methods: This descriptive study was conducted in eight states in Nigeria among all patients with drug-susceptible TB., Result: A total of 230 patients (89.1%) own a phone that no one else uses, and 18 (7.0%) use a family phone. A higher proportion of 189 (73.3%) have airtime credit and 119 (46.1%) have internet credit on their phone. In addition, 216 (83.7%) stated that the reminders they received on their phone helped them remember to take their medicine. Only 11 (4.3%) patients missed a dose of the TB medicine. Equally, 11 (4.3%) patients had taken their TB medicine without using DAT. Of these, 7 (63.3%) did not use DATs because they forgot to text medication labels, and 3 (27.6%) did so because of poor network. Only four (1.6%) purchased additional items to support the use of DATs., Conclusion: DATs are acceptable in a wide variety of settings, even with reported challenges. Implementation efforts should ensure access, address technical challenges, and minimise additional cost to patients., Competing Interests: Conflicts of interest: none declared., (© 2024 The Authors.)

Background: In Nigeria, most children with tuberculosis (TB) present at primary health clinics where there are limited personnel skilled in collecting appropriate respiratory specimens from those who cannot produce sputum. KNCV Nigeria, in collaboration with the National Tuberculosis Control Program, implemented a modified simple, one-step (SOS), stool-based Xpert MTB/RIF method for diagnosis of TB in children who cannot expectorate sputum. We evaluated the impact of its implementation on childhood TB diagnosis., Method: A cross-sectional study was conducted across 14 selected states using secondary data of children presumed to have TB. Stool was collected from children presumed to have TB and processed using Xpert., Result: Out of 52,117 presumptive TB cases, 52% were male and 59.7% were under 5 years old. A total of 2440 (5%) cases were diagnosed with TB, and 2307 (95%) were placed on treatment. Annual TB notifications increased significantly after the introduction of the stool-based Xpert test when compared to those in the pre-implementation period. Increasing contributions from stool testing were observed throughout the implementation period, except in 2020 during the COVID-19 era. Overall, stool Xpert testing improved childhood TB notification in the studied states. Interventions aimed at awareness creation, capacity building, and active case finding improved the performance of the test.

Background: Recognition of the importance of valid, real-time knowledge of infectious disease risk has renewed scrutiny into private providers' intentions, motives, and obstacles to comply with an Integrated Disease Surveillance Response (IDSR) framework. Appreciation of how private providers' attitudes shape their tuberculosis (TB) notification behaviors can yield lessons for the surveillance of emerging pathogens, antibiotic stewardship, and other crucial public health functions. Reciprocal trust among actors and institutions is an understudied part of the "software" of surveillance., Objective: We aimed to assess the self-reported knowledge, motivation, barriers, and TB case notification behavior of private health care providers to public health authorities in Lagos, Nigeria. We measured the concordance between self-reported notification, TB cases found in facility records, and actual notifications received., Methods: A representative, stratified sample of 278 private health care workers was surveyed on TB notification attitudes, behavior, and perceptions of public health authorities using validated scales. Record reviews were conducted to identify the TB treatment provided and facility case counts were abstracted from the records. Self-reports were triangulated against actual notification behavior for 2016. The complex health system framework was used to identify potential predictors of notification behavior., Results: Noncompliance with the legal obligations to notify infectious diseases was not attributable to a lack of knowledge. Private providers who were uncomfortable notifying TB cases via the IDSR system scored lower on the perceived benevolence subscale of trust. Health care workers who affirmed "always" notifying via IDSR monthly reported higher median trust in the state's public disease control capacity. Although self-reported notification behavior was predicted by age, gender, and positive interaction with public health bodies, the self-report numbers did not tally with actual TB notifications., Conclusions: Providers perceived both risks and benefits to recording and reporting TB cases. To improve private providers' public health behaviors, policy makers need to transcend instrumental and transactional approaches to surveillance to include building trust in public health, simplifying the task, and enhancing the link to improved health. Renewed attention to the "software" of health systems (eg, norms, values, and relationships) is vital to address pandemic threats. Surveys with private providers may overestimate their actual participation in public health surveillance., (©Ellen MH Mitchell, Olusola Adedeji Adejumo, Hussein Abdur-Razzaq, Chidubem Ogbudebe, Mustapha Gidado. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 25.04.2024.)

Wellness on Wheels (WoW) is a model of mobile systematic tuberculosis (TB) screening of high-risk populations combining digital chest radiography with computer-aided automated detection (CAD) and chronic cough screening to identify presumptive TB clients in communities, health facilities, and prisons in Nigeria. The model evolves to address technical, political, and sustainability challenges. Screening methods were iteratively refined to balance TB yield and feasibility across heterogeneous populations. Performance metrics were compared over time. Screening volumes, risk mix, number needed to screen (NNS), number needed to test (NNT), sample loss, TB treatment initiation and outcomes. Efforts to mitigate losses along the diagnostic cascade were tracked. Persons with high CAD4TB score (≥80), who tested negative on a single spot GeneXpert were followed-up to assess TB status at six months. An experimental calibration method achieved a viable CAD threshold for testing. High risk groups and key stakeholders were engaged. Operations evolved in real time to fix problems. Incremental improvements in mean client volumes (128 to 140/day), target group inclusion (92% to 93%), on-site testing (84% to 86%), TB treatment initiation (87% to 91%), and TB treatment success (71% to 85%) were recorded. Attention to those as highest risk boosted efficiency (the NNT declined from 8.2 ± SD8.2 to 7.6 ± SD7.7). Clinical diagnosis was added after follow-up among those with ≥ 80 CAD scores and initially spot -sputum negative found 11 additional TB cases (6.3%) after 121 person-years of follow-up. Iterative adaptation in response to performance metrics foster feasible, acceptable, and efficient TB case-finding in Nigeria. High CAD scores can identify subclinical TB and those at risk of progression to bacteriologically-confirmed TB disease in the near term., Competing Interests: RE and DN are now employed by the funder, but at the time of the study RE worked for KNCV TB Foundation. The funder had a limited role in the review of the manuscript., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Background: The measures undertaken to control COVID-19 have disrupted many platforms including tuberculosis (TB) healthcare services. Consequently, declines in TB notifications have been observed in various countries. We visualized changes over time in TB and SARS-CoV-2 infection notifications and reported on country-specific strategies to retain TB care and prevention services in Kyrgyzstan, Nigeria, Tanzania, and Vietnam., Methods: We collected and visualized quarterly, retrospective, and country-specific data (Quarter (Q) 1 2018- Q1 2021) on SARS-CoV-2 infection and TB notifications. Additionally, we conducted a country-specific landscape assessment on COVID-19 measures, including lockdowns, operational level strategy of TB care and prevention services, and strategies employed to recover and retain those services. We used negative binomial regression models to assess the association between the installation of COVID-19 measures and changes in TB notifications., Results: TB notifications declined in Kyrgyzstan and Vietnam, and (slightly) increased in Nigeria and Tanzania. The changes in TB notifications were associated with the installation of various COVID-19 prevention measures for Kyrgyzstan and Vietnam (declines) and Nigeria (increases). All countries reported reduced TB screening and testing activities. Countries reported the following strategies to retain TB prevention and care services: digital solutions for treatment adherence support, capacity building, and monitor & evaluation activities; adjustment in medication supply/delivery & quantity, including home delivery, pick up points, and month supply; integrated TB/COVID-19 screening & diagnostic platform; and the use of community health care workers., Conclusion: Following the COVID-19 pandemic, we did not observe consistent changes in TB notifications across countries. However, all countries reported lower operating levels of TB prevention and care services. Digital health solutions, community-based interventions, and the integration of COVID-19 and TB testing services were employed to recover and retain those services., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Spruijt et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The World Health Organization has developed target product profiles containing minimum and optimum targets for key characteristics for tests for tuberculosis treatment monitoring and optimization. Tuberculosis treatment optimization refers to initiating or switching to an effective tuberculosis treatment regimen that results in a high likelihood of a good treatment outcome. The target product profiles also cover tests of cure conducted at the end of treatment. The development of the target product profiles was informed by a stakeholder survey, a cost-effectiveness analysis and a patient-care pathway analysis. Additional feedback from stakeholders was obtained by means of a Delphi-like process, a technical consultation and a call for public comment on a draft document. A scientific development group agreed on the final targets in a consensus meeting. For characteristics rated of highest importance, the document lists: (i) high diagnostic accuracy (sensitivity and specificity); (ii) time to result of optimally ≤ 2 hours and no more than 1 day; (iii) required sample type to be minimally invasive, easily obtainable, such as urine, breath, or capillary blood, or a respiratory sample that goes beyond sputum; (iv) ideally the test could be placed at a peripheral-level health facility without a laboratory; and (v) the test should be affordable to low- and middle-income countries, and allow wide and equitable access and scale-up. Use of these target product profiles should facilitate the development of new tuberculosis treatment monitoring and optimization tests that are accurate and accessible for all people being treated for tuberculosis., ((c) 2023 The authors; licensee World Health Organization.)

Competing Interests: Declaration of interests ABe reports a grant through the University of California San Francisco (UCSF) from the US Agency for International Development (USAID) for the SMART4TB Initiative. RC reports a grant from USAID. HC is a member of the Data Safety Monitoring Board for the TRIAD study. CMD reports grants from the US National Institutes of Health (NIH), WHO, German Ministry of Education and Research, German Alliance for Global Health Research, USAID, FIND, German Center for Infection Research, UNAIDS, and Roche Diagnostics; is an academic editor for PLOS Medicine; and is a member of the WHO technical advisory group for tuberculosis diagnostics. EG is a board member for the TB Alliance and reports a grant from USAID for the SMART4TB Initiative. JH reports a grant from the Stop TB Partnership Private Sector Constituency. NH is a member of the British Parliament and co-chair of the Global TB Caucus. PHo reports a grant from USAID for the SMART4TB Initiative. AKi reports personal fees and a contract through UCSF (which also provides travel support) from USAID for the SMART4TB Initiative. IK holds a leadership position at the Save the Children Federation. EL reports personal fees from USAID for the SMART4TB initiative and held a leadership position with Treatment Action Group. PN reports a grant from USAID for the SMART4TB Initiative. MRe reports a grant from USAID for the SMART4TB Initiative. MO reports grants from the Global Fund, Johnson & Johnson, and Cepheid. MP serves as an advisor for the Bill & Melinda Gates Foundation, Foundation for Innovative New Diagnostics, WHO, and Stop TB Partnership. PS reports stock in Hyfe AI. AV reports a grant from Johnson & Johnson. GEV reports grants from the NIH/National Institute of Allergy and Infectious Diseases, Harvard Medical School, Harvard Global Health Institute, Unitaid/Partners in Health, and USAID; and is a protocol co-vice chair for a study with the TB Alliance and for a study with Janssen. GY reports grants from the Gates Foundation and WHO. AZ reports personal fees from Open Consultants. AC reports grants from the US NIH, Global Health Labs, and USAID; and is a member of the Centers for Disease Control and Prevention Advisory Council on Elimination of TB. PHe reports a grant from the Gates Foundation. The remaining authors declare no competing interests.

Background: Undiagnosed tuberculosis (TB) cases are the major challenge to TB control in Nigeria. An early warning outbreak recognition system (EWORS) is a system that is primarily used to detect infectious disease outbreaks; this system can be used as a case-based geospatial tool for the real-time identification of hot spot areas with clusters of TB patients. TB screening targeted at such hot spots should yield more TB cases than screening targeted at non-hot spots., Objective: We aimed to demonstrate the effectiveness of an EWORS for TB hot spot mapping as a tool for detecting areas with increased TB case yields in high TB-burden states of Nigeria., Methods: KNCV Tuberculosis Foundation Nigeria deployed an EWORS to 14 high-burden states in Nigeria. The system used an advanced surveillance mechanism to identify TB patients' residences in clusters, enabling it to predict areas with elevated disease spread (ie, hot spots) at the ward level. TB screening outreach using the World Health Organization 4-symptom screening method was conducted in 121 hot spot wards and 213 non-hot spot wards selected from the same communities. Presumptive cases identified were evaluated for TB using the GeneXpert instrument or chest X-ray. Confirmed TB cases from both areas were linked to treatment. Data from the hot spot and non-hot spot wards were analyzed retrospectively for this study., Results: During the 16-month intervention, a total of 1,962,042 persons (n=734,384, 37.4% male, n=1,227,658, 62.6% female) and 2,025,286 persons (n=701,103, 34.6% male, n=1,324,183, 65.4% female) participated in the community TB screening outreaches in the hot spot and non-hot spot areas, respectively. Presumptive cases among all patients screened were 268,264 (N=3,987,328, 6.7%) and confirmed TB cases were 22,618 (N=222,270, 10.1%). The number needed to screen to diagnose a TB case in the hot spot and non-hot spot areas was 146 and 193 per 10,000 people, respectively., Conclusions: Active TB case finding in EWORS-mapped hot spot areas yielded higher TB cases than the non-hot spot areas in the 14 high-burden states of Nigeria. With the application of EWORS, the precision of diagnosing TB among presumptive cases increased from 0.077 to 0.103, and the number of presumptive cases needed to diagnose a TB case decreased from 14.047 to 10.255 per 10,000 people., (©Chidubem Ogbudebe, Dohyo Jeong, Bethrand Odume, Ogoamaka Chukwuogo, Cyril Dim, Sani Useni, Okey Okuzu, Chenchita Malolan, Dohyeong Kim, Fiemu Nwariaku, Nkiru Nwokoye, Stephanie Gande, Debby Nongo, Rupert Eneogu, Temitayo Odusote, Salewa Oyelaran, Obioma Chijioke-Akaniro, Nrip Nihalani, Chukwuma Anyaike, Mustapha Gidado. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 08.02.2023.)

Tuberculosis (TB) is prevalent in Nigeria, and Katsina, along with other 12 states in the country, accounts for a high proportion of unnotified TB cases: constituting the high priority-intervention States in the country. Interventions focused on TB detection and coverage in the state could benefit from a better understanding of hotspot Local Government Areas (LGAs) that trigger and sustain the disease. Therefore, this study investigated the spatial distribution of TB Case Notification Rates (CNRs), diagnostics and coverage across the LGAs. Using 2017 to 2019 TB case finding data, the geocoordinates of diagnostic facilities and shapefiles, a retrospective ecological study was conducted. The data were analysed with QGIS and GeoDa. Moran's I and LISA were used to locate and quantify hotspots. The coverage of microscopy and GeneXpert facilities was assessed on QGIS using a 5 km and 20 km radius, respectively. The CNR in the state, and 29 of the 34 LGAs, increased steadily from 2017 to 2019. Hotspots of high CNRs were also identified in 2017 (Moran's I=0.106, p-value=0.090) and 2018 (Moran's I=-0.020, p-value=0.370). While CNRs increased along with presumptive TB rates across most LGAs over the years, the positivity yield and bacteriological and Xpert diagnostic rates decreased. Bacteriological and GeneXpert coverage were 78% and 49% respectively. Additionally, only 51% of the state's population lived within 20km of a GeneXpert facility. These results suggest that TB program interventions had some positive impact on the CNR, however, diagnostic facilities need to be equitably distributed and more innovative approaches need to be explored to find the missing cases., (©Copyright: the Author(s).)

Background: Nigeria has an estimated TB prevalence of 219 per 100,000 population. In 2019, Nigeria diagnosed and notified 27% of the WHO-estimated cases of all forms of TB and contributed 11% of the missing TB cases globally., Objective: To assess TB underreporting by type and level of health facility (HF), and associated factors in Lagos State, Nigeria., Methodology: Quantitative secondary data analysis of TB cases was conducted in 2015. χ 2 test was used to assess the association between treatment initiation, TB underreporting, local government area (LGA) and HF characteristics., Results: Overall, 2,064 persons with bacteriologically confirmed TB (15.5%) were not matched to patients in sampled TB registers. Treatment status was unknown for 86 cases (IQR 55-97) per LGA. LGAs with higher case-loads had higher proportions of cases with unknown TB status. Discrepant reporting of treated TB was also common (60% HFs). Primary-level TB treatment facilities and unengaged private facilities were less likely to notify., Conclusion: There was TB under-reporting across all types and levels of HFs and LGAs. There is a need to revise or strengthen the process of supervision and data quality assurance system at all levels.

Coronavirus disease 2019 (COVID-19) undermines control of other infectious diseases. Diagnostics are critical in health care. This opinion paper explores approaches for leveraging diagnostics for COVID-19 while retaining diagnostics for other infectious diseases, including tuberculosis (TB) and HIV. The authors reflect on experiences with GeneXpert technology for TB detection and opportunities for integration with other diseases. They also reflect on benefits and risks of integration. Placement of diagnostics in laboratory networks is largely nonintegrated and designated for specific diseases. Restricting the use of diagnostics leaves gaps in detection of TB, HIV, malaria, and COVID-19. Integrated laboratory systems can lead to more efficient testing while increasing access to critical diagnostics. However, the authors have observed that HIV diagnosis within the TB diagnostic network displaced TB diagnosis. Subsequently, COVID-19 disrupted both TB and HIV diagnosis. The World Health Organization recommended rapid molecular diagnostic networks for infectious diseases and there is a need for more investment to achieve diagnostic capacity for TB, HIV, COVID-19, and other emerging infectious diseases. Integrated laboratory systems require mapping laboratory networks, assessing needs for each infectious disease, and identifying resources. Otherwise, diagnostic capacity for one infectious disease may displace another. Further, not all aspects of optimal diagnostic networks fit all infectious diseases, but many efficiencies can be gained where integration is possible., (Copyright © 2022 Association for Molecular Pathology and American Society for Investigative Pathology. Published by Elsevier Inc. All rights reserved.)

Background: The greatest risk of infectious disease undernotification occurs in settings with limited capacity to detect it reliably. World Health Organization guidance on the measurement of misreporting is paradoxical, requiring robust, independent systems to assess surveillance rigor. Methods are needed to estimate undernotification in settings with incomplete, flawed, or weak surveillance systems. This study attempted to design a tuberculosis (TB) inventory study that balanced rigor with feasibility for high-need settings., Objective: This study aims to design a hybrid TB inventory study for contexts without World Health Organization preconditions. We estimated the proportion of TB cases that were not reported to the Ministry of Health in 2015. The study sought to describe TB surveillance coverage and quality at different levels of TB care provision. Finally, we aimed to identify structural-, facility-, and provider-level barriers to notification and reasons for underreporting, nonreporting, and overreporting., Methods: Retrospective partial digitalization of paper-based surveillance and facility records preceded deterministic and probabilistic record linkage; a hybrid of health facilities and laboratory census with a stratified sampling of HFs with no capacity to notify leveraged a priori knowledge. Distinct extrapolation methods were applied to the sampled health facilities to estimate bacteriologically confirmed versus clinical TB. In-depth interviews and focus groups were used to identify causal factors responsible for undernotification and test the acceptability of remedies., Results: The hybrid approach proved viable and instructive. High-specificity verification of paper-based records in the field was efficient and had minimal errors. Limiting extrapolation to clinical cases improved precision. Probabilistic record linkage is computationally intensive, and the choice of software influences estimates. Record absence, decay, and overestimation of the private sector TB treatment behavior threaten validity, meriting mitigation. Data management demands were underestimated. Treatment success was modest in all sectors (R=37.9%-72.0%) and did not align with treatment success reported by the state (6665/8770, 75.99%). One-fifth of TB providers (36/178, 20%) were doubtful that the low volume of patients with TB treated in their facility merited mastery of the extensive TB notification forms and procedures., Conclusions: Subnational inventory studies can be rigorous, relevant, and efficient in countries that need them even in the absence of World Health Organization preconditions, if precautions are taken. The use of triangulation techniques, with minimal recourse to sampling and extrapolation, and the privileging of practical information needs of local decision makers yield reasonable misreporting estimates and viable policy recommendations., (©Ellen M H Mitchell, Olusola Adedeji Adejumo, Hussein Abdur-Razzaq, Chidubem Ogbudebe, Nkem Chukwueme, Samson Bamidele Olorunju, Mustapha Gidado. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 15.03.2021.)

BACKGROUND: Drug-resistant tuberculosis (DR-TB) remains a global public health crisis. In 2013, the World Health Organization recommended the introduction of bedaquiline (BDQ) for eligible DR-TB patients. METHODS: We conducted a retrospective review and analyses of project reports from 2016 to mid-2019 on the processes, activities implemented, available results on enrolment and interim treatment outcomes, across the 23 Challenge TB (CTB) supported countries. RESULTS: Initial introduction of BDQ-containing regimens in the 23 CTB-supported countries took on average 2 years, with subsequent nation-wide scale-up achieved in Ethiopia and Kyrgyzstan within a short time period. Successful implementation required critical interventions including advocacy, revision of policies and guidelines, capacity building of health care workers, and strengthening of laboratory networks. The number of countries providing BDQ increased from 9 to 23; 9398 patients were enrolled on bedaquiline containing regimens; 71% were culture-negative after 6 months of treatment; and the number of countries reporting serious adverse events increased (from 5 to 18). Major challenges included limited in-country coordination with drug regulatory agencies, unrealistic quantification and drug ordering, weak laboratory networks and reporting systems for drug safety. CONCLUSION: BDQ introduction required a systematic and programmatic approach. The initial time investment helped achieve initial introduction and scale-up of coverage, ownership and sustainability by National TB Programmes.

Background: Multimorbidity is increasingly being recognized as a serious public health concern in the control of both drug-susceptible and drug-resistant tuberculosis (DR-TB). This study assessed the pattern of comorbidities and their prevalence in DR-TB patients at treatment initiation in Lagos, Nigeria., Methods: A cross-sectional study was conducted. The baseline laboratory records (human immunodeficiency virus [HIV] status, fasting blood sugar, audiometry, thyroid function tests, serum electrolyte, haemoglobin level and pregnancy test) of DR-TB patients initiated on treatment in Lagos, Nigeria between 1 August 2014 and 31 March 2017 were reviewed., Results: A total of 565 DR-TB patients' laboratory records were reviewed, of which 397 (70.3%) had comorbidities. The proportion with one, two, three and four comorbidities was 60.2%, 29.7%, 8.1% and 2.0%, respectively. Anaemia was the most common (48.1%) comorbid condition, while anaemia and hypokalaemia (7.3%), anaemia and hypothyroidism (6.5%) and anaemia and HIV (5%) were most common among patients with more than one comorbid condition. DR-TB patients with comorbidity were significantly older (34.8±12.3 y) than those without comorbidity (32.0±12.8 y) (p=0.038). Of the 176 females in the reproductive age group, 8 (4.5%) were pregnant at baseline., Conclusions: The prevalence of comorbidity among DR-TB patients was high. There is a need for the national TB program to expand its DR-TB council of experts and also integrate reproductive health services into DR-TB management in Nigeria., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Community-led tuberculosis (TB) active case finding is widely promoted, heavily funded, but many efforts fail to meet expectations. The underlying reasons why TB symptom screening programs underperform are poorly understood. This study examines Nigerian stakeholders' insights to characterize the mechanisms, enabling structures and influences that lead programs to succeed or fail. Eight focus group discussions were held with Community Health Workers (CWs) from four models of community-based TB screening and referral. In-depth interviews were conducted with 2 State TB program managers, 8 Community based organizations (CBOs), and 6 state TB and Leprosy Local Government supervisors. Transcripts were coded using Framework Analysis to assess how divergent understandings of CWs' roles, expectations, as well as design, political and structural factors contributed to the observed underperformance. Altruism, religious faith, passion, and commitment to the health and well-being of their communities were reasons CWs gave for starting TB symptom screening and referral. Yet politicized or donor-driven CWs' selection processes at times yielded implementers without a firm grounding in TB or the social, cultural, and physical terrain. CWs encountered suspicion, stigma, and hostility in both health facilities and communities. As the interface between the TB program and communities, CWs often bore the brunt of frustrations with inadequate TB services and CBO/iNGO collaboration. Some CWs expended their own social and financial capital to cover gaps in the active case finding (ACF) programs and public health services or curtailed their screening activities. Effective community-led TB active case finding is challenging to design, implement and sustain. Contrary to conventional wisdom, CWs did not experience it as inherently empowering. Sustainable, supportive models that combine meaningful engagement for communities with effective program stewardship and governance are needed. Crucially effective and successful implementation of community-based TB screening and referral requires a functional public health system to which to refer., Competing Interests: Declaration of competing interest All authors declares no conflict of interest., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Drug-Resistant tuberculosis (DR-TB) is estimated to cause about 10% of all TB related deaths. There is dearth of data on determinants of DR-TB mortality in Nigeria. Death among DR-TB treated cohorts in Nigeria from 2010 to 2013 was 30%, 29%, 15% and 13% respectively. Our objective was to identify factors affecting survival among DR-TB patients in northern Nigeria., Methods: Demographic and clinical data of all DR-TB patients enrolled in Kano, Katsina and Bauchi states of Nigeria between 1st February 2015 and 30th November 2016 was used. Survival analysis was done using Kaplan-Meier and multiple regression with Cox proportional hazard modeling., Results: Mean time to death during treatment is 19.2 weeks and 3.9 weeks among those awaiting treatment. Death was recorded among 38 of the 147 DR-TB patients assessed. HIV co-infection significantly increased probability of mortality, with an adjusted hazard ratio (aHR) of 2.35, 95% CI: 1.05-5.29, p = 0.038. Treatment delay showed significant negative association with survival (p = 0.000), not starting treatment significantly reduced probability of survival with an aHR of 7.98, 95% CI: 2.83-22.51, p = 0.000. Adjusted hazard ratios for patients started on treatment more than eight weeks after detection or within two to four weeks after detection, was beneficial though not statistically significant with respective p-values of 0.056 and 0.092. The model of care (facility vs. community-based) did not significantly influence survival., Conclusion: Both HIV co-infected DR-TB patients and DR-TB patients that fail to start treatment immediately after diagnosis are at significant risk of mortality. Our study showed no significant difference in mortality based on models of care. The study highlights the need to address programmatic and operational issues pertaining to treatment delays and strengthening DR-TB/HIV co-management as key strategies to reduce mortality., Competing Interests: The authors have declared that no competing interests exist.

Setting: Nigeria adopted GeneXpert MTB Rif as a primary diagnostic tool were available and accessible since 2016. The current geographical coverage of GeneXpert machines by LGAs stands at 48%, with a varied access and utilization., Objectives: To assess the association between the type and level of health facilities implementing GeneXpert MTB/Rif and performance outcome of the machines in Nigeria., Study Design: Retrospective secondary data analysis of GeneXpert performance for 2017 from GXAlert database. The independent variables were type and levels of health care facilities, and dependent variables were GeneXpert performance (utilization, successful test, error rates, MTB detected, and Rifampicin resistance detected)., Results: Only 366 health care facilities are currently implementing and reporting GeneXpert performance, the distribution is 86.9% and 13.1% public and private health care facilities respectively, and only 6.3% of the facilities are primary health care. Of 354,321 test conducted in 2017, 91.5% were successful, and among unsuccessful test 6.8% were errors. The yield was 16.8% MTB detected (54,713) among which 6.8% had Rif resistance. The GeneXpert utilization rate was higher among private health care facilities (55.8%) compared to 33.3% among public health care facilities. There was a statistically significant difference in the number of successful test between public and private health facility-based machines as determined by one-way ANOVA (F(1,2) = 21.81, P = 0.02) and between primary, secondary and tertiary level health facility-based machines (F(1,2) = 41.24, P < 0.01)., Conclusion: Nigeria with very low TB coverage should rapidly scale-up and decentralize GeneXpert services to the private sector., Competing Interests: There are no conflicts of interest.