Sustainable financing for vaccination towards advancing universal health coverage in the WHO African region: The strategic role of national health insurance.

There is a growing political interest in health reforms in Africa, and many countries are choosing national health insurance as their main financing mechanism for universal health coverage. Although vaccination is an essential health service that can influence progress toward universal health coverage, it is not often prioritized by these national health insurance systems. This paper highlights the potential gains of integrating vaccination into the package of health services that is provided through national health insurance and recommends practical policy actions that can enable countries to harness these benefits at population level.

Diagnostic usefulness of serum procalcitonin in patients with bacterial sepsis.

Background: The Sequential Organ Failure Assessment (SOFA) score is used for the diagnosis of sepsis and involves clinical and laboratory parameters that may not be readily and/or timely available in most resource-poor settings. Procalcitonin (PCT) has its level changed in response to bacterial sepsis and its measurement costs only a fraction of the total cost of investigations required to calculate SOFA score. This study aims to determine the diagnostic usefulness of PCT in bacterial sepsis. Materials and Methods: Ninety-nine participants were studied, divided into three groups: apparently healthy volunteers, those with bacterial infection without sepsis (SOFA score <2), and patients with bacterial sepsis (positive culture and SOFA ≥2). PCT level of each participant was measured and median group levels compared. Pearson's correlation was used to determine the correlation between serum PCT levels and SOFA scores in the sepsis group using a significance level of 5 percent (P < 0.05). Diagnostic usefulness of PCT was assessed using receiver operating characteristic (ROC). Result: Positive correlation was found between serum PCT levels and SOFA scores among patients with sepsis r = 0.42, P = 0.016. At a concentration of ≥4.25 ng/ml, serum PCT as a surrogate for SOFA score had a sensitivity and specificity of 57.60% and 84.80%, respectively, for indicating sepsis. The area under the ROC curve (AUC) was 0.74 (95% CI {0.62 to 0.86}, P = 0.001). Conclusion: Serum PCT concentration was significantly higher in bacterial sepsis compared to bacterial infection without sepsis and healthy state. PCT concentration demonstrated positive correlation with SOFA score in bacterial sepsis and can be used as surrogate for sepsis screening/monitoring in resource-poor settings.

Exploring the factors contributing to low vaccination uptake for nationally recommended routine childhood and adolescent vaccines in Kenya.

BACKGROUND: Vaccination remains the most effective means of reducing the burden of infectious disease among children. It is estimated to prevent between two to three million child deaths annually. However, despite being a successful intervention, basic vaccination coverage remains below the target. About 20 million infants are either under or not fully vaccinated, most of whom are in Sub-Saharan Africa region. In Kenya, the coverage is even lower at 83% than the global average of 86%. The objective of this study is to explore the factors that contribute to low demand or vaccine hesitancy for childhood and adolescent vaccines in Kenya. METHODS: The study used qualitative research design. Key Informant Interviews (KII) was used to obtain information from national and county-level key stakeholders. In-depth Interviews (IDI) was done to collect opinions of caregivers of children 0-23 months and adolescent girls eligible for immunization, and Human papillomavirus (HPV) vaccine respectively. The data was collected at the national level and counties such as Kilifi, Turkana, Nairobi and Kitui. The data was analyzed using thematic content approach. A total of 41 national and county-level immunization officials and caregivers formed the sample. RESULTS: Insufficient knowledge about vaccines, vaccine supply issues, frequent healthcare worker's industrial action, poverty, religious beliefs, inadequate vaccination campaigns, distance to vaccination centers, were identified as factors driving low demand or vaccine hesitancy against routine childhood immunization. While factors driving low uptake of the newly introduced HPV vaccine were reported to include misinformation about the vaccine, rumors that the vaccine is a form of female contraception, the suspicion that the vaccine is free and available only to girls, poor knowledge of cervical cancer and benefits of HPV vaccine. CONCLUSIONS: Rural community sensitization on both routine childhood immunization and HPV vaccine should be key activities post COVID-19 pandemic. Likewise, the use of mainstream and social media outreaches, and vaccine champions could help reduce vaccine hesitancy. The findings are invaluable for informing design of context-specific interventions by national and county-level immunization stakeholders. Further studies on the relationship between attitude towards new vaccines and connection to vaccine hesitancy is necessary.

Examining enablers of vaccine hesitancy toward routine childhood and adolescent vaccination in Malawi.

BACKGROUND: The contribution of vaccination to global public health and community wellbeing has been described as one of the greatest success stories of modern medicine. However, 13.5 million children still miss at least one of their routine vaccinations, and this contributes to about 1.5 million deaths from vaccine-preventable diseases. One of the contributing factors has been associated with vaccine hesitancy. Vaccine hesitancy is the delay or refusal of vaccines despite their availability. The study explored factors from multiple perspectives that influence hesitancy among caregivers of children and adolescent girls eligible for childhood routine immunisation and the Human Papillomavirus vaccine in Malawi. METHODS: The methodology used was qualitative such as key informant interviews and focus-group discussion. Information was obtained from caregivers, community and religious leaders, leaders of civil society groups, teachers in schools where Human Papillomavirus vaccine were piloted, healthcare workers, national and district-level officials of the expanded program on immunisation. There were 25 key informant interviews and two focus-group discussions, with 13 participants. The study was conducted between April to May 2020. The Interviews and discussions were audio-recorded, transcribed, and analysed using a thematic content approach. RESULTS: Most vaccine-hesitancy drivers for routine immunisation were also relevant for the HPV vaccine. The drivers included inadequate awareness of the vaccination schedule, rumours and conspiracy theories exacerbated by religious beliefs, low literacy levels of caregivers, distance and transport to the vaccination clinic, gender role and a disconnect between community healthcare workers and community leaders. CONCLUSIONS: The study demonstrated that a network of factors determines vaccine hesitancy for childhood Routine Immunisation and Human Papillomavirus, and some of them are interrelated with one another. This has implications both for current levels of vaccine acceptance and the introduction of any new vaccine, such as those against Malaria, HIV/AIDS, HPV or COVID-19 (coronavirus disease 2019). Therefore, strategies developed to address vaccine hesitancy must be multi-component and wide-ranging.

Implementation research approaches to promoting universal health coverage in Africa: a scoping review.

BACKGROUND: Implementation research has emerged as part of evidence-based decision-making efforts to plug current gaps in the translation of research evidence into health policy and practice. While there has been a growing number of initiatives promoting the uptake of implementation research in Africa, its role and effectiveness remain unclear, particularly in the context of universal health coverage (UHC). Hence, this scoping review aimed to identify and characterise the use of implementation research initiatives for assessing UHC-related interventions or programmes in Africa. METHODS: The review protocol was developed based on the methodological framework proposed by Arksey and O'Malley, as enhanced by the Joanna Briggs Institute. The review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). MEDLINE, Scopus and the Cochrane Library were searched. The search also included a hand search of relevant grey literature and reference lists. Literature sources involving the application of implementation research in the context of UHC in Africa were eligible for inclusion. RESULTS: The database search yielded 2153 records. We identified 12 additional records from hand search of reference lists. After the removal of duplicates, we had 2051 unique records, of which 26 studies were included in the review. Implementation research was used within ten distinct UHC-related contexts, including HIV; maternal and child health; voluntary male medical circumcision; healthcare financing; immunisation; healthcare data quality; malaria diagnosis; primary healthcare quality improvement; surgery and typhoid fever control. The consolidated framework for implementation research (CFIR) was the most frequently used framework. Qualitative and mixed-methods study designs were the commonest methods used. Implementation research was mostly used to guide post-implementation evaluation of health programmes and the contextualisation of findings to improve future implementation outcomes. The most commonly reported contextual facilitators were political support, funding, sustained collaboration and effective programme leadership. Reported barriers included inadequate human and other resources; lack of incentives; perception of implementation as additional work burden; and socio-cultural barriers. CONCLUSIONS: This review demonstrates that implementation research can be used to achieve UHC-related outcomes in Africa. It has identified important facilitators and barriers to the use of implementation research for promoting UHC in the region.

BLOOD PRESSURE CONTROL AMONG HYPERTENSIVE SUBJECTS IN DUTSE, NORTHWESTERN NIGERIA.

AIM: Background: High blood pressure is an independent risk factor for cerebrovascular, renal and cardiovascular disease. According to World Health Organization treatment to target Blood Pressure (BP) of <140/90 mmHg has been associated with decrease in morbidity and mortality. Despite this BP control has been very poor even in developed economies. OBJECTIVE: We set to assess level of BP control among hypertensive patients on treatment in Dutse, Jigawa state, and to identify treatable causes of failure to achieve target for better management. METHODS: It is a cross sectional study of all hypertensives for more than one year attending medical out patients clinic who have consented. An interviewer administered questionnaire was used to obtain information from the patients. RESULTS: A total of 123 patients of which 45% were females with mean age, duration of hypertension of 51.9 and 5.9 years respectively and BMI of 40.9Kg/ m2. Eighty-three per cent, 91% and 94% were aware of salt restriction, cessation of smoking and alcohol moderation as lifestyle modifications respectively. The mean Systolic and Diastolic BP were 142mmHg and 86mmHg respectively. Fifty-two per cent were on two drugs combination including a diuretic while 4.87% were on three drugs or more. Less than a third (27.6%) had their BP controlled at <140/90mmHg. There was no significant difference in the demographic and clinical data between patients with controlled and uncontrolled BP. CONCLUSION: This study found that control of BP is still poor in our setting. This could be due to physician inertia in the treatment, use of inappropriate combination of anti hypertensives or failure to reinforce lifestyle modifications.

Adequacy of Pathologic Reports of Invasive Breast Cancer From Mastectomy Specimens at Tikur Anbessa Specialized Hospital Oncology Center in Ethiopia.

Purpose Although information from pathology reports is essential to the care of individuals with cancer and to population-level cancer control, no systematic evidence exists regarding the adequacy of breast pathology reporting in Ethiopia. This study audited pathology reports of mastectomy specimens from patients evaluated at the Tikur Anbessa Specialized Hospital Oncology Center in Addis Ababa, Ethiopia. Methods Mastectomy pathology reports from February 2014 through January 2016 were assessed for gross and microscopic information considered by the Breast Cancer Initiative 2.5 (BCI 2.5; formerly the Breast Health Global Initiative) guideline to be necessary for care of patients with breast cancer stratified according to basic, limited, and enhanced resource settings. Results Fewer than two thirds (61.6%) of the 417 reports we reviewed included all four of the BCI 2.5 basic pathology data elements we could evaluate with available data (tumor category, lymph node category, histologic type, and histologic grade). Only 1.0% of reports included all three pathology data elements recommended for limited resource settings (estrogen receptor status, margin status, and lymphovascular invasion). Several elements were significantly more likely to be noted in reports from nonpublic hospitals than from public hospitals. Although only three of 417 reports included checklists or templates, all three of these reports included all of the basic pathology information, and they all included at least two of the three limited pathology elements not already on the basic list. Conclusion More than one third (38.4%) of mastectomy pathology reports did not meet BCI 2.5 standards for basic resource settings. Quality measurement and improvement programs and capacity-building interventions by national pathology and oncology organizations, collaboration with medical and public health organizations in neighboring countries, adoption of synoptic reporting templates, use of electronic pathology reporting, and histotechnology and histopathology training collaborations with laboratories in high-resource regions are recommended.

Prevlaence of chronic kidney disease markers in Kumbotso rural Northern Nigeria.

BACKGROUND: Data- on the epidemiology of Chronic Kidney Disease (CKD) from sub-SaharanAfrica are sparse. We investigated the prevalence of CKD and its early markers in Kumbotso, a rural community in northern Nigeria. METHODS: A total of 480 individuals were randomly selected from the general population using multistage stratified random sampling. Relevant- demographic and clinical data were obtained using a structured questionnaire. Biological samples (urine and blood) were drawn for relevant investigations. RESULTS: CKD (estimated glomerular filtration rate [eGFR <60 mls/min) was found in 117 participants (26%). Proteinuria was present in 106 persons (23.6%) and haematuria in 7 individuals (1.6%). The most common CKD stage was stage 1 (20%). CKD was associated with hypertension (P=0.002), diabetes (P=0.001), high cholesterol (P=0.030), smoking (P=0.015), increasing BMI (P=0.020), and increasing age (P=0.003). After adjusting for potential confounding with logistic regression modeling we found BMI, family history of hypertension, history of diabetes mellitus and family history of renal disease to be independent predictors of CKD. CONCLUSIONS: Early markers of CKD are common among rural inhabitants of northern Nigeria and this call for concerted efforts towards institution of preventive measures.

Cervicofacial actinomycosis and mandibular osteomyelitis.

Cervicofacial actinomycosis should be included in the differential diagnosis of any soft tissue swelling in the head and neck region, particularly if malignancy or a granulomatous disease is suspected. The diagnosis often is overlooked because of this entity's ability to mimic other conditions. Mandibular osteomyelitis also is underappreciated by many clinicians in their assessment of head and neck infections. Most cases are traced to an odontogenic source, with periapical tooth abscess and posttraumatic or surgical complication as key antecedent events.

Ischaemic heart disease in Aminu Kano Teaching Hospital, Kano, Nigeria: a 5 year review.

BACKGROUND: Socio-economic changes and rural urban migration have led to emergence of non-communicable disease including ischaemic heart disease (IHD) and many others. The actual prevalence of IHD in Nigeria is not known. The non communicable disease (NCD) survey sought to determine the prevalence of major risk factors, rather than the prevalence of the disease itself. The prevalence is generally considered low in Nigeria but the current impression about its importance stems mostly from anecdotal reports. We therefore set out to describe the prevalence as well as the spectrum of IHD at Aminu Kano Teaching Hospital, Kano. METHOD: Between July 2000 and June 2005, we reviewed the prevalence as well as the spectrum of presentation of IHD in Aminu Kano Teaching Hospital. Information was obtained from the medical records of patients in the medical unit of the hospital. Age, sex, diagnosis, risk factors for IHD, other relevant clinical and laboratory data and outcome of patients for myocardial infarction (MI) were extracted from the records. Data was analyzed using SPSS version 10.0 software. RESULTS: There were 5124 medical patients admitted over the period under review, out of which 1347 had cardiovascular diseases. Forty six patients were diagnosed to have IHD giving it a prevalence of 0.9% of medical conditions and 3.4% of all cardiovascular cases. There were 33 males and 13 females (M : F = 2.5:1). Twenty two patients (47.8%) had myocardial infarction, 14 (30.4%) had ischemic cardiomyopathy and 10 (21.7%) had angina. The patients consist of 41 (89.1%) Nigerians, 3 (6.5%) Lebanese, 1 (2.2%) Indian and 1 (2.2%) Pakistani. The risk factors found were Hypertension in 37 (80.4%) of patients, diabetes in 16 (34.8%), and Dyslipidaemia in 20 (43.5%). Others were cigarette smoking and obesity. CONCLUSION: IHD is an important cause of morbidity and mortality in our population. There is need for us to be on the alert and prepare ourselves to manage these cases. Focus should be on preventive cardiology.

Post transplant Kaposi's sarcoma among Nigerians: a report of two cases.

With the establishment of kidney transplant centres in Nigeria and increase in the number of kidney transplant recipients returning home for follow up after successful transplant abroad, an increasing number of patients with post transplant complications are likely to be seen. There is the need for physicians vested with the care of these patients to be aware of the post transplant complications so that early diagnosis and effective treatment can be instituted so as to save both the patient and the allograft. Two out of seventeen renal transplant recipients followed up in our unit had post renal transplant Kaposi's sarcoma. Both were successfully treated with withdrawal of cyclosporin, reduction of other immunosuppressives and introduction of low dose Mycophenolate Mofetil (MMF). One had a course of radiotherapy followed by weekly intravenous vincristine and the other only had vincristine with complete remission of the lesions in both patients. Post transplant Kaposi's sarcoma occurs in Nigerian transplant patients and this report highlights the need for increased awareness and high index of suspicion of post transplant Kaposi's sarcoma among kidney transplant recipients.

Opportunistic infections of the central nervous system in children with HIV infection: report of 9 autopsy cases and review of literature.

Central nervous system (CNS) abnormalities attributed to direct effects of HIV infection are seen in most of children with acquired immunodeficiency syndrome (AIDS). Secondary CNS infections with opportunistic and common pathogens are infrequent in this age group. We report 9 cases of opportunistic infection of the CNS found among 65 autopsy cases of pediatric AIDS. These included 4 cases of cytomegalovirus (CMV) infection, 1 of which was associated with aspergillosis, and 2 cases of candidiasis, 1 of which coexisted with Mycobacterium avium intracellulare (MAI) infection. There were also 2 cases of leptomeningitis, 1 due to Mycobacterium tuberculosis (MTB) and the other to Cryptococcus neoformans. In 1 child progressive multifocal leukoencephalopathy (PML) coexisted with mycotic encephalitis caused by an Aspergillus sp.

Penectomy in diabetic patients undergoing maintenance dialysis.

Penectomy was performed to sustain life in 2 patients with insulin-dependent and non-insulin-dependent diabetes mellitus, respectively, who were undergoing maintenance hemodialysis. Both patients previously had manifested a series of serious macro- and microvascular diabetic complications. The histopathologic findings in both cases included gangrenous necrosis of penile tissue, while case 2 also evinced calcification of penile arteries. Penectomy has been reported as the result of penile malignancy, anticoagulant toxicity, self-inflicted injury, and criminal assault. Other reports document penectomies attributed to perineal infection (Fournier's syndrome) in diabetic patients with uremia. In five previously reported cases of penectomy in diabetic patients undergoing dialysis, systemwide arteriopathy was present in all. There is an association between uremia in diabetics and predisposition to an ischemic-infectious lesion of the penis that fails to respond to antimicrobial therapy.