Oladayo Biya

Outbreak of Fatal Childhood Lead Poisoning Related to Artisanal Gold Mining in Northwestern Nigeria, 2010

Background: In May 2010, a team of national and international organizations was assembled to investigate children’s deaths due to lead poisoning in villages in northwestern Nigeria. Objectives: Our goal was to determine the cause of the childhood lead poisoning outbreak, investigate risk factors for child mortality, and identify children < 5 years of age in need of emergency chelation therapy for lead poisoning. Methods: We administered a cross-sectional, door-to-door questionnaire in two affected villages, collected blood from children 2–59 months of age, and obtained soil samples from family compounds. Descriptive and bivariate analyses were performed with survey, blood lead, and environmental data. Multivariate logistic regression techniques were used to determine risk factors for childhood mortality. Results: We surveyed 119 family compounds. Of 463 children < 5 years of age, 118 (25%) had died in the previous year. We tested 59% (204/345) of children < 5 years of age, and all were lead poisoned (≥ 10 µg/dL); 97% (198/204) of children had blood lead levels (BLLs) ≥ 45 µg/dL, the threshold for initiating chelation therapy. Gold ore was processed inside two-thirds of the family compounds surveyed. In multivariate modeling, significant risk factors for death in the previous year from suspected lead poisoning included the age of the child, the mother’s work at ore-processing activities, community well as primary water source, and the soil lead concentration in the compound. Conclusion: The high levels of environmental contamination, percentage of children < 5 years of age with elevated BLLs (97%, > 45 µg/dL), and incidence of convulsions among children before death (82%) suggest that most of the recent childhood deaths in the two surveyed villages were caused by acute lead poisoning from gold ore–processing activities. Control measures included environmental remediation, chelation therapy, public health education, and control of mining activities.

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.

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.

An Assessment of the Reasons for Oral Poliovirus Vaccine Refusals in Northern Nigeria

BACKGROUND Accumulation of susceptible children whose caregivers refuse to accept oral poliovirus vaccine (OPV) contributes to the spread of poliovirus in Nigeria. METHODS During and immediately following the OPV campaign in October 2012, polio eradication partners conducted a study among households in which the vaccine was refused, using semistructured questionnaires. The selected study districts had a history of persistent OPV refusals in previous campaigns. RESULTS Polio risk perception was low among study participants. The majority (59%) of participants believed that vaccination was either not necessary or would not be helpful, and 30% thought it might be harmful. Religious beliefs were an important driver in the way people understood disease. Fifty-two percent of 48 respondents reported that illnesses were due to Gods will and/or destiny and that only God could protect them against illnesses. Only a minority (14%) of respondents indicated that polio was a significant problem in their community. CONCLUSIONS Caregivers refuse OPV largely because of poor polio risk perception and religious beliefs. Communication strategies should, therefore, aim to increase awareness of polio as a real health threat and educate communities about the safety of the vaccine. In addition, polio eradication partners should collaborate with other agencies and ministries to improve total primary healthcare packages to address identified unmet health and social needs.

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.

Polio Legacy in Action: Using the Polio Eradication Infrastructure for Measles Elimination in Nigeria—The National Stop Transmission of Polio Program

Abstract From 2012 to date, Nigeria has been the focus of intensified polio eradication efforts. Large investments made by multiple partner organizations and the federal Ministry of Health to support strategies and resources, including personnel, for increasing vaccination coverage and improved performance monitoring paid off, as the number of wild poliovirus (WPV) cases detected in Nigeria were reduced significantly, from 122 in 2012 to 6 in 2014. No WPV cases were detected in Nigeria in 2015 and as at March 2017, only 4 WPV cases had been detected. Given the momentum gained toward polio eradication, these resources seem well positioned to help advance other priority health agendas in Nigeria, particularly the control of vaccine-preventable diseases, such as measles. Despite implementation of mass measles vaccination campaigns, measles outbreaks continue to occur regularly in Nigeria, leading to high morbidity and mortality rates for children <5 years of age. The National Stop Transmission of Polio (NSTOP) program was collaboratively established in 2012 to create a network of staff working at national, state, and district levels in areas deemed high risk for vaccine-preventable disease outbreaks. As an example of how the polio legacy can create long-lasting improvements to public health beyond polio, the Centers for Disease Control and Prevention will transition >180 NSTOP officers to provide technical experience to improve measles surveillance, routine vaccination coverage, and outbreak investigation and response in high-risk areas.

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.

Factors associated with tuberculosis among patients attending a treatment centre in Zaria, North-west Nigeria, 2010

Introduction 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. Methods 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. Results 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. Conclusion 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.