Date Published: April 25, 2019
Publisher: Public Library of Science
Author(s): Charity Oga-Omenka, Christina Zarowsky, Aderonke Agbaje, Joseph Kuye, Dick Menzies, Kingsley Nnanna Ukwaja.
There were an estimated 580,000 new cases of multidrug/rifampicin resistant TB (DR-TB) in 2015, and only 20% were initiated on treatment. This study explored health system and patient factors associated with initiation and timeliness of treatment among DR-TB patients in Nigeria, ranked 4th globally for estimated TB cases in 2015.
A retrospective cohort study using 2015 diagnosis and treatment data from the Nigerian TB program electronic records examined “treatment ever received” (yes/no) and “treatment within 30 days” (yes/no). We compared health system and patient characteristics using binomial logistic regression, while controlling for confounders.
Of 996 patients diagnosed nationwide in 2015 (aged 0–87 years, median 34), 47.8% were never treated. Of those treated (n = 520), 51.2% were treated within the 30 days prescribed in the National treatment guideline. Healthcare facility locations were significantly associated with ever receiving treatment and timely treatment. Predictors of timely treatment at the national level also included level of care and patient treatment history. The South-West zone, where DR-TB programs started, showed overall better access to DR-TB healthcare.
Healthcare facility geographic locations were significantly associated with treatment initiation and timeliness. Significant regional differences in access to DR-TB care in Nigeria persist, reflecting uneven contexts for national DR-TB treatment rollout.
There were an estimated 10.4 million incident TB cases worldwide in 2015 (25% in Africa) and 580,000 DR-TB new cases. Although DR-TB survival rates are lower and treatment more difficult, studies have suggested that treatment outcomes are optimized by timely diagnosis and treatment, as mortality rate is highest within the first month of diagnosis.[2–4] The World Health Organization (WHO) recommends treatment initiation within 4 weeks of diagnosis.
The WHO recommends early treatment initiation within 4 weeks of DR-TB diagnosis and this is prescribed the Nigerian DR-TB treatment guidelines.  Timely diagnosis and treatment initiation is critical for the control of DR-TB in Nigeria, one of the major contributors to the global burden of DR-TB. Our review of current literature did not find any study on the timeliness of or time to DR-TB treatment in Nigeria.
Timely access to diagnosis and treatment services are critical to DR-TB patients’ survival and other treatment outcomes. However, within Nigeria, nearly half of diagnosed DR-TB patients are never initiated on treatment, less than a quarter initiate treatment within the recommended 30 days after diagnosis, and regional inequalities in access to DR-TB care are significant. In a context where DR-TB case detection is less than 5% of the estimated burden, these low rates of treatment for cases already detected pose both practical and ethical challenges to DR-TB control. Disparities persist in access to services at patient, facility, and geopolitical levels. Semi-urban and rural residence as well as being initiated in the facility were predictive of earlier treatment initiation, suggestive of complex access challenges. The geographic location of the diagnosing or treatment facility were significantly associated with treatment initiation and timely treatment highlighting significant geopolitical and state differences. The National TB Program needs to strengthen linkages between diagnosis and treatment, as well as provide adequate access and timely treatment initiation for DR-TB patients, especially in the communities, across all geopolitical zones and states.