Exercise Induced Bronchospasm and associated factors in primary school children: a cross-sectional study.

BACKGROUND: Exercise Induced Bronchospasm(EIB) is not equivalent to asthma. As many as 20%of school aged children are estimated to have EIB. In Nigeria, there is still a dearth of information on EIB as a clinical entity. This study determined the presence of EIB(using pre and post-exercise percentage difference in peak expiratory flow rate(PEFR) and associated factors such as age, gender, social class and nutritional status in primary school children in Nnewi, Anambra state, South-East Nigeria. The study also grouped those with EIB into those with asthma(EIBA) and those without asthma(EIBWA). METHODS: This was a community based cross-sectional study involving 6-12 year olds. The PEFR was taken at rest and after a 6 min free running test on the school play-ground using a Peak Flow Meter. A diagnosis of EIB was made if there was a decline of ≥ 10%. Those who had EIB were grouped further based on the degree of decline in post-exercise PEFR (a decline ≥ 10% < 25% → Mild EIB, ≥ 25% < 50% → Moderate EIB and ≥ 50% → Severe EIB) and then categorized as those with EIBWA/EIBA. RESULTS: EIB in the various minutes post-exercise was as follows: 19.2%(1stmin), 20.9%(5thmin), 18.7%(10thmin), 10%(20thmin), 0.7%(30thmin). Mild EIB accounted for the greater proportion in all minutes post-exercise and none of the pupils had severe EIB. Using values obtained in the 5thmin post-exercise for further analysis, EIBWA/EIBA = 84.1%/15.9% respectively. Mean difference in the post-exercise PEFR of EIB/no EIB and EIBWA/EIBA was -48.45(t = -7.69, p = < 0.001) and 44.46(t = 3.77, p = 0.01) respectively. Age and gender had a significant association to the presence of EIB and 58% of the pupils with EIB were of high social class. The BMI for age and gender z-scores of all study subjects as well as those with EIB was -0.34 ± 1.21, -0.09 ± 1.09 respectively. Other features of allergy(history of allergic rhinitis: OR-5.832, p = 0.001; physical findings suggestive of allergic dermatitis: OR-2.740, p = 0.003)were present in pupils diagnosed with EIB. CONCLUSION: EIB has a high prevalence in primary school children in Nnewi and the greater proportion of those with EIB had EIBWA. EIB therefore needs to be recognized as a clinical entity and stratified properly based on the presence or absence of asthma. This will help the proper management and prognostication.

Sociodemographic profile of psychoactive substance use among selected secondary school students in rural Nigeria.

OBJECTIVES: Use of Psychoactive substances by young people poses an important public health threat despite mass campaigns and education. There have been documentations of rise in prevalence and use of psychoactive substances by Nigerian adolescents in urban areas of Nigeria. Few reports exist on in-school adolescents in rural areas, and differences in their sociodemographic profile such as public/private school attendance, day/boarding status and socioeconomic status of students. The study determined the rate and sociodemographic profile of psychoactive substance use among secondary school students in selected rural communities in Anambra state, Nigeria. METHODS: This was a cross-sectional study in which multistage sampling was used to select 494 students from selected secondary schools in Anambra state. Data on age, gender, socioeconomic status, student status, school category, alcohol, tobacco and intravenous drug use were obtained using pretested semi-structured questionnaires. Analysis of data was done using IBM SPSS statistics software version 20.0, frequency, percentages and means were calculated, with cross-tabulation done for variables (Chi-square and Fishers exact test where applicable). Level of significance for tests of association set at 5%. RESULTS: A total of 494 participants were studied of which 48.8% (n=241) were males. The mean age was 14.5 ± 1.8 years. The prevalence of lifetime use of psychoactive substance was 22.5%. Prevalence for individual substances were 21.9% (n=108), 1.8% (n=9) and 0.8% (n=4) respectively for alcohol, tobacco and illicit intravenous drugs. Neither gender {6 males (2.5%), 3 females (1.2%), p=0.890}, age {10-13 years (1.3%), 14-16 years (2.1%), >16 years (1.7%), p=0.329}, student status {day (2.6%), boarding (1.2%), p=0.320}, social class {upper (0.9%), middle (0.6%), lower (3.1%), p=0.208 } nor school category {private (1.5%), public (2.1%), p=0.742} of students was significantly associated with smoking and respectively. More males (73/241=30.3%, p<0.001) took alcohol than females (35/253 = 13.8%) and this was statistically significant. Participants from the lower socioeconomic class (30.3%, p<0.001) had a significantly higher rate of alcohol consumption than those from the upper (11.8%) and middle classes (16.7%) respectively. Higher rate was noted among those who attended public schools (30.8%, p<0.001) compared to those who attended private schools (13.8%). Day students (30.2%, p<0.001) indulged more in alcohol than boarding students (14.3%). There was no association between either the class (junior=22.5%, senior=21.3%, p=0.759) or age of participants (10-13 years=20.7%, 14-16 years=20.1%, >16 years=33.3%, p=0.071) and alcohol consumption. No association was found between age (0.7%, 1.1%, p=1.000), gender (male=1.2%, female=0.4%, p=0.362), social class (lower=1.3%, upper=0.9%, p=0.443), student status (day=0.9%, boarding=0.8%, p=1.000), school category (junior=0.8%, senior=0.8%, p=1.000) and intravenous drug use. CONCLUSIONS: The rate of about 22% alcohol use by secondary school students in rural south eastern Nigeria, which is strongly associated with male gender, low socioeconomic status, day student status and public school attendance is high.

Clinical illness and outcomes in Nigerian children with persistent early-appearing anaemia following initiation of artemisinin-based combination treatments of uncomplicated falciparum malaria.

In non-anaemic children with malaria, early-appearing anaemia (EAA) is common following artemisinin-based combination treatments (ACTs) and it may become persistent (PEAA). The factors contributing to and kinetics of resolution of the deficit in haematocrit from baseline (DIHFB) characteristic of ACTs-related PEAA were evaluated in 540 consecutive children with malaria treated with artemether-lumefantrine, artesunate-amodiaquine or dihydroartemisinin-piperaquine. Asymptomatic PEAA occurred in 62 children. In a multiple logistic regression model, a duration of illness ≤3 days before presentation, haematocrit <35% before and <25% one day after treatment initiation, drug attributable fall in haematocrit ≥6%, and treatment with dihydroartemisinin-piperaquine independently predicted PEAA. Overall, mean DIHFB was 5.7% (95% CI 4.8-6.6) 7 days after treatment initiation and was similar for all treatments. Time to 90% reduction in DIHFB was significantly longer in artemether-lumefantrine-treated children compared with other treatments. In a one compartment model, declines in DIHFB were monoexponential with overall mean estimated half-time of 3.9 days (95% CI 2.6-5.1), Cmax of 7.6% (95% CI 6.7-8.4), and Vd of 0.17 L/kg (95% CI 0.04-0.95). In Bland-Altman analyses, overall mean anaemia recovery time (AnRT) of 17.4 days (95% CI 15.5-19.4) showed insignificant bias with 4, 5 or 6 multiples of half-time of DIHFB. Ten children after recovery from PEAA progressed to late-appearing anaemia (LAA). Progression was associated with female gender and artesunate-amodiaquine treatment. Asymptomatic PEAA is common following ACTs. PEAA or its progression to LAA may have implications for case and community management of anaemia and for anaemia control efforts in sub-Saharan Africa where ACTs have become first-line antimalarials. Trial registration: Pan Africa Clinical Trial Registration PACTR201709002064150, 1 March 2017 http://www.pactr.org.

Declining responsiveness of childhood Plasmodium falciparum infections to artemisinin-based combination treatments ten years following deployment as first-line antimalarials in Nigeria.

BACKGROUND: The development and spread of artemisinin-resistant Plasmodium falciparum malaria in Greater Mekong Subregion has created impetus for continuing global monitoring of efficacy of artemisinin-based combination therapies (ACTs). This post analyses is aimed to evaluate changes in early treatment response markers 10 years after the adoption of ACTs as first-line treatments of uncomplicated falciparum malaria in Nigeria. METHODS: At 14 sentinel sites in six geographical areas of Nigeria, we evaluated treatment responses in 1341 children under 5 years and in additional 360 children under 16 years with uncomplicated malaria enrolled in randomized trials of artemether-lumefantrine versus artesunate-amodiaquine at 5-year interval in 2009-2010 and 2014-2015 and at 2-year interval in 2009-2010 and 2012-2015, respectively after deployment in 2005. RESULTS: Asexual parasite positivity 1 day after treatment initiation (APPD1) rose from 54 to 62% and 2 days after treatment initiation from 5 to 26% in 2009-2010 to 2014-2015 (P = 0.002 and P <  0.0001, respectively). Parasite clearance time increased significantly from 1.6 days (95% confidence interval [CI]: 1.55-1.64) to 1.9 days (95% CI, 1.9-2.0) and geometric mean parasite reduction ratio 2 days after treatment initiation decreased significantly from 11 000 to 4700 within the same time period (P <  0.0001 for each). Enrolment parasitaemia > 75 000 µl- 1, haematocrit > 27% 1 day post-treatment initiation, treatment with artemether-lumefantrine and enrolment in 2014-2015 independently predicted APPD1. In parallel, Kaplan-Meier estimated risk of recurrent infections by day 28 rose from 8 to 14% (P = 0.005) and from 9 to 15% (P = 0.02) with artemether-lumefantrine and artesunate-amodiaquine, respectively. Mean asexual parasitaemia half-life increased significantly from 1.1 h to 1.3 h within 2 years (P <  0.0001). CONCLUSIONS: These data indicate declining parasitological responses through time to the two ACTs may be due to emergence of parasites with reduced susceptibility or decrease in immunity to the infections in these children. TRIAL REGISTRATION: Pan African Clinical Trial Registration PACTR201508001188143 , 3 July 2015; PACTR201508001191898 , 7 July 2015 and PACTR201508001193368 , 8 July 2015 PACTR201510001189370 , 3 July 2015; PACTR201709002064150 , 1 March 2017; https://www.pactr.samrca.ac.za.

Parasite reduction ratio one day after initiation of artemisinin-based combination therapies and its relationship with parasite clearance time in acutely malarious children.

BACKGROUND: In acute falciparum malaria, asexual parasite reduction ratio two days post-treatment initiation (PRRD2) ≥ 10 000 per cycle has been used as a measure of the rapid clearance of parasitaemia and efficacy of artemisinin derivatives. However, there is little evaluation of alternative measures; for example, parasite reduction ratio one day after treatment initiation (PRRD1) and its relationship with parasite clearance time (PCT) or PRRD2. This study evaluated the use of PRRD1 as a measure of responsiveness to antimalarial drugs. METHODS: In acutely malarious children treated with artesunate-amodiaquine (AA), artemether-lumefantrine (AL) or dihydroartemisinin-piperaquine (DHP), the relationships between PRRD1 or PRRD2 and PCT, and between PRRD1 and PRRD2 were evaluated using linear regression. Agreement between estimates of PCT using PRRD1 and PRRD2 linear regression equations was evaluated using the Bland-Altman analysis. Predictors of PRRD1 > 5000 per half cycle and PRRD2 ≥ 10 000 per cycle were evaluated using stepwise multiple logistic regression models. Using the linear regression equation of the relationship between PRRD1 and PCT previously generated in half of the DHP-treated children during the early study phase, PCT estimates were compared in a prospective blinded manner with PCTs determined by microscopy during the later study phase in the remaining half. RESULTS: In 919 malarious children, PRRD1 was significantly higher in DHP- and AA-treated compared with AL-treated children (P <  0.0001). PRRD1 or PRRD2 values correlated significantly negatively with PCT values (P <  0.0001 for each) and significantly positively with each other (P <  0.0001). PCT estimates from linear regression equations for PRRD1 and PRRD2 showed insignificant bias on the Bland-Altman plot (P = 0.7) indicating the estimates can be used interchangeably. At presentation, age > 15 months, parasitaemia > 10 000/µl and DHP treatment independently predicted PRRD1 > 5000 per half cycle, while age > 30 months, haematocrit ≥31%, body temperature > 37.4 °C, parasitaemia > 100 000/µl, PRRD1 value > 1000 and no gametocytaemia independently predicted PRRD2 ≥ 10 000 per cycle. Using the linear regression equation generated during the early phase in 166 DHP-treated children, PCT estimates and PCTs determined by microscopy in the 155 children in the later phase were similar in the same patients. CONCLUSIONS: PRRD1 and estimates of PCT using PRRD1 linear regression equation of PRRD1 and PCT can be used in therapeutic efficacy studies. TRIAL REGISTRATION: Pan African Clinical Trial Registration PACTR201709002064150, 1 March 2017, http://www.pactr.org.

Efficacy of Artemisinin-Based Combination Treatments of Uncomplicated Falciparum Malaria in Under-Five-Year-Old Nigerian Children Ten Years Following Adoption as First-Line Antimalarials.

The efficacies of 3-day regimens of artemether-lumefantrine (AL), artesunate-amodiaquine (AA), and dihydroartemisinin-piperaquine (DHP) were evaluated in 910 children < 5 years old with uncomplicated malaria from six geographical areas of Nigeria. Parasite positivity 1 day and Kaplan-Meier estimated risk of persistent parasitemia 3 days after therapy initiation were both significantly higher, and geometric mean parasite reduction ratio 1 day after treatment initiation (PRRD1) was significantly lower in AL-treated children than in AA- and DHP-treated children. No history of fever, temperature > 38°C, enrollment parasitemia > 75,000 µL-1, and PRRD1 < 5,000 independently predicted persistent parasitemia 1 day after treatment initiation. Parasite clearance was significantly faster and risk of reappearance of asexual parasitemia after initial clearance was significantly lower in DHP-treated children. Overall, day 42 polymerase chain reaction-corrected efficacy was 98.3% (95% confidence interval [CI]: 96.1-100) and was similar for all treatments. In a non-compartment model, declines of parasitemias were monoexponential with mean terminal elimination half-life of 1.3 hours and unimodal frequency distribution of half-lives. All treatments were well tolerated. In summary, all three treatments evaluated remain efficacious treatments of uncomplicated malaria in young Nigerian children, but DHP appears more efficacious than AL or AA.

Lead poisoning associated with malaria in children of urban areas of Nigeria.

The principal objectives of this study are to (a) investigate the prevalence of elevated blood lead levels (EBLLs) in children of three major cities of Nigeria with different levels of industrial pollution; (b) identify the environmental, social and behavioral risk factors for the EBLLs in the children; and (c) explore the association between malaria (endemic in the study areas) and EBLLs in the pediatric population. The study involved 653 children aged 2-9 years (average, 3.7 years). The mean blood lead level (BLL) for the children was 8.9+/-4.8microg/dL, the median value was 7.8microg/dL, and the range was 1-52microg/dL. About 25% of the children had BLL greater than 10microg/dL. There were important differences in BLLs across the three cities, with the average value in Ibadan (9.9+/-5.2microg/dL) and Nnewi (8.3+/-3.5microg/dL) being higher than that in Port Harcourt (4.7+/-2.2micro/dL). Significant positive associations were found between BLL and a child's town of residence (p<0.001), age of the child (p=0.004), length of time the child played outside (p<0.001), presence of pets in a child's home (p=0.023), but negatively with educational level of caregiver (p<0.001). This study is one of the first to find a significant negative association between BLL and malaria in a pediatric population, and this association remained significant after controlling for confounding diseases and symptoms. The shared environmental and socio-demographic risks factors for lead exposure and Plasmodium (most common malaria parasites) infection in urban areas of Nigeria are discussed along with possible ways that lead exposure may influence the host response to infection with malarial parasites.