Akin Oyemakinde

Factors associated with interruption of treatment among Pulmonary Tuberculosis patients in Plateau State, Nigeria. 2011

Introduction 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. Methods 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. Results 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. Conclusion 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.

Determinants of routine immunization coverage in Bungudu, Zamfara State, Northern Nigeria, May 2010

Introduction 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. Methods 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. Results 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. Conclusion 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.

Knowledge, care-seeking behavior, and factors associated with patient delay among newly-diagnosed pulmonary tuberculosis patients, Federal Capital Territory, Nigeria, 2010.

Introduction 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. Methods 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. Results 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). Conclusion 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.

Development of a Master Health Facility List in Nigeria

Abstract Introduction Routine Health Information Systems (RHIS) are increasingly transitioning to electronic platforms in several developing countries. Establishment of a Master Facility List (MFL) to standardize the allocation of unique identifiers for health facilities can overcome identification issues and support health facility management. The Nigerian Federal Ministry of Health (FMOH) recently developed a MFL, and we present the process and outcome. Methods The MFL was developed from the ground up, and includes a state code, a local government area (LGA) code, health facility ownership (public or private), the level of care, and an exclusive LGA level health facility serial number, as part of the unique identifier system in Nigeria. To develop the MFL, the LGAs sent the list of all health facilities in their jurisdiction to the state, which in turn collated for all LGAs under them before sending to the FMOH. At the FMOH, a group of RHIS experts verified the list and identifiers for each state. Results The national MFL consists of 34,423 health facilities uniquely identified. The list has been published and is available for worldwide access; it is currently used for planning and management of health services in Nigeria. Discussion Unique identifiers are a basic component of any information system. However, poor planning and execution of implementing this key standard can diminish the success of the RHIS. Conclusion Development and adherence to standards is the hallmark for a national health information infrastructure. Explicit processes and multi-level stakeholder engagement is necessary to ensuring the success of the effort.

Polio Eradication in Nigeria and the Role of the National Stop Transmission of Polio Program, 2012–2013

To strengthen the Nigeria polio eradication program at the operational level, the National Stop Transmission of Polio (N-STOP) program was established in July 2012 as a collaborative effort of the National Primary Health Care Development Agency, the Nigerian Field Epidemiology and Laboratory Training Program, and the US Centers for Disease Control and Prevention. Since its inception, N-STOP has recruited and trained 125 full-time staff, 50 residents in training, and 50 ad hoc officers. N-STOP officers, working at national, state, and district levels, have conducted enumeration outreaches in 46,437 nomadic and hard-to-reach settlements in 253 districts of 19 states, supported supplementary immunization activities in 236 districts, and strengthened routine immunization in 100 districts. Officers have also conducted surveillance assessments, outbreak response, and applied research as needs evolved. The N-STOP program has successfully enhanced Global Polio Eradication Initiative partnerships and outreach in Nigeria, providing an accessible, flexible, and culturally competent technical workforce at the front lines of public health. N-STOP will continue to respond to polio eradication program needs and remain a model for other healthcare initiatives in Nigeria and elsewhere.

Psychiatric Treatment of a Health Care Worker After Infection With Ebola Virus in Lagos, Nigeria

Abdulaziz Mohammed, M.B.B.S., M.P.H.-F.E, Taiwo Lateef Sheikh, M.B.B.S., M.S.C., Saheed Gidado, M.B.B.S., M.P.H.-F.E., Ismail Adeshina Abdus-salam, M.B.B.S., M.P.H., Joseph Adeyemi, M.B.B.S., M.Sc., Adebola Olayinka, M.B.B.S., Chima Ohuabunwo, M.B.B.S., Orina Oluwagbemiga Victor, M.S.W., Patrick Nguku, M.B.B.S., M.P.H., Erinfolami Adebayo Rasheed, M.B.B.S., Funmi Doherty, M.S.W., M.P.H., Ndadilnasiya Waziri, D.V.M., M.P.H.-FE, Faisal Shuaib, M.D., Dr.P.H., Babalola Obafemi Joseph, M.B.B.S., Idris Mohammed Bomai, D.V.M., Akin Oyemakinde, M.B.B.S., M.P.H.

Training and Service in Public Health, Nigeria Field Epidemiology and Laboratory Training, 2008 – 2014

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.

Prevalence and Determinants of Childhood Lead Poisoning in Zamfara State, Nigeria

Background. Lead poisoning is a great public health concern in the Nigerian state of Zamfara due to widespread gold ore mining by artisan miners using rudimentary and unsafe processing techniques. ...

Building a public health workforce in Nigeria through experiential training

A competently trained public health workforce that can operate multidisease surveillance and response systems is required for timely detection and response to public health emergencies. The backbone of any disease control is a robust surveillance system that is interlinked with timely quality response[1, 2]. The traditional approaches of training health care workers particularly public health workers have emphasized knowledge acquisition without commensurate competency acquisition; experiential training on the other hand has been successful in creating and sustaining a skilled workforce [3, 4] Experiential training comprises acquisition of necessary knowledge, skills, competencies, attitudes and behaviors that enable a person to perform certain tasks adequately in their profession. Experiential training enables a professional to rapidly move from an awareness level in the proficiency of doing a task to being completely proficient, performing and teaching the task to others-in effect it is teaching and learning by doing. This concept of training has been adopted by a number of countries to build their public health workforces drawing experiences from the Epidemic Intelligence Service(EIS) which began training using this approach in United States of America in 1951[4–10]. This model has been adapted internationally to create the Field Epidemiology and Laboratory Training Program (FELTP) in several countries[1]. Nigeria adopted the experiential training approach to build its public health workforce in 2008 with the implementation of the multiagency Nigeria Field Epidemiology and Laboratory Training Program (NFELTP). This approach was embraced to augment other traditional training approaches by emphasizing a field based, competency-based approach to training public health workforce through a tiered approach. The training typically consists of a 2-year course leading to a masters degree in field epidemiology and public health laboratory management for midlevel public health leaders and competency-based short courses for frontline public health surveillance workers. Trainees and graduates work in multidisciplinary teams to conduct surveillance, outbreak investigations, and epidemiological studies for disease control locally and across borders. The training is multi-sectoral and multi-displinary cutting across various cadres of health care workers and animal health sector professionals in the “one health” approach[11, 12]. NFELTP is a public health service-training program in applied epidemiology aimed at preparing leaders in field epidemiology to address public health issues and strengthen public health systems throughout Nigeria. The overall goals of NFELTP are: 1) to develop a self-sustaining institutionalized capacity to train public health leaders in field epidemiology (including veterinary epidemiology) and field-oriented public health laboratory practice and 2) to provide epidemiological services to the public health system at federal, state and local government levels. It is believed that a country would have an adequate coverage of public health workers trained in the experiential approach of the FELTP if there are three to five graduates of the program per million inhabitants working in suitable public health units [2]. The NFELTP is one of the premier FELTPs on the African continent. NFELTP was started as a joint effort between the Nigeria Federal Government (GON) through the Federal Ministry of Health (FMOH), the Federal Ministry of Agriculture and Rural Development (FMARD) and U.S. government through the Centers for Disease Control and Prevention (CDC). NFELTP aims to provide the country with the public health workforce that is needed to operate public health surveillance and response systems to implement the Integrated Disease Surveillance and Response (IDSR) strategy, address the Millennium Development Goals, implement the revised International Health Regulations and operationalize closer collaborations between the animal and human health (i.e., the “one world one health concept”). The experience of the avian influenza outbreak in Nigeria in 2006 demonstrated the importance of one health through the collaboration of the health sectors (human and animal) in capacity development and disease prevention and control. During and upon completion of training, NFELTP residents and graduates provide skill services to national and sub-national public health surveillance and response systems, with growing responsibility as they gain experience. With a population of 170 million, residing in 36 states and a Federal Capital Territory (FCT) and separated into six geopolitical regions there is a need to provide state and federal public health offices manned by professionals that have the ability to strengthen public health capacity to investigate and respond to outbreaks in addition to working together across disciplines collaboratively. To provide these services and work towards improving public health systems within Nigeria there is a need for the training of highly qualified individuals in field epidemiology to respond to the vast amount of public health concerns and threats that arise throughout the country. The different climatic patterns found in the three main geographic regions of the country: mangrove swamps to equatorial forest in the South, tropical in the Central, and Savannah in the North have implications for development of multiple public health challenges. For example the northern region is vulnerable to drought, desertification, food insecurity, and diseases especially cerebrospinal meningitis. In the south, disasters such as erosion, flooding and landslides, and vector-borne diseases are common. With recurrent infectious disease outbreaks, persistence of wild polio transmission, poor health outcomes, there is a need for investment in development of an effective customized and locally developed skilled public health workforce to address public health needs and priorities across the nation. Weak surveillance systems coupled with untimely and uncoordinated response to disease outbreaks have continued to be a challenge in many African countries including Nigeria. Additionally, emerging pandemic threats require development of worldwide capacity for public health surveillance and response especially given the increased travel and urbanization. Good international public health surveillance and response, which is the basis of International Health Regulations (IHR) of 2005, cannot exist sustainably without good national surveillance and response operated by competent public health workforce in core public health positions at national and sub-national levels with a focus on disease detection, prevention and control. To achieve this, there is need to address several interrelated factors on human resources, disease surveillance and reporting capacity in an integrated and sustainable approach that enables the development of public health work force capacity in order to achieve public health surveillance and response systems that have a sustainable and adaptable capacity to address evolving public health needs[2]. This supplement is a demonstration of some of the results of NFELTP residents and graduates in addressing current public health challenges such as disease outbreaks and surveillance gaps for infectious and non-infectious diseases. The support to the program by the Government and its health development partners has enabled the program to upscale towards attaining its goal of building a public health workforce through experiential training and providing epidemiological services to improve public health in Nigeria and beyond. The authors describe the processes, operations and coverage of the program and provide disease specific examples on public health response. With the increasing appreciation of the need for global health security, NFELTP is laying the foundation for a new cadre of highly skilled public health workforce adaptable to numerous public health needs in a large diverse developing country beset with several health challenges. A skilled workforce is a prerequisite for strengthening national public health institutes and the program is creating the frontline health workers for this global initiative within the newly established Nigeria Centre for Disease Control. The authors in this supplement demonstrate the collaborative efforts of multiple agencies and the multi-disciplinary and multi-sectoral approach to optimal health of the population. With only six years of implementation and a newly developed 5 year strategic plan the program has shown that it can surmount its initial start-up challenges and play its rightful role in public health system strengthening[13].

Outreach to Underserved Communities in Northern Nigeria, 2012–2013

BACKGROUND Persistent wild poliovirus transmission in Nigeria constitutes a major obstacle to global polio eradication. In August 2012, the Nigerian national polio program implemented a strategy to conduct outreach to underserved communities within the context of the countrys polio emergency action plans. METHODS A standard operating procedure (SOP) for outreach to underserved communities was developed and included in the national guidelines for management of supplemental immunization activities (SIAs). The SOP included the following key elements: (1) community engagement meetings, (2) training of field teams, (3) field work, and (4) acute flaccid paralysis surveillance. RESULTS Of the 46,437 settlements visited and enumerated during the outreach activities, 8607 (19%) reported that vaccination teams did not visit their settlements during prior SIAs, and 5112 (11.0%) reported never having been visited by polio vaccination teams. Fifty-two percent of enumerated settlements (23,944) were not found in the existing microplan used for the immediate past SIAs. CONCLUSIONS During a year of outreach to >45,000 scattered, nomadic, and border settlements, approximately 1 in 5 identified were missed in the immediately preceding SIAs. These missed settlements housed a large number of previously unvaccinated children and potentially served as reservoirs for persistent wild poliovirus transmission in Nigeria.