Tuberculosis (TB) is an important cause of illness and death in Nigerian children and adolescents. The HIV epidemic has further increased the burden of the disease. Childhood and adolescent TB is under- diagnosed and under-reported in Nigeria. Any child with presumed or confirmed TB should be tested for HIV infection. All malnourished and HIV positive children and adolescents should be screened routinely for TB. Most children and adolescents with TB tolerate TB medicines and respond well to treatment. All children and adolescents diagnosed with TB should be reported and commenced on treatment. All eligible child and adolescent contacts of TB cases should be placed on TB Preventive Treatment (TPT).
TB and HIV constitute major public health problems in Nigeria. The burden of these diseases is further compounded by the impact they have on each other; HIV fuels the burden of TB while TB on the other hand is the commonest infection among People Living with HIV (PLHIV). The interaction between these two diseases increases the morbidity and mortality among TB/HIV co- infected patients and also stretches the already challenged infrastructure of the health sector.
Nigeria is ranked 6th among 30 high-burden TB countries globally and among the 14th countries for DRTB based on estimated incidence of MDR/RR TB. The national MDR/RR TB burden is estimated to be 21,000 annually, however, case notification is suboptimal, with only 2,384 cases diagnosed, representing an abysmally low 11% case notification rate in 2019. This huge notification gap can be attributed to low DSTB case finding, suboptimal access to rapid molecular diagnostics, challenging clinical and programmatic management system.
These revised guidelines outline key recommendations for the implementation of the all-oral, shorter regimen for DRTB treatment, including diagnosis and bacterial confirmation of drug resistance, treatment regimen design, monitoring of treatment efficacy and safety, and programmatic evaluation
The NTBLCP is committed to the WHO Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) accreditation process for competency aimed at developing and improving laboratory services to attain quality for established national and International standards. As at early, 2014 the two National TB Reference Laboratories (NRLs) and three other TB Reference laboratories had commenced the WHO SLIPTA programme and are at various levels of accreditation. Based on the NSP for NTBLCP 2015- 2020, there are plans for enrolment to achieve accreditation process for other TB Reference laboratories.
The role of laboratories at different levels includes services for the management of individual patients, programmatic activities which includes monitoring trends of drug resistance and surveillance. To carry out these functions TB diagnostic network requires minimum biosafety measures that should be implemented at different levels of testing to reduce the risk of a laboratory acquired infection.
This national guideline on TB laboratory biosafety is developed in line with global recommendations to provide appropriate guidance on biosafety at all levels of TB laboratories in the country.
Prompt diagnosis of both drug-susceptible and DR-TB cases is the first step to achieving TB control. A strong and efficient laboratory network, providing diagnosis according to the established diagnostic algorithm and under quality assured procedures is the key component for this task. The role of laboratories at different levels includes services for the management of individual patients, programmatic activities which includes monitoring trends of drug resistance, and surveillance. The laboratory network is coordinated at the central level by the laboratory team of the NTBLCP. The diagnosis of DR-TB patients (defined here as rifampicin-resistant and Multidrug-Resistant TB (MDR-TB)) is currently based on examination of presumptive DR-TB cases using GeneXpert MTB/Rif or Line Probe Assay (LPA). Sputum specimens from presumptive DR-TB cases are collected from Directly Observed Treatment Short course (DOTS) centres and transported to GeneXpert sites for examination. Currently, all 36 states and the Federal Capital Territory (FCT) have at least one GeneXpert machine for diagnosis of TB and/or resistance to rifampicin. Transportation of specimens from the DOTS centres to the GeneXpert sites is the responsibility of the Local Government TB and Leprosy Supervisor (LGTBLS). Following a positive result for drug resistance by GeneXpert or LPA, sputum specimen is collected for confirmatory TB culture and Drug Susceptibility Testing (DST) for first line anti- TB drugs prior to commencing the patient on treatment.
The NTBLCP has adopted a strategic approach for the implementation of Truenat MTB-RIF Dx that maximizes the utilization of the machine in meeting the country’s TB diagnostic needs. The national tools shall be reviewed to accommodate Truenat MTB-RIF Dx. Sets of key indicators and milestones shall be used to monitor the implementation.
The NTBLCP in collaboration with partners has made tremendous efforts in ensuring that the recommended rapid molecular tests provide positive impact in early diagnosis and increased case detection among presumptive TB cases. Various strategies to enhance accessibility through specimen referral and optimization will be sustained.
In an effort to improve access to TB diagnosis and prompt treatment, the WHO in 2016 released guidelines for the use of TB Loop-isothermal mediated amplification test (TB-LAMP) following its adoption for use in high TB Burden countries for the diagnosis of pulmonary TB. TB-LAMP is a unique, temperature-independent technique for amplifying DNA and results can be read with the naked eyes under ultraviolent light. It is robust, easy to use and requires minimal maintenance and laboratory infrastructure. It requires no cold chain and can be used at peripheral health centers even as a mobile point of care test. It has a short turnaround time with a high throughput of 14 samples per run.
Contact investigation consists of identification, evaluation and provision of appropriate Tuberculosis (TB) treatment or TB preventive treatment (TPT). TPT or treatment of Latent TB infection is treatment offered to individuals who are considered to be at risk of developing TB disease, in order to reduce their risk of developing active TB.
To create demand for services, the NTBLCP encourages community participation and ensures there is awareness creation through the provision of information on the causes, transmission, diagnosis and treatment of the three diseases in the community. Accessibility is also ensured through the continuous strategic expansion of treatment and diagnostic centres across the country in order to provide quality laboratory services, prompt treatment and rehabilitation services. Other areas like controlling TB in children and managing Drug-resistant TB are also being given serious attention.