A systematic analysis of neurologic manifestations of Long COVID in Nigeria.

Long COVID, also called post-acute sequelae of SARS-CoV-2 infection (PASC) affects millions of people in the world. The neurologic manifestations of PASC (Neuro-PASC) are among the most debilitating but they are largely unreported in Africa. We sought to compare the demographics, symptoms and cognitive profile of post-hospitalization Neuro-PASC (PNP) and non-hospitalized Neuro-PASC (NNP) patients in Nigeria. In this cross-sectional study performed at the Lagos University Teaching Hospital, 106/2319 (4.6%) SARS-CoV-2 positive individuals contacted via telephone reported Neuro-PASC symptoms with a higher frequency in PNP than in NNP individuals ((23/200 (11.5%) vs. 83/2119 (3.9%), p = < 0.0001). The predominant neurologic symptoms at any time during the disease course were difficulty remembering / brain fog (63/106; 59.4%), fatigue (59/106; 55.7%), sleep problems (34/106; 32%), headache (33/106; 31%), paresthesia (12/106; 11.3%), and myalgia (10/106; 9.4%). Of 66 participants with Neuro-PASC who underwent in-person neurological evaluation and cognitive screening, all had normal scores on the Intervention for Dementia in Elderly Africans cognition screen, while 11/65 (16.9%) that completed the Montreal Cognitive Assessment had results consistent with mild cognitive impairment (3/16 PNP (18.8%) and 8/49 NNP (16.3%); p = 1.0). Finally, 47/66 (71.2%) had digit span test scores consistent with mild cognitive dysfunction (12/16 PNP (75%) and 35/50 (70%) NNP; p = 1.0). Our findings reveal the previously unrecognized occurrence of Neuro-PASC among COVID-19 survivors in Nigeria and highlight the need for improved screening and diagnosis of Neuro-PASC in our population. Development of cognitive support services for persons suffering from Neuro-PASC in Nigeria is warranted.

Barriers and enablers of post-COVID-19 acute care follow-up in Nigeria from service providers' perspective: a nominal group technique.

BACKGROUND: Despite modest efforts to study and document the complications that arise after acute treatment of patients with coronavirus disease, its ramifications and regional variations are yet to be clearly understood. Progress in sub-Saharan Africa, notably Nigeria, has been impeded by patient disengagement from care and insufficient or non-existent follow-up arrangements. The aim of this study was to describe the barriers and enablers for follow-up services after discharge from COVID-19 care pathway in Nigeria. METHODS: Seventeen experts involved directly in the care of patients with COVID-19 participated in brainstorming using the nominal group technique during a national workshop to review the new guidelines for COVID-19 case management in Nigeria. Participants discussed the barriers and facilitators of post-acute care follow-up of patients discharged from COVID-19 pathway and ranked their recommendations to arrive at three major factors per question. RESULTS: Participants were mostly middle aged and predominantly clinicians. The top three barriers were patients' perception of their symptom severity, lack of organizational clarity/structure/policies on follow-up care after discharge, and financial constraints. Similarly, participants identified providers' initiated education on the reasons for follow-up at discharge, written organizational policies/structure and clarity and free follow-up services as the top three facilitators. CONCLUSION: This study has enumerated barriers to follow-up care after discharge patients with coronavirus disease and highlighted providers, institutional and governmental responses that will facilitator follow-up care after discharge of patients with COVID-19. The implication is that, there is need for clear institutional guidelines for tracking and documenting post-COVID condition. In the future, it would be necessary to assess the achievements and shortcomings of post-COVID condition tracking in Nigeria through the use of implementation science outcomes.

Utility and impact of early diagnostic assessment of sepsis on mortality in an emergency department of a tertiary hospital in Lagos, Nigeria.

Context: Currently, little is known about the timely application of clinical screening tools and blood sampling for decision-making in the management of patients with suspected sepsis in the accident and emergency units of hospitals in Nigeria. Aim: The aim of the study was to ascertain the association between the time taken for the conduct of serum lactate and blood culture investigations following a clinical suspicion of sepsis, and the mortality of patients admitted to a Nigerian tertiary hospital. Methods: Over a 6-month period (November 2021 to April 2022), 119 patients hospitalised for sepsis or septic shock at the Lagos University Teaching Hospital were followed until discharge or death. The proportion of patients whose serum lactate, serum procalcitonin and blood culture samples was taken was also determined. Predictors of mortality were determined using bivariate analysis and logistic regression. Kaplan-Meier plots were used to predict survival using sepsis diagnostic criteria. Results: Eighty (67%) of 119 sepsis patients met systemic inflammatory response syndrome or quick sequential (sepsis-related) organ failure assessment criteria. Only 3 (2.5%) patients had blood cultures and serum procalcitonin and 0 (0%) had serum lactate tests. Forty-one (34.5%) patients died, but clinical and laboratory procedures for sepsis management were not linked to death. A shorter hospital stay increased the death risk (χ2 = 14.83, P = 0.002). Conclusion: This study revealed low compliance with sepsis care guidelines and no impact of timely clinical and laboratory procedures on sepsis mortalities. Further study is needed to explore patient care models that can improve the objective assessment and treatment of sepsis patients in emergency departments of busy tertiary hospitals.

Prevalence of Histoplasmosis among Persons with Advanced HIV Disease, Nigeria.

We sought to determine the prevalence of probable disseminated histoplasmosis among advanced HIV disease (AHD) patients in Nigeria. We conducted a cross-sectional study in 10 sites across 5 of 6 geopolitical zones in Nigeria. We identified patients with urinary samples containing CD4 cell counts <200 cells/mm3 or World Health Organization stage 3 or 4 disease who also had >2 clinical features of disseminated histoplasmosis, and we tested them for Histoplasma antigen using a Histoplasma enzyme immune assay. Of 988 participants we recruited, 76 (7.7%) were antigen-positive. The 76 Histoplasma antigen-positive participants had significantly lower (p = 0.03) CD4 counts; 9 (11.8%) were also co-infected with tuberculosis. Most antigen-positive participants (50/76; 65.8%; p = 0.015) had previously received antiretroviral treatment; 26/76 (34.2%) had not. Because histoplasmosis is often a hidden disease among AHD patients in Nigeria, Histoplasma antigen testing should be required in the AHD package of care.

Determinants of antiretroviral treatment adherence among patients attending secondary health care facilities in north-east and south-west Nigeria: a comparative study.

BACKGROUND: Four decades after its discovery, HIV continues to be a major global public health issue, even with antiretroviral therapy (ART). Strict adherence to ART remains a challenge, with attendant implications for treatment success. This study aimed at comparing ART adherence between north-east and south-west Nigeria. METHODS: A comparative cross-sectional study was conducted in two regions in Nigeria among 400 HIV/AIDS patients on ART. Data were collected using a pre-tested, semi-structured interviewer-administered questionnaire. Multivariable analysis was performed to determine predictors of ART adherence in the regions. The level of significance was set at 0.05. RESULTS: The majority of respondents from both the north-east (87.5%) and south-west (92.5%) of Nigeria had good knowledge about ART. The self-reported adherence level was 90.0% in the north-east and 87.5% in the south-west. Predictors of ART adherence in the north-east were knowledge about ART (AOR 9.949; 95% CI 2.009-49.284) and transport costs to the clinic (AOR 0.177; 95% CI 0.047-0.661). In the south-west, education (AOR 0.198; 95% CI 0.047-0.832) and knowledge of ART (AOR 8.945; 95% CI 1.749-45.751) were identified as predictors of ART adherence. CONCLUSION: In both regions, knowledge about ART was appreciable, but adherence was sub-optimal. Strategies to support adherence should be tailored to specific predictors in each region.

Assessment of the utility of a screening tool for COVID-19 diagnosis in an accident and emergency department in Lagos, Nigeria: A pilot study.

The use of reverse transcription-polymerase chain reaction (RT-PCR) is the gold standard laboratory test for diagnosing SARS-CoV-2 infection. However, it has the disadvantage of a long turnaround time and cost. The Nigeria Centre for Disease Control (NCDC) formulated a case definition for COVID-19. We sought to determine the utility of a 14-item, point-weighted clinical screening questionnaire adapted from the NCDC case definition in identifying patients more likely to have the disease. This was to aid prompt clinical decision-making. Methods: We retrospectively reviewed the data of 113 non-surgical patients presenting to the Accident and Emergency Department (A and E) of Lagos University Teaching Hospital, Lagos, Nigeria. Patients were stratified based on screening scores into low (0-2), moderate (3-5) and high (6) pre-test categories. Patients with low and high scores ≥6 were admitted to the A and E and the COVID-19 holding ward, respectively, while the moderate group had chest computed tomography scans to aid further decision-making, pending the outcome of their RT-PCR results. The validity of the triage score as compared to the RT-PCR test result was calculated and the kappa score of agreement was utilised to evaluate the concordance between two triage scores. The optimum cut-off score was also obtained based on the maximal Younden's index. Results: The frequencies of low, moderate and high pre-test scores were 34 (30%), 43 (38.1%) and 36 (31.9%), respectively. Overall, 38.1% (43/113) were RT-PCR positive. RT-PCR was positive in 26.5% (9/34) with low screening scores, 55.8% (24/43) with moderate scores and 27.8% (10/36) with high scores. The sensitivity and specificity of a high score of 6 were 25% and 92.86%, while the lower score of 3 had sensitivity and specificity of 62.5% and 58.6%, respectively. Conclusion: The screening tool showed a high specificity in its initial design, which suggests that anyone with a low score using this tool has a high probability of testing negative. We recommend a cut-off score of 4 (score A) or 6 (score B) of the current screening tool be used to increase the chances of identifying persons with COVID-19 for RT-PCR testing.

Bridging the knowledge gap on mycoses in Africa: Setting up a Pan-African Mycology Working Group.

Most African countries have poorly funded and overburdened health systems. Additionally, a high prevalence of HIV in Sub-Saharan Africa contributes to a high burden of opportunistic fungal infections. Data generated by GAFFI from 15 of 57 African countries revealed that an estimated 47 million Africans suffer from fungal diseases, of whom an estimated 1.7 million suffer from a serious fungal infection annually. Almost all African countries lack a surveillance system for fungal infections with the exception of South Africa. South Africa is also the only African country with a national mycology reference laboratory. Across the continent, there is a pervasive picture of inadequate/poor diagnostic capacity, low level of awareness among healthcare workers and policymakers and unavailability and non-accessibility to essential antifungal medications. Recent outreach efforts by the International Society for Human and Animal Mycology (ISHAM) and the European Confederation of Medical Mycology (ECMM) have aimed to increase involvement of African countries and experts in global initiatives such as "One World One Guideline" and also the ECMM Academy. Recently, under the auspices of ISHAM, the African sub-region created a network of mycology experts whose goal is to organise and engage African leaders in the field of medical mycology. The aim of this ISHAM Working Group was to facilitate interaction and synergy among regional leaders in order to develop educational programmes for capacity building to aid in the diagnosis and care of patients with fungal infections in Africa. The working group will also encourage country initiatives to develop clinical guidelines, to support surveys and to support the establishment of reference mycology laboratories.

Haematological indices and coagulation profile as predictors of disease severity and associations with clinical outcome among COVID-19 patients in Lagos, Nigeria.

Background: This study aims to evaluate the use of haematological indices and coagulation profiles as possible low-cost predictors of disease severity and their associations with clinical outcomes in COVID-19-hospitalized patients in Nigeria. Materials and Methods: We carried out a hospital-based descriptive 3-month observational longitudinal study of 58 COVID-19-positive adult patients admitted at the Lagos University Teaching Hospital, Lagos, Nigeria. We used a structured questionnaire to obtain the participants' relevant sociodemographic and clinical data, including disease severity. Basic haematologic indices, their derivatives, and coagulation profile were obtained from patients' blood samples. Receiver Operating Characteristic (ROC) analysis was used to compare these laboratory-based values with disease severity. A P < 0.05 was considered statistically significant. Results: The mean age of the patients was 54.4 ± 14.8 years. More than half of the participants were males (55.2%, n = 32) and most had at least one comorbidity (79.3%, n = 46). Significantly higher absolute neutrophil count (ANC), neutrophil-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), lower absolute lymphocyte count (ALC) and lymphocyte-monocyte ratio (LMR) were associated with severe disease (P < 0.05). Patients' hemoglobin concentration (P = 0.04), packed cell volume (P < 0.001), and mean cell hemoglobin concentration (P = 0.03) were also significantly associated with outcome. Receiver operating characteristic (ROC) analysis of disease severity was significant for the ANC, ALC, NLR, LMR, and SII. The coagulation profile did not show any significant associations with disease severity and outcomes in this study. Conclusion: Our findings identified haematological indices as possible low-cost predictors of disease severity in COVID-19 in Nigeria.

Résumé Contexte: Cette étude avait pour objectif d'évaluer l'utilité des indices hématologiques et profils de coagulation comme prédicteurs à faible coût de la sévérité de la maladie et leurs associations avec les résultats cliniques chez les patients hospitalisés pour COVID-19 au Nigéria. Méthodes: Nous avons mené une étude longitudinale observationnelle descriptive pendant 3 mois portant sur 58 patients adultes positifs au COVID-19, admis à Lagos University Teaching Hospital, Lagos, Nigéria. Un questionnaire structuré a été établit pour obtenir les données sociodémographiques et cliniques pertinentes des participants, y compris les données sur la sévérité de la maladie. Les indices hématologiques de base, leurs dérivés, et le profil de coagulation ont été obtenus à partir d'échantillons de sang de patients. La courbe caractéristique opérante du récepteur (ROC) a été utilisée pour comparer ces indices biologiques avec la sévérité de la maladie. Une valeur de P < 0.05 a été considéré statistiquement significatif. Résultats: L'âge moyen des patients était 54.4 ± 14.8 ans. Plus de la moitié des participants étaient des hommes (55.2 %, n = 32), et la majorité des participants présentaient au moins une comorbidité (79.3 %, n = 46). Un nombre absolu de neutrophiles (CNA), un rapport neutrophiles-lymphocytes (NLR), et une indice d'inflammation immunitaire systémique (SII) significativement élevé, et un nombre absolu de lymphocytes (ALC) et un rapport lymphocyte-monocytes (LMR) bas étaient associés à un maladie sévère (P < 0.05). La taux d'hémoglobine des patients (P = 0.04), l'hématocrite (P < 0.001), et concentration moyenne d'hémoglobine cellulaire (P = 0.03) étaient également significativement associés avec la sévérité de la maladie. L'analyse ROC de la gravité de la maladie était significative pour le ANC, ALC, NLR, LMR, et SII. Le profil de coagulation n'a montré aucune association significative avec la gravité de la maladie dans cette étude. Conclusion: Nos résultats ont identifié les indices hématologiques comme des prédicteurs potentielle à faible coût de la sévérité du COVID-19 au Nigeria. Mots-clés: Profil de coagulation, COVID-19, indices hématologiques, Nigéria, prédicteur.

High SARS-CoV-2 seroprevalence in Lagos, Nigeria with robust antibody and cellular immune responses.

Background: Early evidence suggested that the impact of the COVID-19 pandemic was less severe in Africa compared to other parts of the world. However, more recent studies indicate higher SARS-CoV-2 infection and COVID-19 mortality rates on the continent than previously documented. Research is needed to better understand SARS-CoV-2 infection and immunity in Africa. Methods: In early 2021, we studied the immune responses in healthcare workers (HCWs) at Lagos University Teaching Hospital (n = 134) and Oxford-AstraZeneca COVID-19 vaccine recipients from the general population (n = 116) across five local government areas (LGAs) in Lagos State, Nigeria. Western blots were used to simultaneously detect SARS-CoV-2 spike and nucleocapsid (N) antibodies (n = 250), and stimulation of peripheral blood mononuclear cells with N followed by an IFN-γ ELISA was used to examine T cell responses (n = 114). Results: Antibody data demonstrated high SARS-CoV-2 seroprevalence of 72·4% (97/134) in HCWs and 60·3% (70/116) in the general population. Antibodies directed to only SARS-CoV-2 N, suggesting pre-existing coronavirus immunity, were seen in 9·7% (13/134) of HCWs and 15·5% (18/116) of the general population. T cell responses against SARS-CoV-2 N (n = 114) were robust in detecting exposure to the virus, demonstrating 87·5% sensitivity and 92·9% specificity in a subset of control samples tested. T cell responses against SARS-CoV-2 N were also observed in 83.3% of individuals with N-only antibodies, further suggesting that prior non-SARS-CoV-2 coronavirus infection may provide cellular immunity to SARS-CoV-2. Conclusions: These results have important implications for understanding the paradoxically high SARS-CoV-2 infection with low mortality rate in Africa and supports the need to better understand the implications of SARS-CoV-2 cellular immunity.

Prevalence of haemoglobin A1c based dysglycaemia among adult community dwellers in selected states in Nigeria: a descriptive cross-sectional study.

Background: Type 2 diabetes mellitus (T2DM) is a disease of public health importance globally with an increasing burden of undiagnosed pre-diabetes and diabetes in low- and middle-income countries, Nigeria in particular. Pre-diabetes and diabetes are established risk factors for cardiovascular complications. However, data are scanty on the current prevalence of these conditions in Nigeria, based on haemoglobin A1c (HbA1c) diagnosis as recommended by the WHO in 2009. We aimed to determine the prevalence of pre-diabetes, diabetes, and undiagnosed diabetes among the adult population of Nigeria using HbA1c. Methodology: A cross-sectional, multi-site population study was carried out in selected states in Nigeria (namely, Ekiti, Lagos, Osun, Oyo, and Kwara states) involving 2,708 adults (≥18 years) in rural and urban community dwellers, without prior diagnosis of pre-diabetes or diabetes. Participants with ongoing acute or debilitating illnesses were excluded. Data were collected using an interviewer-administered pretested, semi-structured questionnaire. Socio-demographic, clinical (weight, height, blood pressure, etc.), and laboratory characteristics of participants including HbA1c were obtained. Data were analysed using STATA version 16. Results: The mean age of participants was 48.1 ± 15.8 years, and 65.5% were female. The overall prevalence of pre-diabetes and undiagnosed diabetes was 40.5% and 10.7%, respectively, while the prevalence of high blood pressure was 36.7%. The prevalence of pre-diabetes was the highest in Lagos (48.1%) and the lowest in Ekiti (36.7%), while the prevalence of diabetes was the highest in Kwara (14.2%) and the lowest in Ekiti (10%). There was a significant association between age of the participants (p< 0.001), gender (p = 0.009), educational status (p = 0.008), occupation (p< 0.001), tribe (p = 0.004), marital status (p< 0.001), blood pressure (p< 0.001), and their diabetic or pre-diabetic status. Independent predictors of diabetes and pre-diabetes include excess weight gain, sedentary living, and ageing. Participants within the age group 45-54 years had the highest total prevalence (26.6%) of pre-diabetes and diabetes. Conclusion: Over half of the respondents had pre-diabetes and diabetes, with a high prevalence of undiagnosed diabetes. A nationwide screening campaign will promote early detection of pre-diabetes and undiagnosed diabetes among adult Nigerians. Health education campaigns could be an effective tool in community settings to improve knowledge of the risk factors for diabetes to reduce the prevalence of dysglycaemia.

Saliva sample for detection of SARS-CoV-2: A possible alternative for mass testing.

Molecular diagnostic testing has played a critical role in the global response to the novel Coronavirus disease (COVID-19) pandemic, since its first outbreak in late 2019. At the inception of the COVID-19 pandemic, nasopharyngeal swab sample analysis for COVID-19 diagnosis using the real-time polymerase chain reaction (RT-PCR) technique was the most widely used. However, due to the high cost and difficulty of sample collection, the number of available sample types for COVID-19 diagnosis is rapidly increasing, as is the COVID-19 diagnostic literature. The use of nasal swabs, saliva, and oral fluids as viable sample options for the effective detection of SARS-CoV-2 has been implemented successfully in different settings since 2020. These alternative sample type provides a plethora of advantages including decreasing the high exposure risk to frontline workers, enhancing the chances of home self-sampling, reducing the cost, and significantly increasing testing capacity. This study sought to ascertain the effectiveness of Saliva samples as an alternative for COVID-19 diagnosis in Nigeria. Demographic data, paired samples of Nasopharyngeal Swab and Drooling Saliva were obtained from 309 consenting individuals aged 8-83 years presenting for COVID-19 testing. All samples were simultaneously assayed for the detection of SARS-CoV-2 RdRp, N, and E genes using the GeneFinder™ COVID-19 Plus RT-PCR test kit. Out of 309 participants, only 299 with valid RT-PCR results comprising 159 (53.2%) males and 140 (46.8%) females were analyzed in this study using the R Statistical package. Among the 299 samples analyzed, 39 (13.0%) had SARS-CoV-2 detected in at least one specimen type. Both swabs and saliva were positive in 20 (51.3%) participants. Ten participants (25.6%) had swab positive/saliva-negative results and 9 participants (23.1%) had saliva positive/swab-negative results. The percentage of positive and negative agreement of the saliva samples with the nasopharyngeal swab were 67% and 97% respectively with positive and negative predictive values as 69% and 96% respectively. The findings indicate that drooling saliva samples have good and comparable diagnostic accuracy to the nasopharyngeal swabs with moderate sensitivities and high specificities.

Use of exchange blood transfusion in the management of severe COVID-19 infection in pregnancy: experience from Lagos, Nigeria.

Coronavirus disease 2019 (COVID-19) presents with symptoms that may be mild or severe. The individual with the severe form of the disease usually presents with a constellation of respiratory symptoms typical of acute respiratory distress syndrome. In this report, we present our experience of the successful management of an oxygen-dependent pregnant woman with severe COVID-19 infection who had 2 sessions of partial exchange blood transfusion. We discussed the principles that informed this intervention and the need to adopt this novel approach in the care of severe COVID-19 infection.

Psychosocial health effects of Covid-19 infection on persons in treatment centers in Lagos, Nigeria.

INTRODUCTION: Prior research has highlighted the psychosocial impact of infectious diseases on individuals and the community at large. However, little is known about the psychosocial implications of COVID-19. This study set out to determine the rate as well as correlates of anxiety and depressive symptoms among persons managed as in-patients for COVID-19 in Lagos, Nigeria. MATERIALS AND METHODS: We conducted an online survey between April to June ending 2020 using a consecutive sampling technique of persons positive for COVID-19 and who were managed as in-patients across five (5) treatment centres in Lagos, Nigeria. The survey collected information on demographic as well as clinical data including suicidality. Anxiety and depressive symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS). RESULTS: There were one hundred and sixty participants in total. The mean age of respondents was 36.4 (±9.7) years with a higher proportion (56.9%) being males. With regards to diagnosis, 28.1% and 27.5% of the respondents were categorised as probable cases of depression and anxiety respectively, while 3.8% respondents reported suicidal ideation. Majority of the respondents (61.9%) reported the fear of infecting their loved ones. The variables that showed association with psychiatric morbidity were a past history of an emotional concern, employment status, guilt about infecting others and boredom. CONCLUSION: This study revealed a high burden of psychological/psychiatric morbidity among persons treated for COVID-19, particularly persons who have had prior emotional concerns. The findings from this study reiterate the need to pay attention to the mental health of people during disease outbreaks and to incorporate psychosocial interventions as part of the management package.

Predictors of antibiotic prescriptions: a knowledge, attitude and practice survey among physicians in tertiary hospitals in Nigeria.

BACKGROUND: As part of the Global Action Plan against antimicrobial resistance (AMR), countries are required to generate local evidence to inform context-specific implementation of national action plans against AMR (NAPAR). We aimed to evaluate the knowledge, attitude, and practice (KAP) regarding antibiotic prescriptions (APR) and AMR among physicians in tertiary hospitals in Nigeria, and to determine predictors of KAP of APR and AMR. METHODS: In this cross-sectional study, we enrolled physicians practicing in tertiary hospitals from all six geopolitical zones of Nigeria. Implementation of an antimicrobial stewardship programmes (ASP) by each selected hospital were assessed using a 12 item ASP checklist. We used a structured self-administered questionnaire to assess the KAP of APR and AMR. Frequency of prescriptions of 18 different antibiotics in the prior 6 months was assessed using a Likert's scale. KAP and prescription (Pr) scores were classified as good (score ≥ 80%) or average/poor (score < 80%). Independent predictors of good knowledge, attitude, and practice (KAPPr) were ascertained using an unconditional logistic regression model. RESULTS: A total of 1324 physicians out of 1778 (74% response rate) practicing in 12 tertiary hospitals in 11 states across all six geopolitical zones participated in the study. None of the participating hospitals had a formal ASP programme and majority did not implement antimicrobial stewardship strategies. The median KAPPr scores were 71.1%, 77%, 75% and 53.3%, for the knowledge, attitude, practice, and prescription components, respectively. Only 22.3%, 40.3%, 31.6% and 31.7% of study respondents had good KAPPr, respectively. All respondents had prescribed one or more antibiotics in the prior 6 months, mostly Amoxicillin-clavulanate (98%), fluoroquinolones (97%), and ceftriaxone (96.8%). About 68% of respondents had prescribed antibiotics from the World Health Organization reserve group. Prior AMR training, professional rank, department, and hospital of practice were independently associated with good KAPPr. CONCLUSIONS: Our study suggests gaps in knowledge and attitude of APR and AMR with inappropriate prescriptions of antibiotics among physicians practicing in tertiary hospitals in Nigeria. Nigeria's NAPAR should also target establishment and improvement of ASP in hospitals and address institutional, educational, and professional factors that may influence emergence of AMR in Nigeria.

Presenting Symptoms and Predictors of Poor Outcomes Among 2,184 Patients with COVID-19 in Lagos State, Nigeria.

INTRODUCTION: Lagos state remains the epicentre of COVID-19 in Nigeria. We describe the symptoms and signs of the first 2,184 PCR-confirmed COVID-19 patients admitted at COVID-19 treatment centers in Lagos State. We also assessed the relationship between patients' presenting symptoms, sociodemographic and clinical characteristics and COVID-19 deaths.. METHODS: Medical records of PCR-confirmed COVID-19 patients were extracted and analyzed for their symptoms, symptom severity, presence of comorbidities and outcome. RESULTS: The ages of the patients ranged from 4 days to 98 years with a mean of 43.0(16.0) years. Of the patients who presented with symptoms, cough (19.3%) was the most common presenting symptom. This was followed by fever (13.7%) and difficulty in breathing, (10.9%). The most significant clinical predictor of death was the severity of symptoms and signs at presentation. Difficulty in breathing was the most significant symptom predictor of COVID-19 death (OR:19.26 95% CI 10.95-33.88). The case fatality rate was 4.3%. CONCLUSION: Primary care physicians and COVID-19 frontline workers should maintain a high index of suspicion and prioritize the care of patients presenting with these symptoms. Community members should be educated on such predictors and ensure that patients with these symptoms seek care early to reduce the risk of deaths associated with COVID-19.

Morbidity and mortality outcomes of COVID-19 patients with and without hypertension in Lagos, Nigeria: a retrospective cohort study.

BACKGROUND: The current pandemic of coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has shown epidemiological and clinical characteristics that appear worsened in hypertensive patients. The morbidity and mortality of the disease among hypertensive patients in Africa have yet to be well described. METHODS: In this retrospective cohort study all confirmed COVID-19 adult patients (≥18 years of age) in Lagos between February 27 to July 62,020 were included. Demographic, clinical and outcome data were extracted from electronic medical records of patients admitted at the COVID-19 isolation centers in Lagos. Outcomes included dying, being discharged after recovery or being evacuated/transferred. Descriptive statistics considered proportions, means and medians. The Chi-square and Fisher's exact tests were used in determining associations between variables. Kaplan-Meier survival analysis and Cox regression were performed to quantify the risk of worse outcomes among hypertensives with COVID-19 and adjust for confounders. P-value ≤0.05 was considered statistically significant. RESULTS: A total of 2075 adults with COVID-19 were included in this study. The prevalence of hypertension, the most common comorbidity, was 17.8% followed by diabetes (7.2%) and asthma (2.0%). Overall mortality was 4.2% while mortality among the hypertensives was 13.7%. Severe symptoms and mortality were significantly higher among the hypertensives and survival rates were significantly lowered by the presence of additional comorbidity to 50% from 91% for those with hypertension alone and from 98% for all other patients (P < 0.001). After adjustment for confounders (age and sex), severe COVID-19and death were higher for hypertensives {severe/critical illness: HR = 2.41, P = 0.001, 95%CI = 1.4-4.0, death: HR = 2.30, P = 0.001, 95%CI = 1.2-4.6, for those with hypertension only} {severe/critical illness: HR = 3.76, P = 0.001, 95%CI = 2.1-6.4, death: crude HR = 6.63, P = 0.001, 95%CI = 3.4-1.6, for those with additional comorbidities}. Hypertension posed an increased risk of severe morbidity (approx. 4-fold) and death (approx. 7-fold) from COVID-19 in the presence of multiple comorbidities. CONCLUSION: The potential morbidity and mortality risks of hypertension especially with other comorbidities in COVID-19 could help direct efforts towards prevention and prognostication. This provides the rationale for improving preventive caution for people with hypertension and other comorbidities and prioritizing them for future antiviral interventions.

Tackling cryptococcal meningitis in Nigeria, one-step at a time; the impact of training.

BACKGROUND: Nigeria is estimated to have 25,000 cases of cryptococcal antigenemia (CrAg) annually. CrAg screening with pre-emptive fluconazole treatment is recommended but not yet implemented in Nigeria. Trainings were conducted to improve health-care provider (HCP) awareness and clinical skills in the management and prevention of cryptococcal meningitis (CM). METHODS: HCPs providing care for people living with HIV were targeted for training at 13 sites from April to November 2018 Course content was adapted from CDC Cryptococcal Screening Program Training Manual and LIFE-website. "Hands-on" training on CrAg testing and lumbar puncture was included. A 14-point pre and post-test assessment instrument was designed to capture the impact of the training and focus group discussions (FGDs) were conducted. RESULTS: A total of 761 HCPs were trained. 519 HCPs completed the pre-test evaluation while 470 (90.6%) took part in the post-test evaluation. Post-training, HCPs were significantly more likely to respond correctly to all 14 assessment items, with the mean percentage score rising to 91.0% from a pre-training value of 60.0%. FGDs revealed that many of the HCPs were not aware of the CrAg screening and pre-emptive treatment recommendations in Nigerian guidelines, and reported not having seen or managed a case of CM. Also, they highlighted challenges with routine CrAg screening due to a lack of access to CD4 testing, CrAg test kits, antifungal drugs, as well as the need for similar trainings across all tiers of care in Nigeria. CONCLUSION: Training significantly improved HCPs' understanding of Nigerian policy on CrAg screening, CM diagnosis and best management practices. This training could be included in routine capacity building efforts for HCPs involved in HIV care in Nigeria.

Caesarean delivery of first prediagnosed COVID-19 pregnancy in Nigeria.

The COVID-19 pandemic is currently causing widespread infection and deaths around the world. Since the identification of the first case in Nigeria in February 2020, the number of confirmed cases has risen to over 9,800. Although pregnant women are not necessarily more susceptible to infection by the virus, changes to their immune system in pregnancy may be associated with more severe symptoms. Adverse maternal and perinatal outcomes have been reported among pregnant women with COVID-19 infection. However, literature is scarce on the peripartum management and pregnancy outcome of a pregnant woman with COVID-19 in sub-Saharan Africa. We report the first successful and uncomplicated caesarean delivery of a pregnant woman with COVID-19 infection in Nigeria.

The prevalence and clinical profile of adrenocortical deficiency among HIV infected persons in Northern Nigeria.

BACKGROUND: Infection with the human immune deficiency virus (HIV) is still a prevalent problem in Africa. OBJECTIVES: The aim of this study was to determine the prevalence of hypocortisolism among patients with HIV and their clinical profile at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. METHOD: Three hundred and fifty adult patients with HIV infection were recruited from the HIV clinic of AKTH, Kano. Blood samples for serum electrolytes, and cortisol both before and after the short Synacthen test were taken for estimation. Data were analyzed using the SPSS version 20.0 software. RESULTS: One hundred and eight (30.9%) of participants had low baseline serum cortisol levels, while 57 (16.3%) had a low serum cortisol after short synacthen test. There was no significant relationship between the cortisol levels and clinical features of hypocortisolism, WHO clinical stage of HIV, hypernatremia or HAART regimen. There was a negative correlation between the stimulated serum cortisol and duration of diagnosis of HIV, participants BMI and CD4 counts. CONCLUSION: The biochemical evidence of hypocortisolism was common among patients infected with HIV, associated with a longer duration of HIV infection. However, none of CD4 counts, clinical features or HAART regimen were associated with hypocortisolism.

Cryptococcal meningitis after ART: Need for proper baseline evaluation in the era of 'Test & Treat'.

Cryptococcal meningitis (CM) contributes significantly to high early mortality in the setting of advanced HIV. In resource poor settings, the current HIV disease management approach is focused on commencing antiretroviral therapy (ART) on the same day of HIV diagnosis ('Test and Treat'). The HIV program in Nigeria does not currently provide CrAg screening for patients with newly diagnosed and advanced HIV disease. We report a case of severe cryptococcal meningitis presenting following the commencement of ART. There is clear benefit in the early commencement of ART among HIV infected patients and to prevent patients lost to follow-up as aimed with the 'Test & Treat' approach. However, this approach needs to be balanced against the risk of IRIS and its associated morbidity and mortality when those patients are not being properly evaluated for opportunistic infections being present without overt symptoms.