Kingsley N. Ukwaja

Healthcare-seeking behavior, treatment delays and its determinants among pulmonary tuberculosis patients in rural Nigeria: a cross-sectional study

BackgroundNigeria ranks fourth among 22 high tuberculosis (TB) burden countries. Although it reached 99% DOTS coverage in 2008, current case detection rate is 40%. Little is known about delays before the start of TB therapy and health-seeking behaviour of TB patients in rural resource-limited settings. We aimed to: 1) assess healthcare-seeking behaviour and delay in treatment of pulmonary TB patients, 2) identify the determinants of the delay in treatment of pulmonary TB.MethodsWe conducted a cross-sectional study of adult new pulmonary TB patients notified to the National Tuberculosis Control Programme (NTP) by three rural (two mission/one public) hospitals. Data on health-seeking and delays were collected using a standardised questionnaire. We defined patient delay as the interval (weeks) between the onset of cough and the first visit to any health provider, and health system delay as the time interval (weeks) between patients first attendance to any health provider, and the onset of treatment. Total delay is the sum of both delays. Multiple linear regression models using nine exposure variables were built to identify determinants of delays.ResultsOf 450 patients (median age 30 years) enrolled, most were males (55%), subsistent farmers (49%), rural residents (78%); and 39% had no formal education. About 84% of patients reported first consulting a non-NTP provider. For such patients, the first facilities visited after onset of symptoms were drug shops (79%), traditional healers (10%), and private hospitals (10%). The median total delay was 11 (IQR 9–16) weeks, patient delay 8 (IQR 8–12) and health system (HS) delay 3 (IQR 1–4) weeks. Factors associated with increased patient delay were older age (P <0.001) longer walking distance to a public facility (<0.001), and urban residence (P <0.001). Male gender (P = 0.001) and an initial visit to a non-NTP provider (P = 0.025) were independent determinants of prolonged HS delay. Those associated with longer total delay were older age (P <0.001), male gender (P = 0.045), and urban residence (P<0.001).ConclusionOverall, TB treatment delays were high; and needs to be reduced in Nigeria. This may be achieved through improved access to care, further education of patients, engagement of informal care providers, and strengthening of existing public-private partnerships in TB control.

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

BackgroundStudies 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.MethodsData 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.ResultsAverage direct household costs for TB were US

Treatment outcome of HIV-associated tuberculosis in a resource-poor setting.

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 >40xa0years (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).ConclusionsCurrent 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-2015xa0TB strategies and influence policy-making on health services that are meant to be free of charge.

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

Nigeria is among the countries with the worlds highest tuberculosis (TB) burden, and HIV/TB co-infection is an important cause of mortality. We evaluate the treatment outcome of HIV-infected TB patients in Abakaliki, Nigeria. A retrospective cohort study of all TB patients registered at a tertiary hospital between January 2006 and December 2010 was conducted. Of 671 TB patients, 189 (28.2%) were HIV co-infected. Of these, 147 (77.8%) had pulmonary TB and 42 (22.2%) had extra-pulmonary TB. The overall treatment success rate was 52.4% (n = 99) and the defaulted in treatment rate was 30.2% (n = 57). Twenty-one (11.1%) died, and one (0.5%) had treatment failure. Younger age group (<15 years; P = 0.0024) and smear-positive status (P = 0.0056) were independent predictors of successful treatment. TB/HIV co-infection is associated with high mortality and alarming default rates during treatment.

Tuberculosis treatment default in a large tertiary care hospital in urban Nigeria: Prevalence, trend, timing and predictors

OBJECTIVEnTo evaluate the rates, timing and determinants of default and death among adult tuberculosis patients in Nigeria.nnnMETHODSnRoutine 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 identify independent predictors for treatment default and death.nnnRESULTSnOf 1 668 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; CI 1.7-3.5), 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).nnnCONCLUSIONSnTargeted interventions to improve treatment adherence for patients with the highest risk of default or death are urgently needed. This needs to be urgently addressed by the National Tuberculosis Programme.

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

OBJECTIVESnFew studies have investigated tuberculosis treatment default in tertiary care settings. We aimed to determine the prevalence, trend, timing and predictors of defaulting from tuberculosis treatment in a Nigerian tertiary hospital.nnnMETHODSnData entered from 2006 to 2010 in the Federal Medical Centre, Abakaliki, tuberculosis treatment register were sorted into six treatment outcomes. Five outcomes were combined into one variable called non-defaulters and were compared with defaulters. The statistical analysis was conducted using SPSS.nnnRESULTSnOf 671 tuberculosis patients, 192 (28.6%) defaulted. Of these, 126 (66%) were ≥30 years old, and 115 (60%) had pulmonary tuberculosis. Furthermore, 106 (55%) were males, and 125 (65%) lived in a rural area. The annual proportion of defaulters dropped from 34.8% to 20.6%, but the decreasing trend was not statistically significant (P=0.132 for trend). Of the defaulters, 148 (77.1%) defaulted during their intensive phase of treatment. The median default time was 7 (IQR 5-8) weeks. The independent predictors of treatment default were older age (aOR 1.5), rural residence (aOR 2.3), and HIV seropositivity (aOR, 2.8).nnnCONCLUSIONnTB treatment default is high and must be reduced. This may be achieved through improved rural DOT, further patient education, and enhanced coordination of TB/HIV care.

Trends in treatment outcome of smear-positive pulmonary tuberculosis in Southeastern Nigeria, 1999 - 2008

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.

Reaching the underserved: Active tuberculosis case finding in urban slums in southeastern Nigeria

Background: the Directly Observed Treatment Short Course (DOTS) strategy was introduced into the tuberculosis control programme of Ebonyi, Southeastern, Nigeria in 1996. The impact of the programme on the treatment outcomes for smear-positive tuberculosis has not been assessed ever since. We assessed the trends in treatment outcome for new smear-positive pulmonary tuberculosis between 1999 and 2008. Methods: we conducted a retrospective analysis of the Ebonyi state Ministry of Health quarterly smear-positive tuberculosis statistical returns. Patients were treated and treatment outcome categories computed according to the WHO/National Tuberculosis Control Programme’s guidelines. Chi-square for trends was used to determine significance. Results: the number of smear-positive cases who registered for treatment fell from 1 361 patients in 1999 to 977 in 2008 (Trend χ2=349; P<0.001). The follow-up smear results at month two were not available for 16% of the patients in 1999; this unavailability decreased to 1.7% in 2008. The negative conversion rate at month two increased from 77.5% in 1999 to 95.9% in 2008 (Trend χ2=16.5; P<0.001). Treatment success rose from 74.9% in 1999 to 88.7% in 2008 (Trend χ2=12.8; P<0.001), whilst default rate declined from 12% to 4.3% (Trend χ2=55.6; P<0.001). Though decreasing (Trend χ2=4.64; P=0.031), the annual death rate remained at around 5% during the study period. Conclusions: monitoring, supervision and home visits have improved, and our DOTS programme has achieved an 85% treatment success and declining default rates. However, with the current low case notification and high mortality rates, alternative mechanisms are needed to achieve global stop-TB targets in the State.

Trend in case detection rate for all tuberculosis cases notified in Ebonyi, Southeastern Nigeria during 1999-2009.

BACKGROUNDnNigeria ranks 10th among 22 high TB burden countries with low TB case detection that relies on passive case finding. Although there is increasing body of evidence that active case finding (ACF) has improved TB case finding in urban slums in some parts of the world, this strategy had not been implemented in Nigeria despite the pervasiveness of urban slums in the country.nnnOBJECTIVEnTo assess the yield and profile of TB in urban slums in Nigeria through ACF.nnnMETHODSnA prospective, implementation study was conducted in three urban slums of southeastern Nigeria. Individuals with TB symptoms were identified through targeted screening using a standardized questionnaire and investigated further for TB. Descriptive and bivariate analyses were performed using SPSS.nnnRESULTSnAmong 16,743 individuals screened for TB, 6361 (38.0%) were identified as TB suspects; 5894 suspects were evaluated for TB. TB was diagnosed in 1079 individuals, representing 6.4% of the screened population and 18.3% of those evaluated for TB. Of the 1079 cases found, 97.1% (n=1084) had pulmonary TB (PTB), and majority (65%) had new smear-positive TB. Children (<15years) accounted for 6.7% of the cases. Also, 22.6% (216) of the cases were HIV co-infected, among whom 55.1% (n=119) were females. The average number of individuals needed to screen to find a case of TB was 16.nnnCONCLUSIONSnThere is high prevalence of TB in Nigeria slum population. Targeted screening of out-patients, TB contacts, and HIV-infected patients should be optimized for active TB case finding in Nigeria.

Profile and treatment outcome of smear-positive TB patients who failed to smear convert after 2 months of treatment in Nigeria

Unlike previous annual WHO tuberculosis reports that reported case detection rate for only smear-positive tuberculosis cases, the 2010 report presented case detection rate for all tuberculosis cases notified in line with the current Stop TB strategy. To help us understand how tuberculosis control programmes performed in terms of detecting tuberculosis, there is need to document the trend in case detection rate for all tuberculosis cases notified in high burden countries. This evidence is currently lacking from Nigeria. Therefore, this study aimed to assess the trend in case detection rate for all tuberculosis cases notified from Ebonyi state compared to Nigeria national figures. Reports of tuberculosis cases notified between 1999 and 2009 were reviewed from the Ebonyi State Ministry of Health tuberculosis quarterly reports. Tuberculosis case detection rates were computed according to WHO guidelines. 22, 508 patients with all forms of tuberculosis were notified during the study. Case detection rate for all tuberculosis rose from 27% in 1999 to gradually reach a peak of 40% during 2007 to 2008 before a slight decline in 2009 to 38%. However, the national case detection rate for all tuberculosis cases in Nigeria rose from 7% in 1999 and progressively increased to reach a peak of 19% during 2008 and 2009. Since the introduction of DOTS in Ebonyi, the programme has achieved 40% case detection rate for all tuberculosis cases - about 20% better than national figures. However, with the current low case detection rates, alternative mechanisms are needed to achieve the current global stop- TB targets in Nigeria.