In 2010, 18 States of Nigeria reported cholera outbreaks with a total of 41,787 cases including 1,716 deaths (case-fatality rate [CFR]: 4.1%). This exceeded the mean overall CFR of 2.4% reported in Africa from 2000–2005 and the WHO acceptable rate of 1%. We conducted a descriptive analysis of the 2010 cholera outbreak to determine its epidemiological and spatio-temporal characteristics.
We conducted retrospective analysis of line lists obtained from 10 of the 18 states that submitted line lists to the Federal Ministry of Health (FMOH). We described the outbreak by time, place and person and calculated the attack rates by state as well as the age- and sex-specific CFR from cholera cases for whom information on age, sex, place of residence, onset of symptoms and outcome were available.
A total of 21,111 cases were reported with an overall attack rate and CFR of 47.8 cases /100,000 population and 5.1%, respectively. The CFR ranged in the states between 3.8% and 8.9%. The age-specific CFR was highest among individuals 65 years and above (14.6%). The epidemiological curve showed three peaks with increasing number of weekly reported cases. A geographical clustering of LGAs reporting cholera cases could be seen in all ten states. During the third peak which coincided with flooding in five states the majority of newly affected LGAs were situated next to LGAs with previously reported cholera cases, only few isolated outbreaks were seen.
Our study showed a cholera outbreak that grew in magnitude and spread to involve the whole northern part of the country. It also highlights challenges of suboptimal surveillance and response in developing countries as well as potential endemicity of cholera in the northern part of Nigeria. There is the need for a harmonized, coordinated approach to cholera outbreaks through effective surveillance and response with emphasis on training and motivating front line health workers towards timely detection, reporting and response. Findings from the report should be interpreted with caution due to the high number of cases with incomplete information, and lack of data from eight states.
Cholera; Outbreak; Nigeria; Case fatality rate; Attack rate
Background. After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC).
Methods. Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review.
Results. Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year.
Conclusions. Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.
poliomyelitis; eradication; routine immunization; health systems
Ebola; Public Health; Systems; Workforce
Immunization is a cost-effective public health intervention to reduce morbidity and mortality associated with infectious diseases. The Nigeria Demographic and Health Survey of 2008 indicated that only 5.4% of children aged 12-23 months in Bungudu, Zamfara State were fully immunized. We conducted this study to identify the determinants of routine immunization coverage in this community.
We conducted a cross-sectional study. We sampled 450 children aged 12-23 months. We interviewed mothers of these children using structured questionnaire to collect data on socio-demographic characteristics, knowledge on immunization, vaccination status of children and reasons for non-vaccination. We defined a fully immunized child as a child who had received one dose of BCG, three doses of oral polio vaccine, three doses of Diptheria-Pertusis-Tetanus vaccine and one dose of measles vaccine by 12 months of age. We performed bivariate analysis and logistic regression using Epi-info software.
The mean age of mothers and children were 27 years (standard error (SE): 0.27 year) and 17 months (SE: 0.8 month) respectively. Seventy nine percent of mothers had no formal education while 84% did not possess satisfactory knowledge on immunization. Only 7.6% of children were fully immunized. Logistic regression showed that possessing satisfactory knowledge (Adjusted OR=18.4, 95% CI=3.6-94.7) and at least secondary education (Adjusted OR=3.6, 95% CI=1.2-10.6) were significantly correlated with full immunization.
The major determinants of immunization coverage were maternal knowledge and educational status. Raising the level of maternal knowledge and increasing maternal literacy level are essential to improve immunization coverage in this community.
Immunization; routine immunization; routine immunization coverage; fully immunized child; Nigeria
Tuberculosis (TB) is a public health problem in Nigeria. Adherence to the total duration of treatment is critical to cure the patients. We explored the knowledge of the health care workers on management of TB patients including their perceived reasons for patient non adherence to treatment to develop strategies to improve the quality of the TB control service in the state.
We conducted a cross sectional study. We used self administered questionnaire to extract information from the health workers on their trainings for TB control, knowledge of the control services, patients’ education including prevention of defaulting from treatment. We conducted focus group discussion with the health care workers. We performed descriptive analysis using epiInfo software.
Of the 76 respondents 41 (53.9%) were female, 39.9% were community health extension workers, 26.3% were nurses/midwifes 30.3% lacked training on management of TB patient. Only 43.4% knew when to take action on patients who miss their drugs in the intensive phase, 30.3% and 35.5% knew defaults among category 1 and category 2 in the continuation phases of treatment respectively. They identified side effects of drugs (80%), daily clinic attendance (76.3%), health workers attitude (73.4%) and lack of knowledge on duration of treatment (71.1%) including their unfriendly attitudes towards the patients as the major barriers to patients’ adherence to treatment.
Lack of knowledge of the health care workers on management of TB patients and poor interpersonal relation and communication with patients have negative effect on patients’ adherence to the long duration of TB treatment.
Tuberculosis; adherence; attitude; knowledge; health care workers; Nigeria
Non-communicable diseases (NCDs) are a leading cause of adult mortality globally, accounting for 63% of all deaths in 2008 with nearly 80% of those deaths occurring in developing countries. These NCDs which include hypertension and obesity alongside their complications accounted for 27% of all deaths in Nigeria, in 2008. We conducted a study among Kaduna State civil servants to determine the prevalence of hypertension, overweight/obesity and also to identify associated behavioural factors.
A cross-sectional design, with multi-stage cluster sampling technique was used. A structured questionnaire was used in gathering data on socio-demographics, physical activity, dietary habit, tobacco, and alcohol consumption. Blood pressure, body weight and height were measured, and body mass index (BMI) calculated. Descriptive statistics and logistic regression were used in identifying associations between these behavioural factors and hypertension/overweight/obesity.
A total of 801 civil servants, mean age 43±9 years were interviewed, of which 62% were male. Prevalence of hypertension, overweight and obesity were 29%, 35% and 27% respectively. Physical inactivity was the most prevalent behavioural factor, 91%, followed by unhealthy diet 90%, and cigarette smoking 6%. Prevalence of overweight/obesity was higher among the senior cadre than the junior cadre (69% versus 54%, p<0.01). Increasing age was an independent predictor of hypertension. Female respondents were four times more likely to be overweight/obese than males (AOR=3.7, 95%CI 2.5-5.4).
Hypertension and overweight/obesity with their behavioural risks are prevalent among civil servants in Kaduna. Age and gender-specific public health strategies to promote healthy- living in the workplace are being advocated for with concerned authorities.
Hypertension; overweight; obesity; body mass index; civil servants; Kaduna
Tuberculosis remains a global public health problem. In 2011, tuberculosis incidence was 133 per 100,000 in Nigeria. In Nigeria, little is known about the factors associated with tuberculosis, especially in the northern part and only few studies have characterized the Mycobacterium species that cause tuberculosis infection in humans. This study determined factors associated with tuberculosis and identified Mycobacterium species causing human tuberculosis in North-West, Nigeria.
We conducted a hospital based case control study between April and July 2010 in Zaria. Cases were newly diagnosed sputum smear-positive tuberculosis patients >15 years while controls were patients >15 years attending the hospital for other reasons but were negative for tuber-culosis. We used a structured questionnaire to obtain information on demographics, knowledge of transmission of tuberculosis, and exposure to some factors. We preformed descriptive, bivariate and backward elimination logistic regression. Sputa from cases were analyzed by multiplex polymerase chain reaction (PCR) based on genomic regions of difference.
The mean ages of the cases and controls were 36, standard deviation (SD) 9.0 and 36, SD 9.7 respectively. Only 10 (9.8%) and nine (8.8%) of cases and controls respectively had a good knowledge of the transmission of tuberculosis. Contact with a tuberculosis patient (adjusted odds ratio (AOR) 12.3, 95% confidence interval (CI) 5.2-28.8), consumption of unpasteurized milk (AOR 6.4, CI 2.4-17.2), keeping pets (AOR 5.6, CI 2.3-13.7), associating closely with cattle (AOR 5.6, CI 1.3-6.8), and overcrowding (AOR 4.8, CI 1.8-13.1) were significantly associated with tuberculosis. Of the 102 sputa analyzed, 91 (89%) were M. tuberculosis, 8 (7.8%) were M africanum.
We identified possible opportunities for intervention to limit the spread of tuberculosis. We recommend that the Nigeria tuberculosis control program consider some of these factors as a way to mitigate the spread of tuberculosis in Nigeria.
Tuberculosis; mycobacterium tuberculosis complex; polymerase chain reaction; adjusted odds ratio
Highly pathogenic avian influenza H5N1 was first reported in poultry in Nigeria in February 2006. The only human case that occurred was linked to contact with poultry in a live bird market (LBM). LBM surveillance was instituted to assess the degree of threat of human exposure to H5N1. The key indicator was detection of H5N1 in LBMs. We evaluated the surveillance system to assess its operations and attributes.
We used the US Centers for Disease Control and Prevention (CDC) updated guidelines for evaluating public health surveillance systems. We reviewed and analyzed passive surveillance data for HPAI (January 2006-March 2009) from the Avian Influenza National Reference Laboratory, and live bird market surveillance data from the Food and Agriculture Organization of the United Nations, Nigeria. We interviewed key stakeholders and reviewed reports of live bird market surveillance to obtain additional information on the operations of the system. We assessed the key system attributes.
A total of 299 cases occurred in 25 (72%) states and the Federal Capital Territory (FCT). The system detected HPAI H5N1 virus in 7 (9.5%) LBMs; 2 (29%) of which were from 2 (18.2%) states with no previous case. A total of 17,852 (91.5%) of samples arrived at the laboratory within 24 hours but laboratory analysis took over 7 days. The sensitivity and positive predictive value (PPV) were 15.4% and 66.7% respectively.
The system is useful, flexible, complex and not timely, but appears to be meeting its objectives. The isolation of HPAI H5N1 virus in some of these markets is an indication that the markets are possible reservoirs of the virus in Nigeria. We recommend that the Federal Government of Nigeria should dedicate more funds for surveillance for HPAI as this will aid early warning and reduce the risk of a pandemic.
Live bird market; highly pathogenic avian influenza; surveillance; Nigeria
Field epidemiology; experiential training; workforce; NFELTP; competent
Early treatment of Tuberculosis (TB) cases is important for reducing transmission, morbidity and mortality associated with TB. In 2007, Federal Capital Territory (FCT), Nigeria recorded low TB case detection rate (CDR) of 9% which implied that many TB cases were undetected. We assessed the knowledge, care-seeking behavior, and factors associated with patient delay among pulmonary TB patients in FCT.
We enrolled 160 newly-diagnosed pulmonary TB patients in six directly observed treatment short course (DOTS) hospitals in FCT in a cross-sectional study. We used a structured questionnaire to collect data on socio-demographic variables, knowledge of TB, and care-seeking behavior. Patient delay was defined as > 4 weeks between onset of cough and first hospital contact.
Mean age was 32.8 years (± 9 years). Sixty two percent were males. Forty seven percent first sought care in a government hospital, 26% with a patent medicine vendor and 22% in a private hospital. Forty one percent had unsatisfactory knowledge of TB. Forty two percent had patient delay. Having unsatisfactory knowledge of TB (p = 0.046) and multiple care-seeking (p = 0.02) were significantly associated with patient delay. After controlling for travel time and age, multiple care-seeking was independently associated with patient delay (Adjusted Odds Ratio = 2.18, 95% CI = 1.09-4.35).
Failure to immediately seek care in DOTS centers and having unsatisfactory knowledge of TB are factors contributing to patient delay. Strategies that promote early care-seeking in DOTS centers and sustained awareness on TB should be implemented in FCT.
Directly observed treatment short course; Tuberculosis; patient delay; Federal Capital Territory; Nigeria
Disclosure of HIV status especially to sexual partners is an important prevention goal. This study was conducted to determine the prevalence of HIV status disclosure and the factors associated with disclosure by HIV positive patients attending the adult Anti-retroviral therapy (ART) clinic in State Specialist Hospital Gombe (SSHG) a secondary health facility in north-eastern Nigeria.
We conducted a cross sectional study among adult HIV positive patients enrolled into the HIV/AIDS programme of SSHG. Study participant were sampled using a systematic random sampling. Interviewer administered questionnaire was used to collect data on socio-demographic characteristics, disclosure status and factors associated with disclosure. Data was analyzed using Epi-info software.
Of the 198 (99%) respondents, 159 (80.3%) were females. The mean age of respondents was 32.9years (SD ± 9.5). Sixty percent of the respondents were married. Most (97.5%) had disclosed their HIV status and majority (36.8%) disclosed to their spouses. Sixty four percent of the respondents had treatment supporter and spouses (42.9%) were their choice of a treatment supporter. Disclosure of HIV status was found to be associated with age < 40years Adjusted Odds Ratio (AOR) 38.16; 95% Confidence Interval (CI) 2.42-602.61. Gender, employment status, educational level, duration of infection and marital status were not found to be significantly associated with disclosure of HIV status.
Disclosure of HIV status was high in the study population. Spouses were the most preferred choice of persons to disclose HIV status to, and the most adopted as treatment supporter. HIV status disclosure is encouraged after diagnosis because of its importance especially among couples.
Disclosure Factors; HIV status; Gombe state; North-East; Nigeria
In May 2010, lead poisoning (LP) was confirmed among children <5years (U5) in two communities in Zamfara state, northwest Nigeria. Following reports of increased childhood deaths in Bagega, another community in Zamfara, we conducted a survey to investigate the outbreak and recommend appropriate control measures.
We conducted a cross-sectional survey in Bagega community from 23rd August to 6th September, 2010. We administered structured questionnaires to parents of U5 to collect information on household participation in ore processing activities. We collected and analysed venous blood samples from 185 U5 with LeadCare II machine. Soil samples were analysed with X-ray fluorescence spectrometer for lead contamination. We defined blood lead levels (BLL) of >10ug/dL as elevated BLL, and BLL ≥45ug/dL as the criterion for chelation therapy. We defined soil lead levels (SLL) of ≥400 parts per million (ppm) as elevated SLL.
The median age of U5 was 36 months (Inter-quartile range: 17-48 months). The median BLL was 71µg/dL (range: 8-332µg/dL). Of the 185 U5, 184 (99.5%) had elevated BLL, 169 (91.4%) met criterion for CT. The median SLL in tested households (n = 37) of U5 was 1,237ppm (range: 53-45,270ppm). Households breaking ore rocks within the compound were associated with convulsion related-children's death (OR: 5.80, 95% CI: 1.08 - 27.85).
There was an LP outbreak in U5 in Bagega community possibly due to heavy contamination of the environment as a result of increased ore processing activities. Community-driven remediation activities are ongoing. We recommended support for sustained environmental remediation, health education, intensified surveillance, and case management.
Lead poisoning; outbreak; child mortality; Nigeria
The health workforce is one of the key building blocks for strengthening health systems. There is an alarming shortage of curative and preventive health care workers in developing countries many of which are in Africa. Africa resultantly records appalling health indices as a consequence of endemic and emerging health issues that are exacerbated by a lack of a public health workforce. In low-income countries, efforts to build public health surveillance and response systems have stalled, due in part, to the lack of epidemiologists and well-trained laboratorians. To strengthen public health systems in Africa, especially for disease surveillance and response, a number of countries have adopted a competency-based approach of training - Field Epidemiology and Laboratory Training Program (FELTP). The Nigeria FELTP was established in October 2008 as an inservice training program in field epidemiology, veterinary epidemiology and public health laboratory epidemiology and management. The first cohort of NFELTP residents began their training on 20th October 2008 and completed their training in December 2010. The program was scaled up in 2011 and it admitted 39 residents in its third cohort. The program has admitted residents in six annual cohorts since its inception admitting a total of 207 residents as of 2014 covering all the States. In addition the program has trained 595 health care workers in short courses. Since its inception, the program has responded to 133 suspected outbreaks ranging from environmental related outbreaks, vaccine preventable diseases, water and food borne, zoonoses, (including suspected viral hemorrhagic fevers) as well as neglected tropical diseases. With its emphasis on one health approach of solving public health issues the program has recruited physicians, veterinarians and laboratorians to work jointly on human, animal and environmental health issues. Residents have worked to identify risk factors of disease at the human animal interface for influenza, brucellosis, tick-borne relapsing fever, rabies, leptospirosis and zoonotic helminthic infections. The program has been involved in polio eradication efforts through its National Stop Transmission of Polio (NSTOP). The commencement of NFELTP was a novel approach to building sustainable epidemiological capacity to strengthen public health systems especially surveillance and response systems in Nigeria. Training and capacity building efforts should be tied to specific system strengthening and not viewed as an end to them. The approach of linking training and service provision may be an innovative approach towards addressing the numerous health challenges.
Public Health; field epidemiology; training; Capacity building; Nigeria
According to a study conducted in1989, Enugu State has an estimated urinary schistosomiasis prevalence of 79%. Recently, studies have implicated bacteriuria co-infection in bladder cancer. These bacteria accelerate the multi-stage process of bladder carcinogenesis. Knowledge about the prevalence of this co-infection is not available in Enugu and the information provided by the 1989 study is too old to be used for current decision making.
We carried out a cross-sectional survey of primary school children aged5-15years, who were randomly selected through a multi stage sampling method using guidelines recommended by WHO for schistosomiasis surveys. An interviewer administered questionnaire was used to collect data on demography, socioeconomic variables and clinical presentations. Urine samples were collected between 10.00am and 2.00pm. Each sample was divided into two: (A) for prevalence and intensity using syringe filtration technique and (B) for culture. Intensity was categorized as heavy (>50ova/10mls urine) and light (<50ova/10mls urine). Significant bacteriuria was bacteria count ≥ 105 colony forming units/ml of urine.
Of the 842 pupils, 50.6% were females. The prevalence of urinary schistosomiasis was 34.1%. Infection rate was higher(52.8%) among 13-15 years(Prevalence Ratio = 2.45, 95% Confidence Interval 1.63-3.69). Heavy infections wad 62.7% and egg count/10mls urine ranged from 21-1138. Significant bacteriuria among pupils with urinary schistosomiasis was 53.7% compared to 3.6% in the uninfected(PR = 30.8,95% CI 18.91- 52.09). The commonest implicated organism was Escherchia coli.
We found high prevalence of bacteriuria co-infection among children with urinary schistosomiasis in Enugu State. This underscores the need for concurrent antibiotics administration and follow-up to avert later complications.
Bacteriuria; co-infection; urinary schistosomiasis; Enugu State
Dogs are the major reservoir of rabies virus in Nigeria; transmission to humans is via a bite by rabid dog. Between 2006 and 2008 National Veterinary Research Institute (NVRI) rabies laboratory reported increased numbers of rabies in dogs and human dog bites. The objective of the study was to use veterinary and health records to develop a profile of bite victims and recommend appropriate public health actions.
We used the dog brain specimen result register of Rabies Laboratory of NVRI, from “January, 2006” to “December, 2008” and traced dog bite cases. Structured questionnaires were administered to persons who reported dog bite incident and could be traced. We reviewed records from Evangelical Churches of West Africa (ECWA) clinic from “January, 2006” to “December, 2008” to collect detailed profiles of bite victims.
Bite victims linked to positive dog samples were traced to “ECWA clinic” from “January, 2006” to “December, 2008”. Most bite victims were <16 years 141 (72.3%), male 128 (65.6%), and 48.2% had primary school education. Bites were unprovoked 184 (94.4%), mostly on arms. 54.4% victims received complete post exposure prophylaxis (PEP). Majority of the biting dogs were housed and unvaccinated.
This study provided important information on the profile of dog bite victims and highlights the need for a sustained awareness and education of children on the dangers of dog bite. It has shown lack of enforcement of regulations for licensing of dogs and rabies vaccination.
Rabies; control; dog bites
Nigeria's population of 160 million and estimated HIV prevalence of 3.34% (2011) makes Nigeria the second highest HIV burden worldwide, with 3.2 million people living with HIV (PLHIV). In 2010, US government spent about US$456.5 million on the Nigerian epidemic. Antenatal clinic (ANC) HIV sero-prevalence sentinel survey has been conducted biennially in Nigeria since 1991 to track the epidemic. This study looked at the trends of HIV in Nigeria over the last decade to identify progress and needs.
We conducted description of HIV sero-prevalence sentinel cross-sectional surveys conducted among pregnant women attending ANC from 2001 to 2010, which uses consecutive sampling and unlinked-anonymous HIV testing (UAT) in160 sentinel facilities. 36,000 blood samples were collected and tested. We used Epi-Info to determine national and state HIV prevalence and trends. The Estimation and Projection Package with Spectrum were used to estimate/project the burden of infection.
National ANC HIV prevalence rose from 1.8% (1991) to 5.8% (2001) and dropped to 4.1% (2010). Since 2001, states in the center, and south of Nigeria had higher prevalence than the rest, with Benue and Cross Rivers notable. Benue was highest in 2001 (14%), 2005 (10%), and 2010 (12.7%). Overall, eight states (21.6%) showed increased HIV prevalence while six states (16.2%) had an absolute reduction of at least 2% from 2001 to 2010. In 2010, Nigeria was estimated to have 3.19 million PLHIV, with the general population prevalence projected to drop from 3.34% in 2011 to 3.27% in 2012.
Examining a decade of HIV ANC surveillance in Nigeria revealed important differences in the epidemic in states that need to be examined further to reveal key drivers that can be used to target future interventions.
Sentinel; HIV; Pregnant; Nigeria; antenatal; clinic; prevalence; estimates; projection; testing
Tuberculosis (TB) is public health concern in Nigeria. The country uses the Directly Observed Treatment Short course (DOTS) strategy for its control. Plateau state started using the DOTS strategy in 2001 and had the Private health facilities (PHF) as an important stakeholder. We evaluated their contributions to case finding and quality of the services to identify gaps in monitoring and evaluation in the TB control services within the PHF to plan for intervention so as to meet the set target for TB control in the state.
We used the logical framework approach to identify and analyze the problem. We drew up an objective tree and from the objective tree developed a logical framework matrix including evaluation plan. We also conducted desk review to extract data on case findings, case management and outcomes of the treatment. We interviewed TB focal persons and laboratory personnel using structured questionnaire. The data was analyzed using excel spread sheet.
Of the 127 health facilities with TB patients on treatment 27 (21.3%) were PHF. The PHF reported 54.6% (1494) of TB cases in 2011. The sputum conversion rates, cured rate, treatment success rate, and default rates were 85%, 73%, 81.4% and 6.6% respectively. The discordant rates were 3.1% and 1.2% for the state and private health facilities respectively.
Log frame approach is a useful tool for evaluation of TB control services and helps provide evidence for decision making to improve quality of the TB services in the public and private health facilities in the state.
Private facilities; Tuberculosis; monitoring and evaluation; Logframe approach
Nigeria has one of the highest tuberculosis (TB) burdens in the world with estimated incidence of 133 per 100,000 populations. Multi-drug resistant TB (MDR-TB) is an emerging threat of the TB control in Nigeria caused mainly by incomplete treatment. This study explored factors that affect adherence to treatment among patients undergoing direct observation of TB treatment in Plateau state, Nigeria.
Between June and July 2011, we reviewed medical records and interviewed randomly selected pulmonary TB patients in their eighth month of treatment. Information on patients? clinical, socio-demographic and behavioral characteristics was collected using checklist and structured questionnaire for knowledge of treatment duration and reasons for interruption of treatment. We conducted focus group discussions with patients about barriers to treatment adherence. Data were analyzed with Epi Info software.
Of 378 records reviewed, 229 (61%) patients were male; mean age 37.6 ±13.5 years and 71 (19%) interrupted their treatment. Interruption of treatment was associated with living > 5 km from TB treatment site (AOR: 11.3; CI 95%: 5.7-22.2), lack of knowledge of duration of treatment (AOR: 6.1; CI 95%: 2.8-13.2) and cigarette smoking (AOR: 3.4; CI 95%: 1.5- 8.0). Major reasons for the interruption were lack of transport fare (40%) and feeling well (25%). Focused group discussions revealed unfriendly attitudes of health care workers as barriers to adherence to treatment.
This study revealed knowledge of the patients on the duration of treatment, distance and health workers attitude as the major determinants of adherent to TB treatment. Training for health care workers on patient education was conducted during routine supportive supervision.
Interruption; treatment; Tuberculosis; Nigeria
Brucellosis, a neglected debilitating zoonosis, is a recognized occupational hazard with a high prevalence in developing countries. Transmission to humans can occur through contact with infected animals or animal products. Brucellosis presents with fever. In Nigeria, there is a possibility of missed diagnoses by physicians leading to a long debilitating illness. We conducted a study to determine the seroprevalence and factors associated with Human Brucellosis (HB) among abattoir-workers in Abuja, Nigeria.
We conducted a cross-sectional study and selected abattoir-workers using stratified random sampling. Structured questionnaires were used to collect data on demographics and exposure-factors. We tested the workers’ serum-samples using Rose-Bengal (RBPT) and ELISA tests. A worker with HB was one whose serum tested positive to RBPT or ELISA. We tested differences in proportions between workers with HB and those without HB using odds-ratio and X2 tests.
Of 224 workers, 172 (76.8%) were male and mean age was 30 + 9.0 years. Of 224 sera collected, 54 were positive giving a seroprevalence of 24.1%. Of these, 32 (59.3%) were butchers, and 11 (20.4%) were meat-sellers. Slaughtering animals while having open-wounds (Odds-ratio (OR) = 2.15, 95% Confidence Interval (CI) = 1.15-4.04); occupational-exposure of >5years (OR = 2.30, CI = 1.11-4.78) and eating raw meat (OR = 2.75, CI = 1.21-6.26) were significantly associated with HB. Multivariate analyses showed that occupational-exposure of >5years (Adjusted OR (AOR) =2.45, CI = 1.15 – 5.30) and eating raw-meat (AOR = 2.64, CI = 1.14 - 6.14) remained significantly associated with HB.
Seroprevalence of HB among abattoir-workers in Abuja was high. Factors associated with HB were occupational-exposure of >5years and eating raw-meat. Abattoir-workers should be discouraged from eating raw-meat and educated on adherence to safe animal-product handling practices.
Brucellosis; seroprevalence; exposure factors; abattoir; occupational hazard; Nigeria
We investigated gender differences in treatment outcome during first line antiretroviral treatment (ART) in a hospital setting in Tanzania, assessing clinical, social demographic, virological and immunological factors.
We conducted a cohort study involving HIV infected patients scheduled to start ART and followed up to 1 year on ART. Structured questionnaires and patients file review were used to collect information and blood was collected for CD4 and viral load testing. Gender differences were assessed using Kruskal-Wallis test and chi-square test for continuous and categorical data respectively. Survival distributions for male and female patients were estimated using the Kaplan-Meier method and compared using Cox proportional hazards models.
Of 234 patients recruited in this study, 70% were females. At baseline, women had significantly lower education level; lower monthly income, lower knowledge on ARV, less advanced HIV disease (33% women; 47% men started ART at WHO stage IV, p = 0.04), higher CD4 cell count (median 149 for women, 102 for men, p = 0.02) and higher BMI (p = 0.002). After 1 year of standard ART, a higher proportion of females survived although this was not significant, a significantly higher proportion of females had undetectable plasma viral load (69% women, 45% men, p = 0.003), however females ended at a comparable CD4 cell count (median CD4, 312 women; 321 men) signifying a worse CD4 cell increase (p = 0.05), even though they still had a higher BMI (p = 0.02). The unadjusted relative hazard for death for men compared to women was 1.94. After correcting for confounding factors, the Cox proportional hazards showed no significant difference in the survival rate (relative hazard 1.02).
We observed women were starting treatment at a less advanced disease stage, but they had a lower socioeconomical status. After one year, both men and women had similar clinical and immunological conditions. It is not clear why women lose their immunological advantage over men despite a better virological treatment response. We recommend continuous follow up of this and more cohorts of patients to better understand the underlying causes for these differences and whether this will translate also in longer term differences.
The impact of vertical programs on health systems is a much-debated topic, and more evidence on this complex relationship is needed. This article describes a research protocol developed to assess the relationship between the Global Polio Eradication Initiative, routine immunization, and primary health care in multiple settings.
This protocol was designed as a combination of quantitative and qualitative research methods, making use of comparative ethnographies. The study evaluates the impact of the Global Polio Eradication Initiative on routine immunization and primary health care by: (a) combining quantitative and qualitative work into one coherent study design; (b) using purposively selected qualitative case studies to systematically evaluate the impact of key contextual variables; and (c) making extensive use of the method of participant observation to create comparative ethnographies of the impact of a single vertical program administered in varied contexts.
The study design has four major benefits: (1) the careful selection of a range of qualitative case studies allowed for systematic comparison; (2) the use of participant observation yielded important insights on how policy is put into practice; (3) results from our quantitative analysis could be explained by results from qualitative work; and (4) this research protocol can inform the creation of actionable recommendations. Here, recommendations for how to overcome potential challenges in carrying out such research are presented. This study illustrates the utility of mixed-methods research designs in which qualitative data are not just used to embellish quantitative results, but are an integral component of the analysis.
Polio; Eradication; Vertical program; Routine immunization; Primary health care; Comparative ethnography; Health systems
Background In 2000 Uganda adopted the Integrated Disease Surveillance and Response (IDSR) strategy, which aims to create a co-ordinated approach to the collection, analysis, interpretation, use and dissemination of surveillance data for guiding decision making on public health actions.
Methods We used a monitoring framework recommended by World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC)-Atlanta to evaluate performance of the IDSR core indicators at the national level from 2001 to 2007. To determine the performance of IDSR at district and health facility levels over a 5-year period, we compared the evaluation results of a 2004 surveillance survey with findings from a baseline assessment in 2000. We also examined national-level funding for IDSR implementation during 2000–07.
Results Our findings show improvements in the performance of IDSR, including: (1) improved reporting at the district level (49% in 2001; 85% in 2007); (2) an increase and then decrease in timeliness of reporting from districts to central level; and (3) an increase in analysed data at the local level (from 10% to 47% analysing at least one target disease, P < 0.01). The case fatality rate (CFR) for two target priority diseases (cholera and meningococcal meningitis) decreased during IDSR implementation (cholera: from 7% to 2%; meningitis: from 16% to 4%), most likely due to improved outbreak response. A comparison before and after implementation showed increased funding for IDSR from government and development partners. However, funding support decreased ten-fold from the government budget of 2000/01 through to 2007/08. Per capita input for disease surveillance activities increased from US$0.0046 in 1996–99 to US$0.0215 in 2000–07.
Conclusion Implementation of IDSR was associated with improved surveillance and response efforts. However, decreased budgetary support from the government may be eroding these gains. Renewed efforts from government and other stakeholders are necessary to sustain and expand progress achieved through implementation of IDSR.
Integrated disease surveillance and response; surveillance indicators; epidemic preparedness and response; infectious disease surveillance; Uganda
The Central African Field Epidemiology and Laboratory Training Program (CAFELTP) is a
2-year public health leadership capacity building training program. It was established in
October 2010 to enhance capacity for applied epidemiology and public health laboratory
services in three countries: Cameroon, Central African Republic, and the Democratic
Republic of Congo. The aim of the program is to develop a trained public health workforce
to assure that acute public health events are detected, investigated, and responded to
quickly and effectively. The program consists of 25% didactic and 75% practical training
(field based activities). Although the program is still in its infancy, the residents have
already responded to six outbreak investigations in the region, evaluated 18 public health
surveillance systems and public health programs, and completed 18 management projects.
Through these various activities, information is shared to understand similarities and
differences in the region leading to new and innovative approaches in public health. The
program provides opportunities for regional and international networking in field
epidemiology and laboratory activities, and is particularly beneficial for countries that
may not have the immediate resources to host an individual country program. Several of the
trainees from the first cohort already hold leadership positions within the ministries of
health and national laboratories, and will return to their assignments better equipped to
face the public health challenges in the region. They bring with them knowledge, practical
training, and experiences gained through the program to shape the future of the public
health landscape in their countries.
epidemiology; education; training; public health; Central Africa
In an effort to contain the frequently devastating epidemics in sub-Saharan Africa, the
World Health Organization (WHO) Regional Office for Africa launched the Integrated Disease
Surveillance and Response (IDSR) strategy in an effort to strengthen surveillance and
response. However, 36 sub-Saharan African countries have been described as experiencing a
human resource crisis by the WHO. Given this human resource situation, the challenge
remains for these countries to achieve, among others, the health-related Millennium
Development Goals (MDGs). This paper describes the process through which the African Field
Epidemiology Network (AFENET) was developed, as well as how AFENET has contributed to
addressing the public health workforce crisis, and the development of human resource
capacity to implement IDSR in Africa. AFENET was established between 2005 and 2006 as a
network of Field Epidemiology Training Programs (FETPs) and Field Epidemiology and
Laboratory Training Programs (FELTPs) in Africa. This resulted from an expressed need to
develop a network that would advocate for the unique needs of African FETPs and FELTPs,
provide service to its membership, and through which programs could develop joint projects
to address the public health needs of their countries. A total of eight new programs have
been developed in sub-Saharan Africa since 2006. Programs established after 2006 represent
over 70% of current FETP and FELTP enrolment in Africa. In addition to growth in
membership and programs, AFENET has recorded significant growth in external partnerships.
Beginning with USAID, CDC and WHO in 2004-2006, a total of at least 26 partners have been
added by 2011. Drawing from lessons learnt, AFENET is now a resource that can be relied
upon to expand public health capacity in Africa in an efficient and practical manner.
National, regional and global health actors can leverage it to meet health-related targets
at all levels. The AFENET story is one that continues to be driven by a clearly recognized
need within Africa to develop a network that would serve public health systems
development, looking beyond the founders, and using the existing capacity of the founders
and partners to help other countries build capacity for IDSR and the International Health
Regulations (IHR, 2005).
African Field Epidemiology Network; AFENET; Network
As of 2010 sub-Saharan Africa had approximately 865 million inhabitants living with numerous public health challenges. Several public health initiatives [e.g., the United States (US) President's Emergency Plan for AIDS Relief and the US President's Malaria Initiative] have been very successful at reducing mortality from priority diseases. A competently trained public health workforce that can operate multi-disease surveillance and response systems is necessary to build upon and sustain these successes and to address other public health problems. Sub-Saharan Africa appears to have weathered the recent global economic downturn remarkably well and its increasing middle class may soon demand stronger public health systems to protect communities. The Epidemic Intelligence Service (EIS) program of the US Centers for Disease Control and Prevention (CDC) has been the backbone of public health surveillance and response in the US during its 60 years of existence. EIS has been adapted internationally to create the Field Epidemiology Training Program (FETP) in several countries. In the 1990s CDC and the Rockefeller Foundation collaborated with the Uganda and Zimbabwe ministries of health and local universities to create 2-year Public Health Schools Without Walls (PHSWOWs) which were based on the FETP model. In 2004 the FETP model was further adapted to create the Field Epidemiology and Laboratory Training Program (FELTP) in Kenya to conduct joint competency-based training for field epidemiologists and public health laboratory scientists providing a master's degree to participants upon completion. The FELTP model has been implemented in several additional countries in sub-Saharan Africa. By the end of 2010 these 10 FELTPs and two PHSWOWs covered 613 million of the 865 million people in sub-Saharan Africa and had enrolled 743 public health professionals. We describe the process that we used to develop 10 FELTPs covering 15 countries in sub-Saharan Africa from 2004 to 2010 as a strategy to develop a locally trained public health workforce that can operate multi-disease surveillance and response systems.
Field epidemiology; laboratory management; multi-disease surveillance and response systems; public health workforce capacity building