Evaluation of early diagnostic approaches for malaria and pneumonia in children under-five presenting at the primary healthcare level in Benin City, Nigeria: a mixed methods study

Background Malaria and pneumonia are the leading causes of under-five mortality in sub-Saharan Africa especially in Nigeria. The Integrated Management of Childhood Illness (IMCI) guidelines were developed by the World Health Organisation (WHO)/United Nations Children’s Fund (UNICEF) as a strategy to reduce the burden of these and other preventable childhood diseases. However, there appears to be a paucity of evidence on the diagnostic performance of the revised IMCI guidelines and whether they offer an advantage over lay diagnosis (caregiver) for malaria and pneumonia management in Nigeria. Aim and specific objectives This study evaluates early diagnostic approaches (IMCI guidelines and lay diagnosis) for malaria and pneumonia in children under-five at the primary healthcare level. To address the overarching aim of the study, the following four specific objectives were studied: I. To assess the diagnostic accuracy of the IMCI guidelines and lay diagnosis (caregiver) for malaria and pneumonia in comparison to reference diagnostic approaches (microscopy and chest X-ray for malaria and pneumonia respectively). The extent of agreement between caregivers’ and health workers’ diagnosis of malaria and pneumonia is also assessed. II. To estimate the burden of malaria and pneumonia among children under-five presenting to study primary healthcare centres (PHCs) according to various diagnostic approaches. III. To determine the clinical outcomes in children diagnosed with malaria and pneumonia according to the IMCI guidelines and risk factors for severe outcomes. IV. To qualitatively explore caregivers’ and health professionals’ perspectives on lay diagnosis and IMCI guidelines as diagnostic approaches for childhood malaria and pneumonia. Methods A mixed methods approach was used for this study. The quantitative component used a consecutive sampling approach to recruit 903 children aged 2–59 months who met study eligibility criteria for malaria and pneumonia assessment according to the IMCI guidelines at presentation to five study PHCs in Benin City, Nigeria. Caregivers of these children were also asked what they thought the diagnosis was (lay diagnosis). Diagnostic accuracy was assessed in terms of sensitivity, specificity, positive and negative predictive values, Area under the Receiver Operating Characteristic Curves (AUROC) values and 95% Confidence Intervals (C.I). The extent of agreement was assessed in terms of Cohen’s kappa statistic (k) and 95% CI. The estimated burden of malaria and pneumonia during the study period was assessed using proportions and 95% C.I. Clinical outcomes in children diagnosed with malaria and pneumonia by the IMCI guidelines were described in terms of frequency and percentages, while the potential risk factors associated with clinical outcomes were assessed using odds ratios (ORs) and 95% C.I. For the qualitative component, health stakeholders (17 health professionals and 13 caregivers) who met the study eligibility criteria were purposively recruited and interviewed using semi-structured interviews. An inductive approach to thematic analysis was used for data analysis. Results Compared to microscopy, the diagnosis of malaria by health workers using the IMCI guidelines was poorly accurate with an AUROC value of 0.57 (with sensitivity and specificity of 51.8% and 61.3% respectively). Similarly, caregivers’ diagnosis of malaria was poor with an AUROC value of 0.55 (with sensitivity and specificity of 31.1% and 79.5% respectively) as compared to microscopy. Using the IMCI guidelines as the reference diagnostic test, caregivers’ diagnosis of malaria was more accurate (AUROC 0.60) in comparison to that of pneumonia (AUROC 0.54). There was a slight or minimal level of agreement (k=0.14; 95% CI: 0.09-0.19) between caregivers and health workers in the diagnosis of malaria and pneumonia. The estimated burden of malaria and pneumonia was relatively low, varying by the study local government areas, PHCs and seasonality, irrespective of the diagnostic approach. Where follow-up data were available, approximately 57% (172/304) and 78% (81/104) of the children diagnosed with malaria and pneumonia, respectively, recovered without complications within 30 days. Self-medication prior to presenting to study PHCs and use of preventive measures against malaria were independently and significantly associated with improved clinical outcomes. In contrast, exposure to solid fuels increased the odds of severe illness following malaria or pneumonia diagnosis. The qualitative component of the study found that caregivers rely on lay diagnosis despite the awareness of its limitations. The perceptions of malaria and pneumonia appeared to influence caregivers’ home management practices and health seeking behaviours. Caregivers showed willingness to be trained in the IMCI guidelines for improved home-based management of malaria and pneumonia. Health professionals believed that the IMCI guidelines were useful for managing both malaria and pneumonia. However, there are some recurring challenges to the wide-scale and sustainable implementation of the IMCI strategy in Nigeria. These include inaccurate diagnosis of malaria and inadequate funding. Conclusion The IMCI guidelines are crucial in the effective management (diagnosis and treatment) of malaria and pneumonia at the primary healthcare level in Nigeria. Although not perfect, lay diagnosis has an important contribution in the early detection and management of malaria and pneumonia at the community level in Nigeria. However, there is need for further investment in the training of both health professionals and caregivers in the IMCI guidelines for better health outcomes in under-five population. The training of caregivers in the IMCI guidelines and potential for a scale-up will benefit from careful design, piloting, implementation, and monitoring

Assessing the capacity of symptom scores to predict COVID-19 positivity in Nigeria: A national derivation and validation cohort study

s This study aimed to develop and validate a symptom prediction tool for COVID-19 test positivity in Nigeria.A cohort of 43 221 individuals within the national COVID-19 surveillance dataset from 27 February to 27 August 2020. Complete dataset was randomly split into two equal halves: derivation and validation datasets. Using the derivation dataset (n=21 477), backward multivariable logistic regression approach was used to identify symptoms positively associated with COVID-19 positivity (by real-time PCR) in children (≤17 years), adults (18–64 years) and elderly (≥65 years) patients separately

Descriptive epidemiology of coronavirus disease 2019 in Nigeria, 27 February-6 June, 2020

The objective of this study was to describe the epidemiology of COVID-19 in Nigeria with a view of generating evidence to enhance planning and response strategies. A national surveillance dataset between 27 February and 6 June, 2020 was retrospectively analysed, with confirmatory testing for COVID-19 done by real-time polymerase chain reaction (RT-PCR). The primary outcomes were cumulative incidence (CI) and case fatality (CF). A total of 40926 persons (67% of total 60839) had complete records of RT-PCR test across 35 States and the Federal Capital Territory, 12289 (30.0%) of whom were confirmed COVID-19 cases. Of those confirmed cases, 3467 (28.2%) had complete records of clinical outcome (alive or dead), 342 (9.9%) of which died. The overall CI and CF were 5.6 per 100000 population and 2.8%, respectively

Covid-19 vaccine effectiveness studies in Nigeria: Quo vadis?

The “lickety-split” development of COVID-19 vaccines 326 days from when the SARS-COV-2 virus was first sequenced is indeed one of the public health successes of the 21st century. Particularly because an 18-month target was initially considered reasonable, and having achieved this success, a “moonshot” goal to ensure that a vaccine is available within 100 days after the next pandemic pathogen is recognized has been set [1]

Nigeria's public health response to the COVID-19 pandemic: January to May 2020

The novel coronavirus disease 2019, COVID-19, which is caused by severe acute respiratory syndrome virus 2 (SARS-CoV-2) [1] was first reported in December 2019 by Chinese Health Authorities following an outbreak of pneumonia of unknown origin in Wuhan, Hubei Province [2,3]. SARS-CoV-2 is likely of zoonotic origin, similar to SARS and Middle East Respiratory Syndrome (MERS), and transmitted between humans through respiratory droplets and fomites. Since its emergence, it has rapidly spread globally [4]

Enablers and barriers to implementing cholera interventions in Nigeria: a community–based system dynamics approach

From Crossref journal articles via Jisc Publications RouterHistory: epub 2024-07-26, issued 2024-07-26Article version: AMPublication status: PublishedFunder: Forte, Sweden; Grant(s): 2020-00027Karin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Nigeria accounts for a substantial cholera burden globally, particularly in its northeast region, where insurgency is persistent and widespread. We used participatory group model building (GMB) workshops to explore enablers and barriers to implementing known cholera interventions, including water, sanitation, and hygiene (WASH), surveillance and laboratory, case management, community engagement, oral cholera vaccine, and leadership and coordination, as well as explore leverage points for interventions and collaboration. The study engaged key cholera stakeholders in the northeastern states of Adamawa and Bauchi, as well as national stakeholders in Abuja. Adamawa and Bauchi States’ GMB participants comprised 49 community members and 43 healthcare providers, while the 23 national participants comprised government ministry, department and agency staff, and development partners. Data were analysed thematically and validated via consultation with selected participants. The study identified four overarching themes regarding the enablers and barriers to implementing cholera interventions: (1) political will, (2) health system resources and structures, (3) community trust and culture, and (4) spill-over effect of COVID-19. Specifically, inadequate political will exerts its effect directly (e.g., limited funding for prepositioning essential cholera supplies) or indirectly (e.g., overlapping policies) on implementing cholera interventions. The healthcare system structure (e.g., centralisation of cholera management in a state capital) and limited surveillance tools weaken the capacity to implement cholera interventions. Community trust emerges as integral to strengthening the healthcare system’s resilience in mitigating the impacts of cholera outbreaks. Lastly, the spill-over effects of COVID-19 helped promote interventions similar to cholera (e.g., WASH) and directly enhanced political will. In conclusion, the study offers insights into the complex barriers and enablers to implementing cholera interventions in Nigeria’s cholera-endemic settings. Strong political commitment, strengthening the healthcare system, building community trust, and an effective public health system can enhance the implementation of cholera interventions in Nigeria.inpressinpres

Resource availability and capacity to implement multi-stranded cholera interventions in the north-east region of Nigeria

Background: Limited healthcare facility (HCF) resources and capacity to implement multi-stranded cholera interventions (water, sanitation, and hygiene (WASH), surveillance, case management, and community engagement) can hinder the actualisation of the global strategic roadmap goals for cholera control, especially in settings made fragile by armed conflicts, such as the north-east region of Nigeria. Therefore, we aimed to assess HCF resource availability and capacity to implement these cholera interventions in Adamawa and Bauchi States in Nigeria as well as assess their coordination in both states and Abuja where national coordination of cholera is based. Methods: We conducted a cross-sectional survey using a face-to-face structured questionnaire to collect data on multi-stranded cholera interventions and their respective indicators in HCFs. We generated scores to describe the resource availability of each cholera intervention and categorised them as follows: 0–50 (low), 51–70 (moderate), 71–90 (high), and over 90 (excellent). Further, we defined an HCF with a high capacity to implement a cholera intervention as one with a score equal to or above the average intervention score. Results: One hundred and twenty HCFs (55 in Adamawa and 65 in Bauchi) were surveyed in March 2021, most of which were primary healthcare centres (83%; 99/120). In both states, resource availability for WASH indicators had high to excellent median scores; surveillance and community engagement indicators had low median scores. Median resource availability scores for case management indicators ranged from low to moderate. Coordination of cholera interventions in Adamawa State and Abuja was high but low in Bauchi State. Overall, HCF capacity to implement multi-stranded cholera interventions was high, though higher in Adamawa State than in Bauchi State. Conclusions: The study found a marked variation in HCF resource availability and capacity within locations and by cholera interventions and identified cholera interventions that should be prioritised for strengthening as surveillance and laboratory, case management, and community engagement. The findings support adopting a differential approach to strengthening cholera interventions for better preparedness and response to cholera outbreaks

Preparedness and perception of graduates and trainees of Nigeria Field Epidemiology and Laboratory Training Program towards participation in COVID-19 outbreak response

Introduction: Health workforce is one of the six building blocks of a resilient health system and is key to outbreak control. We assessed preparedness and perception of graduates and trainees of Nigeria Field Epidemiology and Laboratory Training Program (NFELTP) towards participation in COVID-19 response. Methods: A cross-sectional study was carried out among 231 respondents. Respondents were graduates and trainees of NFELTP. Electronic self-administered questionnaire was used to collect information from the respondents. We described binary variables using frequencies and percentages; and normally distributed continuous variables using means and standard deviations. Responses to open-ended questions were analyzed in themes. Results: Many respondents (68.4%) had undergone at least one training on COVID-19 surveillance (72.2%), infection prevention and control (63.9%), risk communication (38.6%) and sample collection (31.7%). Respondents had previously participated in outbreaks of 27 health-related events especially Lassa fever, poliomyelitis, measles, cholera and yellow fever. Respondents were willing to be engaged in the response (86.6%), despite its novelty, although, 33.8% expressed apprehension for being infected in the course of response to COVID-19 outbreak, while 52.8% mentioned feeling safe in participating in the response. Conclusion: NFELTP trainees and graduates should be continuously engaged in outbreak response activities to enhance capacity of Nigerian health workforce

Influences of community engagement and health system strengthening for cholera control in cholera reporting countries

From BMJ via Jisc Publications RouterHistory: received 2023-08-25, accepted 2023-11-25, ppub 2023-12, epub 2023-12-06Peer reviewed: TrueAcknowledgements: We want to acknowledge the Karolinska Institute Librarians' assistance in constructing this study's search strategy.Publication status: PublishedKarin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725The 2030 Global Task Force on Cholera Control Roadmap hinges on strengthening the implementation of multistranded cholera interventions, including community engagement and health system strengthening. However, a composite picture of specific facilitators and barriers for these interventions and any overlapping factors existing between the two, is lacking. Therefore, this study aims to address this shortcoming, focusing on cholera-reporting countries, which are disproportionately affected by cholera and may be cholera endemic. A scoping methodology was chosen to allow for iterative mapping, synthesis of the available research and to pinpoint research activity for global and local cholera policy-makers and shareholders. Using the Arksey and O’Malley framework for scoping reviews, we searched PubMed, Web of Science and CINAHL. Inclusion criteria included publication in English between 1990 and 2021 and cholera as the primary document focus in an epidemic or endemic setting. Data charting was completed through narrative descriptive and thematic analysis. Forty-four documents were included, with half relating to sub-Saharan African countries, 68% (30/44) to cholera endemic settings and 21% (9/44) to insecure settings. We identified four themes of facilitators and barriers to health systems strengthening: health system cooperation and agreement with external actors; maintaining functional capacity in the face of change; good governance, focused political will and sociopolitical influences on the cholera response and insecurity and targeted destruction. Community engagement had two themes: trust building in the health system and growing social cohesion. Insecurity and the community; cooperation and agreement; and sociopolitical influences on trust building were themes of factors acting at the interface between community engagement and health system. Given the decisive role of the community–health system interface for both sustained health system strengthening and community engagement, there is a need to advocate for conflict resolution, trust building and good governance for long-term cholera prevention and control in cholera reporting countries.pubpu