KEY CHANGES IN THE NEW NTBLCP GUIDELINES

BACKGROUND INFORMATION (2) It is now: National Tuberculosis, leprosy and Buruli ulcer Management and control Guidelines 6th edition, 2014 A three in one document i.e. it now contains the implementation policy for TB, Leprosy and BU in Nigeria There are five major Sections: Implementing TB control activities Implementing Leprosy activities Implementing Buruli Ulcer activities Logistic Management System Of the NTBLCP Monitoring And Evaluation System Of the NTBLCP

BACKGROUND INFORMATION (2) There are major changes in the new guideline; therefore every stakeholder who is to implement TB, Leprosy and BU activities in Nigeria is encouraged to take time and read this document meticulously to avoid unnecessary confusion and argument on the field during the course of implementation. The guideline was reviewed in line with the new global documents for TB, leprosy and BU. All changes in this guidelines takes effect from the 1st of January, 2015. All STBLCO is to enforce full implementation of this guideline for all TBL and BU activities in their state as from 1st January 2015.

DIAGNOSIS (1) All adults suspected of having TB must have their sputum sent for AFB microscopy for diagnosis irrespective of their HIV status. All presumptive TB cases who are HIV Positive or who have had previous TB treatment must have their sputum (1 sample) sent for GeneXpert MTB/RIF along side AFB microscopy for diagnosis. All Children with symptoms of TB who can produce sputum must have sputum collected for AFB Microscopy and GeneXpert MTB/RIF for diagnosis. All other clinical samples other than sputum from any child suspected of having PTB should be examined using GeneXpert MTB/RIF only for diagnosis.

DIAGNOSIS (2) The new algorithm for children to a large extent allows GHCW to diagnose and treat PTB in children (applying the principle of task shifting). Sputum collection for AFB Microscopy is now 2 samples collected on the spot and the early morning of the 2nd day. The categories of persons to be sent for GeneXpert MTB/RIF has now increased to nine refer to GeneXpert priority group in Nigeria.docx All TB suspects with smear negative AFB results should be given broad spectrum antibiotics and reviewed after two weeks. Sputum samples from only those who remain symptomatic should be sent for GeneXpert MTB/RIF for diagnosis and further actions

DIAGNOSIS (3) The new guideline allows for clinical diagnosis of TB in children where clinical specimen are not available for diagnosis. The evaluation of a child for IPT is simpler, does not need the availability of a doctor (task shifting) and allows for increased IPT uptake among under children. A patient who had both AFB microscopy & Xpert test done simultaneously & whose isolate is susceptible to TB should be interpreted as follows: Smear positive PTB: If MTB detected & at least 1+ acid-fast bacilli (10-99 AFB per 100 oil immersion fields) in at least one sputum smear microscopy Smear negative PTB: MTB detected using GeneXpert MTB/RIF and at least two sputum smear microscopy negative for AFBs.

Treatment & MONITORING (1) Four standardized treatment Regimen are currently recommended for the treatment of all susceptible TB cases in Nigeria. These regimens include the following: Standard treatment regimen for New and Previously treated adult PTB & EPTB* cases: Regimen 1 for adult: 2(RHZE)/4(RH). Standard treatment regimen for New and Previously treated child PTB & EPTB* cases: Regimen 1 for children: 2(RHZE)/4(RH). Standard treatment regimen for all cases of TB Meningitis & Osteo-articular TB in adults: Regimen for adult with EPTB*: 2(RHZE)/10(RH). Standard treatment regimen for all cases of TB Meningitis & Osteo-articular TB in children: : Regimen for children with EPTB*: 2(RHZE)/10(RH) *All EPTB Cases with the exception of TB Meningitis & Osteo-articular TB

Treatment & MONITORING (2) All TB cases who are resistant to Rifampicin should be treated with second line anti-TB regimen. All smear positive cases who do not convert at the end of the 2nd month of treatment should have their AFB sputum repeated at the end of 3rd month if it remains positive should have sputum submitted for Xpert and manage as per NTBLCP guidelines. GeneXpert MTB/RIF is not used for treatment monitoring in the NTBLCP, it only aids decision making to rule out DR-TB as early as possible.

Electronic Reporting System (1) Current reporting system is paper based. And at best excel based which does not allow for critical data analysis and availability of information for quick decision making. Associated with high workload, delay reporting, data discrepancies. All reports of reviews conducted pointed towards the need for the NTBLCP to migrate to an electronic reporting system as soon as possible. The closest to us now is the e-tb manager for which we already have some experience up to the state level.

Electronic Reporting System (2) The new plan entails capturing of patient information at the facility by the LGTBLS through the use of Android phones. When fully established, it will reduce the workload and data discrepancies. The new tools & reporting templates are already designed to fit into this system. Major challenges will be availability of funding and data quality assurance systems. The State M&E Officer will need to be more pro-active to ensure data quality at information entering point.

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