Chemoprophylaxis for malaria - in pregnancy by public and private health providers in Lagos

Objectives: Malaria in pregnancy is a major public health problems contributing significantly to high morbidity and mortality. Intermittent preventive treatment of malaria during pregnancy (IPTp) is a key intervention in the national strategy for malaria control, Sulphadoxine-Pyrimethamine, the current drug of choice, is recommended to be administered in the second and third trimesters of pregnancy during antenatal care (ANC) visits. Aim was therefore, to determine and compare the provision of chemoprevention using intermittent preventive treatment (IPTp) in public and private secondary hospitals in Lagos State.Method: This is a comparative, cross sectional study that assessed the factors influencing health care providers - provision of chemoprohylaxis - in public and private secondary health facilities in Lagos State. Data was collected using a pretested questionnaires administered to 302 healthcare providers selected through multistage sampling. Data generated was analysed with Epi-Info 2012 version.Results: The private providers had a better practice and provision of chemotherapy. Only 69.0% of public providers and 74.8% of private providers prescribed IPT using sulphadoxine-pyrimethamine. The private providers were more aware of the timing (recommended time to give IPTp) of IPTp.Conclusion: Both public and private health care providers have not fully embraced the evidence based World Health Organization recommendation of administration of least two doses of sulphadoxinepyrimethamine for malaria in pregnancy.Keywords: Chemoprophylaxis, Malaria, Pregnanc

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions. Funding: Bill & Melinda Gates Foundation

Pattern of management for malaria in pregnancy by public and private health providers in Lagos

Background: Malaria in pregnancy is a major public health problem contributing significantly to high morbidity and mortality. Malaria infection during pregnancy predisposes to adverse pregnancy outcomes which include; miscarriage, premature delivery, small for date babies, maternal anaemia and even intrauterine death. Utilization of current national antimalarial treatment guideline showed low level of use of antimalaria guideline by healthcare providers.Objective: The aim of this study was to determine and compare the knowledge, attitude and practice of healthcare providers about malaria in pregnancy in public and private secondary hospitals in Lagos State.Method: This is a comparative, cross sectional study that assessed the factors influencing health care providers knowledge, attitude and practice in public and private secondary health facilities in Lagos State. Data was collected using a pretested questionnaire administered to 302 healthcare providers selected through multistage sampling. Date generated was analysed with Epi-Info 2012 version.Results: The public providers were more (85.4% and 66.75) knowledgeable about the use of microscopic test and rapid diagnostic tool respectively compared to private providers (75.6% and 42.0%). Majority of the providers (87.7% and 84.9%) in both public and private facilities respectively had knowledge of IPTp. Majority of the public providers (93.6%) believed that malaria in pregnancy is very serious while a lesser proportion (82.4%) of the private providers believed the same. Majority of the public health providers (64.9%) used Artemisinin based combination therapy (ACT) in treatment of malaria in pregnancy in 2nd trimester while a lower proportion (55.5%) of the private providers used ACT in treatment of malaria in pregnancy in 2nd trimester.Conclusion: In conclusion, the pattern of antimalarial prescription among secondary health care providers in Lagos State varied widely among the practitioners and the fact that less than half of both public and private health care providers strongly agreed to direct observation of therapy showed that their practice does not fully embraced the evidence based recommendations of the World Health Organization and the National Antimalarial treatment  guideline. However, the public providers had a better practice regarding the management of malaria in pregnancy.Keywords: Case management, malaria, pregnanc