Victor Inem

Pre-vaccination nasopharyngeal pneumococcal carriage in a Nigerian population: epidemiology and population biology.

Background Introduction of pneumococcal vaccines in Nigeria is a priority as part of the Accelerated Vaccine Introduction Initiative (AVI) of the Global Alliance for Vaccines and Immunisation (GAVI). However, country data on the burden of pneumococcal disease (IPD) is limited and coverage by available conjugate vaccines is unknown. This study was carried out to describe the pre vaccination epidemiology and population biology of pneumococcal carriage in Nigeria. Methods This was a cross sectional survey. Nasopharyngeal swabs (NPS) were obtained from a population sample in 14 contiguous peri-urban Nigerian communities. Data on demographic characteristics and risk factor for carriage were obtained from all study participants. Pneumococci isolated from NPS were characterised by serotyping, antimicrobial susceptibility and Multi Locus Sequencing Typing (MLST). Results The prevalence of pneumococcal carriage was 52.5%. Carriage was higher in children compared to adults (67.4% vs. 26%), highest (≈90%) in infants aged <9 months and reduced significantly with increasing age (P<0.001). Serotypes 19F (18.6%) and 6A (14.4%) were most predominant. Potential vaccine coverage was 43.8%, 45.0% and 62% for PCV-7, PCV-10 and PCV-13 respectively. There were 16 novel alleles, 72 different sequence types (STs) from the isolates and 3 Sequence Types (280, 310 and 5543) were associated with isolates of more than one serotype indicative of serotype switching. Antimicrobial resistance was high for cotrimoxazole (93%) and tetracycline (84%), a third of isolates had intermediate resistance to penicillin. Young age was the only risk factor significantly associated with carriage. Conclusions Pneumococcal carriage and serotype diversity is highly prevalent in Nigeria especially in infants. Based on the coverage of serotypes in this study, PCV-13 is the obvious choice to reduce disease burden and prevalence of drug resistant pneumococci. However, its use will require careful monitoring. Our findings provide sound baseline data for impact assessment following vaccine introduction in Nigeria.

Preference for private hospital-based maternity services in inner-city Lagos Nigeria: An observational study.

OBJECTIVES To determine factors associated with maternal preference for delivery in private hospitals in an urban community in sub-Saharan Africa. METHODS A cross-sectional study of socio-demographic and obstetric characteristics of mothers and their newborns attending Bacille Calmette-Guérin (BCG) immunization clinics in inner-city Lagos, Nigeria. Factors associated with delivery in private hospitals were determined using multivariable logistic regression analyses. RESULTS Of the 3296 mothers enlisted for this study 1659 (50.3%) delivered in private hospitals and 1637 (49.7%) in public hospitals. Government hospitals had a higher proportion of doctors at delivery. Use of private obstetric services was significantly associated with ethnicity, religion, social class and obstetric history. Infants delivered at private hospitals were significantly more likely to be undernourished and have severe hyperbilirubinemia but less likely to be preterm and at no greater risk of hearing loss. CONCLUSIONS Current global strategies to expand facility-based deliveries in order to reduce maternal and child mortality rates need to be complemented by improved regulatory/supervisory framework at country levels to better serve mothers and their offspring in urban areas who may opt for private hospitals usually lacking adequate obstetric and pediatric facilities against the backdrop of the rapid urban transition in Africa.

Infants Delivered in Maternity Homes Run by Traditional Birth Attendants in Urban Nigeria: A Community-Based Study

We explored factors associated with traditional maternity/herbal homes (TMHs) run by traditional birth attendants (TBAs) compared with hospital or home delivery in Lagos, Nigeria, and found that infants delivered at TMHs were less likely to have severe hyperbilirubinemia compared with infants delivered in hospitals or residential homes. These infants were also less likely to be preterm compared with those delivered in hospitals or undernourished compared with infants delivered in residential homes. We concluded that infants delivered at TMHs who survive are unlikely to be at greater risks of some adverse perinatal outcomes than those delivered in hospitals or family homes.

Role of complementary and alternative medicine in cardiovascular diseases.

Introduction. This special issue focuses on the role of complementary and alternative medicine (CAM) in cardiovascular diseases (CVD). The role of CAM in healthcare specifically in cardiovascular diseases (CVDs) has been a contentious issue for centuries. With demographic shifts, urbanization, and changing lifestyles, disease burden of cardiovascular diseases (CVDs) has increased dramatically and can further increase in the future. Despite the growing popularity of CAM therapies, limited information is available regarding patterns of use of CAM therapies in cardiovascular diseases. The definition of CAM has continued to evolve. As defined by the National Center of complementary and alternative medicine (NCCAM), “it is a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine.” The 5 domains of CAM as classified by the NCCAM are whole medical systems (e.g., homeopathy, and ayurvedic medicine), mind-body interventions (e.g., yoga, meditation, and hypnotherapy), biologically based therapies (e.g., herbal treatments, mega-dose vitamins), manipulative and body-based methods (e.g., chiropractic therapy), and energy therapies (e.g., Reiki, and magnetic therapy). Over the last several decades, the use of CAM has become increasingly popular in both developed and the developing countries. A high proportion of patients using CAM believe CAM has remedial benefits and are safe compared to their prescribed treatments; this serves as a strong motivational factor for both present and future use of CAM. In addition, patients with CVD might be more likely to seek CAM treatments to decrease the psychological stress associated with this condition. Misconceptions regarding their efficacy have largely driven the popularity of these products whereas the adverse effects have been underreported. In disadvantaged societies where access to biomedical services is poor, the reliance on traditional/herbal medicines is more. In affluent population CAM is more used for disease prevention and health promotion. Data from the National Health Interview Surveys (NHIS) reported that 38% of adults in the USA were using CAM therapy in 2007 and among those 36% had CVD. CVD patients are often unwilling to inform their medical practitioners of CAM use and the majority of attending physicians do not discuss CAM use with their patients. Since many commonly used CAM products have the potential to interfere with the intended action of concomitant prescription medications, this could lead to serious drug interactions. In addition, the use of CAM may have negative impact on the compliance with prescription medications. A number of CAM therapies have purported cardiovascular effects; but most research on these products is either inconclusive, conflicting, or shows no benefit for their use. Several systematic reviews and meta-analysis on the effectiveness and possible side effects of CAM interventions suggest that some approaches may be beneficial as adjuncts to conventional management of cardiovascular disease, but no evidence exists to support their role as primary treatment. Dietary supplements (fish oil, coenzyme Q10, garlic, etc.) are among the most commonly used treatment modalities in patients with CVD. Fish oil supplements are accepted as a part of the treatment regimen for elevated serum triglycerides and the maintenance of vascular wall health. However, the efficacy of vitamin E has been questionable. Another intervention of CAM, that is, mind-body therapies (relaxation, stress management, meditation, etc.) have minimal side effects. However, in some countries unavailability of trained professionals in the field poses hindrance in its usage. Several styles of meditation have been tested and found to reduce blood pressure, improve heart rate, and even provide survival benefit. Evidence-based trials have been supportive of the conclusion that yoga can lower blood pressure and improve physical fitness. This one issue cannot answer all the questions regarding the safety, quality, and effectiveness of CAM therapies in CVDs. However, the main purpose of this issue is to open the communication line between patients and physicians on CAM use. It also illustrates the necessity of more rigorous researches to determine the precise pharmacological effects and long-term benefits on cardiovascular morbidity and mortality with CAM usage. Altogether, 27 papers were submitted for publication, out of which 19 papers were accepted. The articles in this issue represent a wide range of therapeutic approaches of CAM in preventing cardiovascular diseases. There are papers on extracts of herbal plants such as Nigella sativa, extract of black chokeberry, Salvia miltiorrhiza, polyphenol and Pueraria lobata, and their cardioprotective role in treating hypertension. Ethanolic extract of black chokeberry fruits has a potential role as prophylactic agent but can also function as a nutritional supplement in the management of arterial hypertension. In addition, a study on the use of repeatedly heated oil (a common practice in Asian countries) concluded that it has the predisposing factor of atherosclerosis leading to cardiovascular diseases. Therefore, it is advisable to avoid the consumption of repeatedly heated palm oil. This special issue also has a number of reviews on the role of CAM in preventing CVD. There is a review on the role of garlic in cardiovascular diseases: treatment and prevention which concluded that garlic can be used as an adjuvant with lipid lowering drugs for control of lipids. Moreover, another evidence-based review discusses CAM and CVDs; this review recommends that more rigorous researches are needed to determine the precise physiologic effects and long-term benefits on cardiovascular morbidity and mortality with CAM usage. In addition, there is a review on Chinese herbal medications (CHM) for hypertension. This review on 10 systematic reviews found that the majority of the RCTs (randomised controlled trials) do not include primary endpoints and therefore their conclusions remain uncertain. Another review on a traditional Chinese herbal formula, Zhen Gan Xi Feng Decoction, appears to be effective in improving blood pressure and symptoms in patients with essential hypertension. The edition also includes a paper on protein kinase II signal transduction pathway that inhibits cardiac arrhythmias in rats with myocardial infarction. Another study on palm tocotrienol-rich fraction found that it was comparable to folate in reducing high-methionine diet-induced plasma hyperhomocysteinemia, aortic oxidative stress, and inflammatory changes in rats. Conclusion. The articles presented in this issue represent the recognition of CAMs role in CVD patients. Nevertheless, better education of patients and medical practitioners is needed to improve the understanding of the risks and benefits of CAM use in CVD patients. Further pieces of evidence are required to determine the impacts of CAM use in CVD patients, particularly its clinical and prognostic impact when used in conjunction with prescription medicines. An open dialogue between healthcare professionals and patients regarding intended or present CAM use is also warranted. Acknowledgments. We hope that this special issue informs and stimulates thinking about the rationale use of CAM in CVD patients. We also hope that readers will find the papers included in this issue a valuable contribution to the field and it reflects the recent trends. We would like to thank the contributors to this special issue for their insightful papers. We would also like to acknowledge the many reviewers for their detailed comments and constructive suggestions. I wish to express my gratitude to all the Guest Editors for encouraging this project throughout, and meticulously carrying out the numerous and often arduous tasks involved with this project. Waris Qidwai Peng Nam Yeoh Victor Inem Kashmira Nanji Tabinda Ashfaq

Comparing the knowledge, attitude and practices of health care workers in public and private primary care facilities in Lagos State on Ebola virus disease.

Introduction The West African sub-region is currently witnessing an outbreak of EVD that began in December 2013. The first case in Nigeria was diagnosed in Lagos, at a private medical facility in July 2014. Health care workers are known amplifiers of the disease. The study aimed to determine and compare EVD knowledge, attitude and practices among HCWs in public and private primary care facilities in Lagos, Nigeria. Methods This was a comparative cross-sectional study. Seventeen public and private primary care facilities were selected from the 3 senatorial districts that make up Lagos State. 388 respondents from these facilities were selected at random and interviewed using a structured questionnaire. Results Proportion of respondents with good knowledge and practice among public HCWs was 98.5% and 93.8%; and among private HCW, 95.9% and 89.7%. Proportion of respondents with positive attitude was 67% (public) and 72.7% (private). Overall, there were no statistically significant differences between the knowledge, attitude and preventive practices of public HCWs and that of private HCWs, (p≤0.05). Conclusion Timely and intense social mobilization and awareness campaigns are the best tools to educate all segments of the community about public health emergencies. There exists significant surmountable gaps in EVD knowledge, negative attitude and sub-standard preventive practices that can be eliminated through continued training of HCW and provision of adequate material resources.

Uptake of hepatitis B vaccination among staff of an accident and emergency facility in Lagos, southwest Nigeria

Background: Hepatitis B vaccine has been available since 1982; it is safe and 95% effective in the prevention of chronic infection in adults and children. People with reasonable exposure to blood and blood products (health workers and those in accident and emergency facilities) ought to be vaccinated against Hepatitis B. Materials and Methods: A descriptive cross-sectional study was carried out among the staff of an accident and emergency facility in Lagos, southwest Nigeria. A pretested, structured, and self-administered questionnaire was used for collection of data on the sociodemographic characteristics and the uptake of hepatitis B vaccination among the respondents. The uptake was based on whether the respondents had received the vaccine, the number of doses received (i.e., whether complete or not), and whether they were undergoing a postvaccination test. The responses on the uptake of hepatitis B vaccination was scored and graded as good (≥50%) and poor (<50%). Results: A total of 84 respondents participated in the study. The majority of them (84.5%) had poor uptake of hepatitis B vaccination and the mean uptake score (%) was 24.2 ± 25.0. Among the respondents, 47 (56.0%) had received at least a dose of the hepatitis B vaccine, 11 (13.1%) received the three complete doses, while only 7 (9.9%) did a postvaccination test to check immune status. Among the 37 respondents who did not receive any dose of the vaccine before the study was carried out, a majority of them (67.6%) cited nonavailability of the vaccine as the reason for this while four (10.8%) cited cost as the reason. Conclusion: The uptake of hepatitis B vaccination among the staff of the accident and emergency facility was poor mainly due to nonavailability of the vaccine. There is, therefore, a need for the government to provide this vaccine and make it available at an affordable cost for workers. In addition, an immunization policy should be put in place at the facility, and implementation and monitoring should be done to ensure that the staff are immunized and protected against the hepatitis B virus (HBV).