Estimating vaccine coverage in conflict settings using geospatial methods: a case study in Borno state, Nigeria.

Reliable estimates of subnational vaccination coverage are critical to track progress towards global immunisation targets and ensure equitable health outcomes for all children. However, conflict can limit the reliability of coverage estimates from traditional household-based surveys due to an inability to sample in unsafe and insecure areas and increased uncertainty in underlying population estimates. In these situations, model-based geostatistical (MBG) approaches offer alternative coverage estimates for administrative units affected by conflict. We estimated first- and third-dose diphtheria-tetanus-pertussis vaccine coverage in Borno state, Nigeria, using a spatiotemporal MBG modelling approach, then compared these to estimates from recent conflict-affected, household-based surveys. We compared sampling cluster locations from recent household-based surveys to geolocated data on conflict locations and modelled spatial coverage estimates, while also investigating the importance of reliable population estimates when assessing coverage in conflict settings. These results demonstrate that geospatially-modelled coverage estimates can be a valuable additional tool to understand coverage in locations where conflict prevents representative sampling.

Implementing a community-level intervention to control hypertensive disorders in pregnancy using village health workers: lessons learned.

INTRODUCTION: Hypertensive disorders in pregnancy result in about 76,000 maternal deaths per year worldwide. Pre-eclampsia and eclampsia cause the most deaths. Interventions for managing these disorders are available in health facilities. We assess the effect of monitoring pregnant women's blood pressure (BP) in their homes using village health workers (VHWs) equipped with a BP-measuring device on hypertension in pregnancy, in a resource-poor setting. Also, we assess the VHWs' competence with the BP device, acceptability and appropriateness of the intervention, and factors that affect the implementation of the intervention. METHOD: This is a mixed method study comprising quantitative and qualitative data collection. We implemented the intervention over 6 months across three local government areas in Gombe state, northeast Nigeria. The Replicating Effective Program (REP) framework guided the development of the implementation strategy. The quantitative data include routine measurement of pregnant women's blood pressure and observation of 118 VHW-client interactions. The routine data collection occurred between February and June 2019, and the observation occurred in January and June 2019. The qualitative data collection occurred via six focus group discussions with VHWs and ten in-depth interviews with community health extension workers in June 2019. We analyzed the data from the quantitative arm with SPSS version 23. For the qualitative arm, we transcribed the audio files, coded the texts, and categorized them using thematic analysis. RESULT: Nine thousand pregnant women were recruited into the program. We observed a significant reduction in the prevalence of hypertension in pregnancy from 1.5 to 0.8% (Z = 4.04; p < 0.00001) after starting the program. Also, we found that VHWs can assess pregnant women's BP using a semi-automatic BP-measuring device. The intervention is acceptable and appropriate in resource-poor settings. Poor payment of VHW stipend and cooperation of local health staff are barriers to sustaining the intervention. CONCLUSION: In resource-poor settings, health systems can train and equip non-technical people to identify and refer cases of high blood pressure in pregnancy to local health facilities on time. This may contribute to reducing maternal mortality and morbidity in these settings.

Diarrhoea deaths and disability-adjusted life years attributable to suboptimal breastfeeding practices in Nigeria: findings from the global burden of disease study 2016.

Background: In Nigeria, diarrhoea contributes significantly to childhood morbidity and mortality, with suboptimal breastfeeding practices playing a key role. The present study aimed to report on diarrhoea deaths and disability-adjusted life years (DALYs) among children aged under five years attributable to suboptimal breastfeeding practices in Nigeria. Methods: This study used data from the Global Burden of Disease study 2016, which estimated mortality from diarrhoea in the Cause of Death Ensemble model. Suboptimal breastfeeding was assessed as a combination of non-exclusive breastfeeding and discontinued breastfeeding. The comparative risk assessment approach was used to estimate the attributable burden of diarrhoea deaths and DALYs due to suboptimal breastfeeding practices in the spatial-temporal Gaussian Process Regression tool. Results: In 2016, suboptimal breastfeeding practices accounted for an estimated 56.5% (95% uncertainty intervals [UI]: 47.5, 68.3) of diarrhoea deaths in the late neonatal period, 39.0% (31.0, 46.3) in post-neonatal period, 39.0% (31.3, 46.20) in infancy period and 22.8% (16.9, 29.9) in children aged under five years in Nigeria. In the same year, 22,371 (14,259, 32,746) total diarrhoea deaths in children under five years could be attributed to suboptimal breastfeeding practices. DALYs from diarrhoea attributable to suboptimal breastfeeding practices was 1.9 million (1.2, 2.8 million) among children under five years in 2016. Between 1990 and 2016, the proportion of children who died from diarrhoea due to suboptimal breastfeeding did not change substantially across all age groups in Nigeria. Conclusions: Suboptimal breastfeeding practices remain a significant contributor to diarrhoea mortality and disability among children under five years in Nigeria. The study builds on previously published works on breastfeeding practices in Nigeria and provides evidence to support calls for the scale-up of efforts to improve infant feeding outcomes and reduce diarrhoea burden in Nigeria.

Tuberculosis disease burden and attributable risk factors in Nigeria, 1990-2016.

BACKGROUND: According to the World Health Organization, Nigeria is one of the countries with a high burden of tuberculosis (TB) worldwide. Improving the burden of TB among HIV-negative people would require comprehensive and up-to-date data to inform targeted policy actions in Nigeria. The study aimed to describe the incidence, prevalence, mortality, disability-adjusted life years (DALYs) and risk factors of tuberculosis in Nigeria between 1990 and 2016. METHODS: This study used the most recent data from the global burden of disease study 2016. TB deaths were estimated using the Cause of Death Ensemble model, while TB incidence, prevalence and DALYs, as well as years of life lost and years of life lived with disability were calculated in the DisMod-MR 2.1, a Bayesian meta-regression tool. Using a comparative risk assessment approach, TB burden attributable to risk factors was estimated in a spatial-temporal Gaussian Process Regression tool. RESULTS: In 2016, the prevalence of TB among HIV-negative people was 27% (95% uncertainty interval [95% UI] 23-31%) in Nigeria. TB incidence rate (new and relapse cases) was 158 per 100,000 people (95% UI; 128-193), while the total number of TB mortality was 39,933 deaths (95% UI; 30,488-55,039) in 2016. Between 2000 and 2016, the age-standardised prevalence and incidence rates of TB-HIV negative decreased by 20.0 and 87.6%, respectively. The age-standardised mortality rate also dropped by 191.6% over the same period. DALYs due to TB among HIV-negative Nigerians was high but varied across the age groups. Of the risk factors studied, alcohol use accounted for the highest number of TB deaths and DALYs, followed by diabetes and smoking in 2016. CONCLUSION: The study shows an improving trend in TB disease burden among HIV-negative individuals in Nigeria from 1990 to 2016. Despite this progress, this study suggests that additional efforts are still needed to ensure that Nigeria is not left behind in the current global strategy to end TB disease. Reducing TB disease burden in the country will require a multipronged approach that includes increased funding, health system strengthening and improved TB surveillance, as well as preventive efforts for alcohol use, smoking and diabetes.

Maternal determinants of complete child immunization among children aged 12-23 months in a southern district of Nigeria.

This study was conducted to identify determinants of complete immunization status among children aged 12-23 months in a southern district of Nigeria. The World Health Organization cluster survey was used to evaluate immunization coverage of infants. Mothers of 525 children selected by the two-stage sampling method and interviewed using an adapted questionnaire responded. Completion of the immunization schedule was verified by an immunization card or by reported history indicating that the child had received full doses of four of the antigens included in the Nigeria routine immunization schedule. Multivariate logistic regression was used to identify factors associated with completion of immunization. Only 32.4% of children had completed the immunization schedule. Determinants of complete immunization status included a maternal age less than 30 years (AOR=2.26, 95% CI:1.27-4.03), availability of an immunization card at first contact (AOR=7.72, 95% CI:4.43-13.44), fewer than three children (AOR=2.22, 95% CI:11.1-4.42), completion of post secondary education (AOR=2.34, 95% CI:1.12-4.47) and maternal unemployment (AOR=1.71, 95% CI:1.01-2.89). Identifying mothers whose children are at risk of not completing the immunization schedule and educating them is an important strategy to improve antigen coverage and prevent early childhood deaths from diseases like tuberculosis, poliomyelitis, tetanus, diphtheria, pertussis and measles.