Roll out of a successful antimicrobial stewardship programme in Lagos University Teaching Hospital Nigeria using the Global-Point Prevalence Survey

Background: Antimicrobial resistance (AMR) has become a public health emergency with increasing rates and spread globally. Antimicrobial stewardship (AMS) has been advocated to reduce the burden of antimicrobial resistance, promote rational and appropriate use of antibiotics and improve clinical outcomes. Education and training are one of the AMS interventions to improve antimicrobial use. We present the roll out of a successful AMS programme with education and training using the Global-PPS as data collection tool to measure AMS interventions and impact.Methodology: This was a cross sectional study on the implementation of an AMS programme at the Lagos University Teaching Hospital. Global PPS was conducted in 2015 to collect baseline data which was used to identify targets for quality improvement in AMS and was repeated in 2017 and 2018 to measure impact of AMS interventions. AMS interventions included education, feedback of Global-PPS result and writing of the hospitalwide antibiotic policy based on the baseline data.Results: Out of the 746 inpatients surveyed, 476 (68.3%) had received at least one antimicrobial on the days of Global-PPS. The antimicrobial prescribing rates reduced significantly over the three time periods. In 2015, 82.5% were placed on antimicrobials, 65.5% in 2017 and 51.1% in 2018 (p<0.00001). The documentation of indication for treatment significantly improved from 53.4% in 2015 to 97.2% in 2018 (p<0.0001). Stop review date also significantly improved from 28.7% to 70.2% in 2018 (p<0.00001). Surgical prophylaxis for more than 24 hours reduced significantly from 93.3% in 2015 to 65.7% in 2018 (p=0.002) even though the prevalence was still high. The three most commonly administered antimicrobial groups were third generation cephalosporins, imidazole derivatives and quinolones. The most commonly prescribed antibiotics for surgical prophylaxis were ceftriaxone and metronidazole in 2015 and ceftriaxone in 2017.Conclusion: The use of education and training as AMS intervention in a limited resource setting clearly made impact on antimicrobial prescribing patterns in the hospital. Global-PPS is useful to set quality improvement targets and for monitoring, evaluation and surveillance of an AMS programme. Keywords: Antibiotic, Stewardship, Resistance, Education, Global-PP

Persistence of Ebola virus RNA in some body fluids of Ebola virus disease (EVD) survivors – the Nigerian experience

Introduction: Ebola virus (EBOV) has been shown to persist in some body fluids of Ebola Virus Disease (EVD) survivors with implication for future transmission particularly in Nigeria where EVD was experienced for the first time in 2014. Thus, this paper was aimed at providing information on the duration of persistence of EBOV in Nigeria. Materials and Methods: Ten consenting EVD survivors were enrolled. Baseline specimens; urine and semen (males), urine and high vaginal swab (HVS) (females) were obtained within one month after discharge from the Ebola Treatment Centre (ETC) and subsequently every fortnight. Samples were analyzed using quantitative Real-Star Filovirus Screen RT-PCR kit 1.0 at the National Reference Laboratory in Lagos.Results: Ten EVD survivors comprising 4 (40%) males and 6 (60%) females with age ranges of 28 to >33 years (mean age: 33.0 ± 6.9 years) were evaluated. EBOV RNA was not detected in the urine of all the participants and HVS from the females. However, EBOV RNA was detected in the semen of all 4 (100%) male participants at baseline, and at 2 months after discharge from the ETC. Two men were still positive for EBOV RNA 4 months after discharge from the ETC despite persistent negative vireamia. Conclusions: Our data confirm that a negative viremia in the convalescent period is not predictive of the absence of the virus in semen. Despite an early clearance of the virus from the urine and HVS, there was persistence of EBOV RNA in semen of male survivors 4 months after recovery

HIV Related Stigma and Discrimination: The Attitudes and Behavior of Workers in Insurance Companies in Lagos State

One of the greatest health problems threatening the human race is the HIV/AIDS pandemic. HIV/AIDS stigma and its related discrimination is a major constraint to the prevention and control of HIV. The HIV/AIDS pandemic has had a selective impact on young men and women who constitute the main stay of the workforce. This study aims to assess the opinion of workers in a corporate setting regarding HIVrelated stigma and discrimination and their attitudes towards HIV positive persons in the workplace. A cross sectional descriptive study was carried out. Asemi-structured, self-administered pre-tested questionnaire was filled by four hundred workers in three randomly selected insurance companies in Lagos State. All workers present at work on the day of the survey were given the questionnaires to fill. All questionnaires were filled independently and collected immediately after they had been filled. Data was collated and analyzed using Epi info software version 6. Most of the respondents (83%) were of the opinion that HIV positive persons were being unfairly treated in the society and almost all of them (93%) believed that they did not deserve such treatment. However up to 25% of them felt that an employer had the right to deny a person employment solely based on his/her HIV status and up to 15% believed that HIV positive persons should be isolated. Fortyfour percent of respondents would not share an office computer with a known HIV positive coworker, 47.7% would not share the same eating utensils and 55.9% would not share the same toilet with a known HIV positive co-worker. Similarly, up to 64% felt that there should be separate dining facilities for HIV positive persons and almost 60% felt that there should be separate toilet facilities for HIV positive persons. This was despite the fact that over 95% of the respondents were aware that HIV could not be transmitted by such means. Almost a quarter (23.5%) of the respondents would not openly associate with known HIV positive persons. There was no statistically significant relationship between sex, income, ethnicity or religion and the decision to openly associate with HIV positive persons. (p>0.05) however educational level was found to be significantly associated with the decision to openly associate with HIV positive persons. (

Enablers and barriers for implementing high-quality hypertension care in a rural primary care setting in Nigeria: perspectives of primary care staff and health insurance managers

Background: Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care. Objective: We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria. Design: Qualitative study using semi-structured individual interviews with primary care staff (n = 11) and health insurance managers (n=4). Data were analysed using standard qualitative techniques. Results: Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider–insurer relationships; automated administration systems; and tailoring guidelines/patient education. Conclusions: By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA

How Group-Based Cardiovascular Health Education Affects Treatment Adherence and Blood Pressure Control among Insured Hypertensive Nigerians: A Pre-Test, Post-Test Study

In sub Saharan Africa (SSA), access to affordable hypertension care through health insurance is increasing. But due to poor adherence, hypertension treatment outcomes often remain poor. Patient-centered educational interventions may reverse this trend. Using a pre-test/post-test design, in this study we investigated the effects of a structured cardiovascular health education program (CHEP) on treatment adherence, blood pressure (BP) control and body mass index (BMI) among Nigerian hypertensive patients who received guideline-based care in a rural primary care facility, in the context of a community based health insurance program. Study participants included 149 insured patients with uncontrolled BP and/or poor self-reported medication adherence after 12 months of guideline-based care. All patients received three group-based educational sessions and usual primary care over 6 months. We evaluated changes in self-reported adherence to prescribed medications and behavioral advice (primary outcomes); systolic BP (SBP) and/or diastolic BP (DBP) and BMI (secondary outcomes); and beliefs about hypertension and medications (explora- tory outcomes). Outcomes were analyzed with descriptive statistics and regression analysis. 140 patients completed the study (94%). At 6 months, more participants reported high adherence to medications and behavioral advice than at baseline: respectively, 101 (72%) versus 70 (50%), (p < 0.001) and 126 (90%) versus 106 (76%), (p < 0.001). Participants with controlled BP doubled from 34 (24%) to 65 (46%), (p = 0.001). The median SBP and DBP decreased from 129.0 to 122.0 mmHg, (p = 0.002) and from 80.0 to 73.5 mmHg, (p < 0.001), respectively. BMI did not change (p = 0.444). Improved medication adherence was associated with a decrease in medication concerns (p = 0.045) and improved medication self-efficacy (p < 0.001). By positively influencing patient perceptions of medications, CHEP strengthened medication adherence and, consequently, BP reduction among insured hypertensive Nigerians. This educational approach can support cardiovascular disease prevention programs for Africa’s growing hypertensive population