Tuberculosis (TB) is still a serious public health issue in Nigeria accounting for 46,000 deaths (27 per 100,000 populations) per year [1] . The 2012 national TB prevalence survey showed that the prevalence of smear positive TB in Nigeria (318 per 100,000) was about twice as much as the previous World Health Organization (WHO) estimate, which was based on routine surveillance data [2] . This recent figure placed Nigeria 4^th among the 22 high burden TB countries [3] . Another WHO report showed that 2.9% (2.1% - 4.0%) of TB cases in Nigeria present with multi drug resistant TB [4] . Despite the efforts of the National TB and Leprosy Control Program (NTBLCP) since the commencement of directly observed treatment short course (DOTS) for management of TB in 1993, inadequate skills and poor knowledge of health care providers and programme officers at the DOTS centers were some of the barriers of TB control in Nigeria [1] [5] .

Adherence to the national TB guidelines is therefore necessary in ensuring that TB patients get quality service irrespective of the service point. Thus, successful treatment could be achieved if the healthcare workers (both public and private medical practitioners) follow the national guidelines for the treatment of TB.

This present study compared adherence of private and public DOTS providers with the national guidelines and the factors associated with adherence with the national guidelines in the Lagos State TB control program, Nigeria.

Treatment cards of 1896 TB patients were reviewed out of which 1524 (80.4%), 132 (7.0%) and 240 (12.6%) were from the public, PFP, and PNFP DOTS facilities respectively (Figure 1). The mean age of TB patients treated at the public and private DOTS facilities were respectively 34.3 ± 13.4 and 32.2 ± 12.4. More males were treated for TB at the public DOTS facilities (M:F ratio = 1:076) while at the private DOTS facilities the M:F ratio was almost equal (M:F = 1:0.98). Over 60% of the TB cases reviewed were sputum smear positive. However, a significantly higher proportion of the sputum smear positive cases were managed at the private DOTS facilities (p < 0.001). Of the patients that had HIV test done, 15.3% and 11.8% were HIV positive from the public and private DOTS facilities respectively as shown in Table 1.

NB: ^# = Not included in the analysis. All participants in this study were Negros.

Table 2 shows the management pattern of patients treated at the public and private DOTS facilities. HIV test was not done for a significantly higher proportion of patients managed (22.6% vs 10.6%) at the private DOTS facilities (p < 0.001). A slightly higher proportion of TB patients treated at the public DOTS facilities (2% vs 0.5%) did not do smear microscopy before commencement of treatment and also did not do three follow up

Note: X = Fisher’s exact test.

sputum (54.2% vs 52.4%) (p < 0.05) during the entire treatment duration. However, more of the patients treated at the public DOTS facilities did weight measurements (53.1% vs 41.4%) and had the correct dosage of TB drugs based on weight (90.6% vs 71.0%) compared with those managed at the private DOTS facilities (p < 0.001). A higher proportion of patients managed at the private DOTS facilities interrupted treatment (22.8% vs 24.7%) compared with those managed at the public DOTS facilities (p = 0.437).

Recording of sputum smear results (7.7% vs 14.0%), treatment outcome (43.8% vs 53.8%) and filling of the treatment cards (22.6% vs 32.8%) were poorly done for significantly higher proportion of patients managed at the private DOTS facilities compared with those treated at the public DOTS facilities as shown in Table 3. Table 4 shows the proportion of patients treated in full adherence with the national guidelines at the public and private DOTS facilities. Overall, the proportion of patients treated full adherence with the national guidelines was low in both the public and private DOTS facilities. About 19%, 25% and none of the cases seen at the public PNFP and PFP DOTS facilities were treated in full adherence with the NTBLCP guidelines respectively (p < 0.001). Table 5 shows that a significantly higher proportion of adults, smear positives and those that had successful treatment were treated in full compliance with the national guidelines (p < 0.05).

One of the goals of the public private mix (PPM) for TB is to provide rational and standardized treatment to TB patients especially those managed at the private sector, thereby reducing the spread of TB within the community and emergence of multi drug resistance TB. Routinely, the NTBLCP and the LSTBLCP organizes training and retraining programs for health care workers at the public DOTS facilities and private sector involved in the PPM. This training is expected to facilitate adherence with the national guidelines. This study however shows that the proportion of patients managed in full adherence with the national guidelines at the public and private DOTS facilities was low. Particularly striking was the fact that none of the patients managed at the PFP facilities were managed in full adherence with the national guidelines. Studies from Nigeria and other high TB burden countries have shown that private practitioners and health care workers from the public sector do not comply with the National Tuberculosis Programme (NTP) [7] -[10] .

Many reasons have been shown to be responsible for the poor adherence of health care workers at the TB treatment centers. Some studies found that insufficient knowledge of health workers at the public and private

sector about the guidelines was responsible for the poor adherence [8] [11] . Other studies also showed that some health workers refused to comply despite their awareness of the NTP guidelines although reasons for their refusal were not highlighted [12] [13] .

Health care workers are usually trained before they were allowed to provide TB services. However, maintaining trained staff has been a major challenge in the TB programme especially in a cosmopolitan city like Lagos. The high staff turnover experienced in the private sector maybe due to poor job satisfaction and/or job insecurity. In addition, the regular redeployment and poor distribution of trained staff within the public health sector is a cause of concern in the sustainability of public health programmes in developing countries like Nigeria [14] -[16] .

Sputum microscopy is the main diagnostic tool for pulmonary tuberculosis and all presumptive TB clients should have sputum microscopy as the first diagnostic tool. In this study almost all the patients managed at the public and private DOTS facilities did sputum smear microscopy before commencement of anti-TB treatment. This is similar to findings from studies from Nigeria and elsewhere [9] [11] [17] [18] . However other studies from another part of Nigeria and Ethiopia showed that some of the patients treated at the public and private DOTS facilities did not do smear microscopy before initiation of anti-TB treatment [7] [19] . Less than half of the patients managed at the public and private DOTS facilities had three follow up sputum smear microscopy in this study. This may be due to shortages of laboratory equipment and supplies in some of the DOTS laboratories in Lagos [20] which has also been reported in other studies from Ghana, India and Ethiopia [19] [21] [22] and the incessant strike action by health care workers in Lagos Nigeria also contributed to failure of patients to do follow up sputum microscopy.

There is a strong synergy between TB and HIV/AIDS and the WHO recommends HIV testing for TB patients to reduce the burden of TB/HIV [23] . In this study, a high proportion of patients managed at the public and private DOTS facilities did HIV test which was consistent with findings from another study from another part of the country [6] but higher than what was reported in a similar study from Ethiopia [19] . Majority of the Anti retrovital therapy (ART) centres in Lagos state are located at the public health care facilities. This may explain why a significantly higher proportion of patients managed at the public DOTS facilities did HIV test compared with those managed at the private DOTS facilities.

One of the goals of the NTBLCP was to increase the success rate of TB patients [1] . In order to achieve this target, TB patients must be treated in full adherence with the NTP guidelines. This study shows that none of the patients that had unsuccessful treatment at the public and private DOTS facilities were treated in full adherence with the NTP guidelines. A WHO report documented that within 10 years of DOTS implementation, 16 million people globally were cured [24] in addition to the reduction in incidence of TB in most region of the world except the sub Saharan Africa. For the NTBLCP to achieve the global targets, it is paramount that patients are treated according to the NTP guidelines irrespective of their age, gender, sputum smear results and HIV status.

The study was a retrospective review of treatment cards and as such did not consider other factors such as training of health personnel at DOTs facilities, availability laboratory equipment and supplies and provision of logistic necessary to track patients lost to follow which could affect adherence to the national guidelines.

Majority of the patients treated at the public and private DOTS facilities in Lagos State were not treated in full adherence with the national guidelines. There is an urgent need for the LSTBLCP to reorient health care providers in public and private health facilities to ensure full adherence with the national guidelines on the management of TB in Nigeria.

The authors wish to acknowledge all the Lagos State TB control officer, TB focal persons, LGA TB supervisors and the Lagos State Ministry of Health for their support. The research was self funded; the findings and conclusion are those of the authors.

Authors have declared that no competing interests exist.

OAA conceived the study, involved with data collection, data analysis and discusssion. OJD wrote the methodology and was involved in the writing process, MD was involved in reading the manuscript and literature search, ENA was involved in data collection and proff reading the manuscript. EOJ and OEI were involved with data collection and literature search while OOO supervised the research.

Olusola AdedejiAdejumo,Olusoji JamesDaniel,MustaphaGidado,Andrew FolarinOtesanya,Esther NgoziAdejumo,EbunoluwaO. Jaiyesimi,OluwatoyinEsther Idowu,OlumuyiwaO. Odusanya, (2016) Are Tuberculosis Patients Managed According to the National Guidelines in Lagos State Nigeria?. International Journal of Clinical Medicine,07,16-24. doi: 10.4236/ijcm.2016.71003