Private sector tuberculosis care quality during the COVID-19 pandemic: A repeated cross-sectional standardized patients study of adherence to national TB guidelines in urban Nigeria (preprint)

Only a third of TB cases in Nigeria in 2020 were diagnosed and notified, in part due to low detection and underreporting from the private health sector. Using a standardized patient (SP) survey approach, we assessed how management of presumptive TB in the private sector aligns with national guidelines and whether this differed from a study conducted before the start of the COVID-19 pandemic. Thirteen standardized patients presented a presumptive TB case to 511 private providers in urban areas of Lagos and Kano states in May and June 2021. Private provider case management was compared with national guidelines divided into three main steps: SP questioned about cough duration; sputum collection attempted for TB testing; and non-prescription of anti-TB medications, antibiotics, and steroids. SP visits conducted in May-June 2021 were directly compared to SP visits conducted in the same areas in June-July 2019. Overall, only 145 of 511 (28%, 95% CI: 24.5-32.5%) interactions were correctly managed according to Nigerian guidelines, as few providers completed all three necessary steps. Providers in 71% of visits asked about cough duration (362 of 511, 95% CI: 66.7-74.7%), 35% tested or recommended a sputum test (181 of 511, 95% CI: 31.3-39.8%), and 79% avoided prescribing or dispensing unnecessary medications (406 of 511, 95% CI: 75.6-82.8%). COVID-19 related questions were asked in only 2.4% (12 of 511, 95% CI: 1.3-4.2%) of visits. During the COVID-19 pandemic, few providers completed all steps of the national guidelines. Providers performed better on individual steps, particularly asking about symptoms and avoiding prescription of harmful medications. Comparing visits conducted before and during the COVID-19 pandemic showed that COVID-19 did not significantly change the quality of TB care. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LILess than half of new TB cases in Nigeria are diagnosed and notified. As most initial health care seeking for TB in Nigeria occurs in the private sector, increasing the quality of TB care in the private sector is of great importance. C_LIO_LICOVID-19 may have put further stressors on TB care quality due to changes in care seeking behavior, stigma against COVID-19, and disproportionate attention at the health system level on pandemic control. C_LIO_LIThis study explored whether private providers practices are in alignment with national standards for TB screening in Nigeria, how these practices have changed following the onset of the COVID-19 pandemic, and what factors are associated with providers that deliver clinically correct TB screening services. C_LI What this study addsO_LIFewer than one-third of the SP visits conducted in this study were correctly managed according to the Nigerian National TB and Leprosy Control Program guidelines. C_LIO_LIClinical correctness of TB care in the private sector of urban Nigeria has not been majorly affected by COVID-19 according to our study results. C_LIO_LIOur results indicate that very little observed attention was paid to COVID-19 in this sample of private facilities. C_LI How this study might affect research, practice or policyO_LIIncreased efforts to engage and support private providers, and implementing solutions such as working with drug shop proprietors to make referring for testing a standard part of their practice may help reduce the testing bottleneck at drug shops. C_LIO_LIAlthough Nigeria has maintained pre-pandemic levels of TB notification, it is important to establish high-quality screening by all providers to find the missing patients with TB and close the gap in TB notification. C_LI

Higher Relative Viral Load Excretion Determined by Normalised Threshold Crossing Value in Acute Cases infected with the B.1.1.7 Lineage VOC 202012/01 (Using S gene target failure as a Proxy) When Compared to other Circulating Lineages in Wales (preprint)

Since the emergence of SARS-CoV-2, global monitoring of the virus using whole genome sequencing has identified mutations occurring across the viral genome. Whilst the majority have little impact on the virus, they are used effectively to monitor the movement of the virus globally and to inform locally on transmission chains. In late 2020, a variant of SARS-CoV-2 (B.1.1.7 - VOC 202012/01) was identified in the UK with a distinct constellation of mutations, including in the spike gene that increased transmissibility. A deletion in spike also affected one of the screening qPCR tests being used in the UK outside of Wales, causing a failure to detect the target. This quickly became a surrogate marker for the variant to allow rapid monitoring of the virus as it seeded into new regions of the UK. A screening study using this assay as a proxy marker, was undertaken to understand the prevalence of the variant in Wales. Secondary analysis of a screening qPCR that didn’t target the S gene and also included an endogenous control, was also performed to understand viral load excretion in those infected with the variant compared to other circulating lineages. Using a combination of analytical methods based on the C t values of two gene targets normalised against the endogenous control, there was a difference in the excreted viral load. Those with the variant excreting more virus than those not infected with the variant. Supporting not only increased infectivity but offering a plausible reason why increased transmission was associated with this particular variant. Whilst there are limitations in this study, the method using C t as a proxy for viral load can be used at the population level to determine differences in viral excretion kinetics associated with different variants.