Epidemiologic and Clinical Features of Lassa Fever Outbreak in Nigeria, January 1-May 6, 2018.

Lassa fever (LF) is endemic to Nigeria, where the disease causes substantial rates of illness and death. In this article, we report an analysis of the epidemiologic and clinical aspects of the LF outbreak that occurred in Nigeria during January 1-May 6, 2018. A total of 1,893 cases were reported; 423 were laboratory-confirmed cases, among which 106 deaths were recorded (case-fatality rate 25.1%). Among all confirmed cases, 37 occurred in healthcare workers. The secondary attack rate among 5,001 contacts was 0.56%. Most (80.6%) confirmed cases were reported from 3 states (Edo, Ondo, and Ebonyi). Fatal outcomes were significantly associated with being elderly; no administration of ribavirin; and the presence of a cough, hemorrhaging, and unconsciousness. The findings in this study should lead to further LF research and provide guidance to those preparing to respond to future outbreaks.

Increase in Lassa Fever Cases in Nigeria, January-March 2018.

We reviewed data pertaining to the massive wave of Lassa fever cases that occurred in Nigeria in 2018. No new virus strains were detected, but in 2018, the outbreak response was intensified, additional diagnostic support was available, and surveillance sensitivity increased. These factors probably contributed to the high case count.

Field evaluation of validity and feasibility of Pan-Lassa rapid diagnostic test for Lassa fever in Abakaliki, Nigeria: a prospective diagnostic accuracy study.

BACKGROUND: Lassa fever is a viral haemorrhagic fever with few options for diagnosis and treatment; it is also under-researched with knowledge gaps on its epidemiology. A point-of-care bedside test diagnosing Lassa fever, adhering to REASSURED criteria, is not currently available but is urgently needed in west African regions with high Lassa fever burden. We aimed to assess the validity and feasibility of a rapid diagnostic test (RDT) to confirm Lassa fever in people in Nigeria. METHODS: We estimated the diagnostic performance of the ReLASV Pan-Lassa RDT (Zalgen Labs, Frederick, MD, USA) as a research-use-only test, compared to RT-PCR as a reference standard, in 217 participants at a federal tertiary hospital in Abakaliki, Nigeria. We recruited participants between Feb 17, 2022, and April 17, 2023. The RDT was performed using capillary blood at the patient bedside and using plasma at the laboratory. The performance of the test, based on REASSURED criteria, was assessed for user friendliness, rapidity and robustness, sensitivity, and specificity. FINDINGS: Participants were aged between 0 and 85 years, with a median age of 33·0 years (IQR 22·0-44·3), and 24 participants were younger than 18 years. 107 (50%) participants were women and 109 (50%) were men; one participant had missing sex data. Although the specificity of the Pan-Lassa RDT was high (>90%), sensitivity at bedside using capillary blood was estimated as 4% (95% CI 1-14) at 15 min and 10% (3-22) at 25 min, far below the target of 90%. The laboratory-based RDT using plasma showed better sensitivity (46% [32-61] at 15 min and 50% [36-64] at 25 min) but did not reach the target sensitivity. Among the 52 PCR-positive participants with Lassa fever, positive RDT results were associated with lower cycle threshold values (glycoprotein precursor [GPC] gene mean 30·3 [SD 4·3], Large [L] gene mean 32·3 [3·7] vs GPC gene mean 24·5 [3·9], L gene mean 28·0 [3·6]). Personnel conducting the bedside test procedure reported being hindered by the inconvenient use of full personal protective equipment and long waiting procedures before a result could be read. INTERPRETATION: The Pan-Lassa RDT is not currently recommended as a diagnostic or screening tool for suspected Lassa fever cases. Marked improvement in sensitivity and user friendliness is needed for the RDT to be adopted clinically. There remains an urgent need for better Lassa fever diagnostics to promote safety of in-hospital care and better disease outcomes in low-resource settings. FUNDING: Médecins Sans Frontières.

Immunological insights into COVID-19 in Southern Nigeria.

Introduction: One of the unexpected outcomes of the COVID-19 pandemic was the relatively low levels of morbidity and mortality in Africa compared to the rest of the world. Nigeria, Africa's most populous nation, accounted for less than 0.01% of the global COVID-19 fatalities. The factors responsible for Nigeria's relatively low loss of life due to COVID-19 are unknown. Also, the correlates of protective immunity to SARS-CoV-2 and the impact of pre-existing immunity on the outcome of the COVID-19 pandemic in Africa are yet to be elucidated. Here, we evaluated the natural and vaccine-induced immune responses from vaccinated, non-vaccinated and convalescent individuals in Southern Nigeria throughout the three waves of the COVID-19 pandemic in Nigeria. We also examined the pre-existing immune responses to SARS-CoV-2 from samples collected prior to the COVID-19 pandemic. Methods: We used spike RBD and N- IgG antibody ELISA to measure binding antibody responses, SARS-CoV-2 pseudotype assay protocol expressing the spike protein of different variants (D614G, Delta, Beta, Omicron BA1) to measure neutralizing antibody responses and nucleoprotein (N) and spike (S1, S2) direct ex vivo interferon gamma (IFNγ) T cell ELISpot to measure T cell responses. Result: Our study demonstrated a similar magnitude of both binding (N-IgG (74% and 62%), S-RBD IgG (70% and 53%) and neutralizing (D614G (49% and 29%), Delta (56% and 47%), Beta (48% and 24%), Omicron BA1 (41% and 21%)) antibody responses from symptomatic and asymptomatic survivors in Nigeria. A similar magnitude was also seen among vaccinated participants. Interestingly, we revealed the presence of preexisting binding antibodies (N-IgG (60%) and S-RBD IgG (44%)) but no neutralizing antibodies from samples collected prior to the pandemic. Discussion: These findings revealed that both vaccinated, non-vaccinated and convalescent individuals in Southern Nigeria make similar magnitude of both binding and cross-reactive neutralizing antibody responses. It supported the presence of preexisting binding antibody responses among some Nigerians prior to the COVID-19 pandemic. Lastly, hybrid immunity and heterologous vaccine boosting induced the strongest binding and broadly neutralizing antibody responses compared to vaccine or infection-acquired immunity alone.

Marked variability in institutional deliveries and neonatal outcomes during the COVID-19 lockdown in Nigeria.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and the interventions to mitigate its spread impacted access to healthcare, including hospital births and newborn care. This study evaluated the impact of COVID-19 lockdown measures on newborn service utilization in Nigeria. METHODS: The records of women who delivered in hospitals and babies admitted to neonatal wards were retrospectively reviewed before (March 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic lockdown in selected facilities in Nigeria. RESULTS: There was a nationwide reduction in institutional deliveries during the COVID-19 lockdown period in Nigeria, with 14 444 before and 11 723 during the lockdown-a decrease of 18.8%. The number of preterm admissions decreased during the lockdown period (30.6% during lockdown vs 32.6% pre-lockdown), but the percentage of outborn preterm admissions remained unchanged. Newborn admissions varied between zones with no consistent pattern. Although neonatal jaundice and prematurity remained the most common reasons for admission, severe perinatal asphyxia increased by nearly 50%. Neonatal mortality was significantly higher during the COVID-19 lockdown compared with pre-lockdown (110.6/1000 [11.1%] vs 91.4/1000 [9.1%], respectively; p=0.01). The odds of a newborn dying were about four times higher if delivered outside the facility during the lockdown (p<0.001). CONCLUSIONS: The COVID-19 lockdown had markedly deleterious effects on healthcare seeking for deliveries and neonatal care that varied between zones with no consistent pattern.

Humoral and cellular immune responses to Lassa fever virus in Lassa fever survivors and their exposed contacts in Southern Nigeria.

Elucidating the adaptive immune characteristics of natural protection to Lassa fever (LF) is vital in designing and selecting optimal vaccine candidates. With rejuvenated interest in LF and a call for accelerated research on the Lassa virus (LASV) vaccine, there is a need to define the correlates of natural protective immune responses to LF. Here, we describe cellular and antibody immune responses present in survivors of LF (N = 370) and their exposed contacts (N = 170) in a LASV endemic region in Nigeria. Interestingly, our data showed comparable T cell and binding antibody responses from both survivors and their contacts, while neutralizing antibody responses were primarily seen in the LF survivors and not their contacts. Neutralizing antibody responses were found to be cross-reactive against all five lineages of LASV with a strong bias to Lineage II, the prevalent strain in southern Nigeria. We demonstrated that both T cell and antibody responses were not detectable in peripheral blood after a decade in LF survivors. Notably LF survivors maintained high levels of detectable binding antibody response for six months while their contacts did not. Lastly, as potential vaccine targets, we identified the regions of the LASV Glycoprotein (GP) and Nucleoprotein (NP) that induced the broadest peptide-specific T cell responses. Taken together this data informs immunological readouts and potential benchmarks for clinical trials evaluating LASV vaccine candidates.

Addressing constraints to informal providers' involvement in tuberculosis control: a qualitative study of patent medicine dealers and tuberculosis programme managers.

BACKGROUND: A major constraint to tuberculosis control is low case finding with under-reporting to national authorities. Evidence shows that Patent Medicine Dealers are first port of call for most people with symptoms of tuberculosis, yet there is poor referral of such clients to tuberculosis treatment facilities for further evaluation. This study investigated constraints to involvement of Patent Medicine Dealers in tuberculosis control. METHODS: This was a cross-sectional qualitative study among Patent Medicine Dealers and Tuberculosis Control Programme Managers in Ebonyi State Nigeria. Sixty-four Patent Medicine Dealers and five Tuberculosis Control Programme Managers were interviewed using Focus Group Discussion and In-Depth Interview respectively. Data was collected with electronic audio-recording device and analyzed using thematic approach. RESULTS: There are some knowledge gaps about tuberculosis signs, symptoms, free-treatment policy and mode of operation of care service among Patent Medicine Dealers. Patent Medicine Dealers and Tuberculosis Control Programme Managers are willing to collaborate in tuberculosis control effort but constant demand for incentives by Patent Medicine Dealers and inability of National Tuberculosis Control Programme to keep up with such demands are obvious constraints. CONCLUSIONS: Knowledge gaps in tuberculosis, its control, constant demand for incentives by Patent Medicine Dealers and inability of National Tuberculosis Control Programme to satisfy such demands are constraints to involvement of Patent Medicine Dealers in tuberculosis control. More robust engagement of Patent Medicine Dealers in tuberculosis control with clear job description through tuberculosis education and provision of incentives to support them are recommended policy approaches to improve linkage of clients to tuberculosis treatment facilities.

Correlates of patients' satisfaction with antenatal care services in a tertiary hospital in Abakaliki, Ebonyi State, Nigeria.

INTRODUCTION: antenatal care is a specialized pattern of care organized for pregnant women to improve their chances of a safe delivery. Assessment of patients' perception of healthcare services is one of the ways of measuring the quality of healthcare as satisfied patients are likely to come back for the services they need and to recommend the services to others. METHODS: this is a cross-sectional study. Two hundred and eighty-four booked antenatal attendees were randomly selected at the antenatal clinic of Federal Teaching Hospital, Abakaliki in November 2016 and interviewed using semi-structured questionnaire. Items in the questionnaire included sociodemographic and obstetric variables, assessment of amenities, total time spent, services and level of satisfaction. Data obtained were analyzed using Epi info TM 7.1.3.10 and presented with a simple percentage and chi-square. Main outcome measure: satisfaction with antenatal care. RESULTS: the mean age of the respondents was 28.2 ± 4.2 years, majority 130 (45.8%) were within the 25-29 age bracket. Most had tertiary education (146, 51.4%) and less than 10% are grand multipara. In general, 89.4% of the respondents were satisfied with the quality of antenatal care services. Majority of the respondents 170 (59.9%) were unsatisfied with the water supply while 128 (45.1%) were unsatisfied with cervical cancer prevention discussion during the health talk. The mean total time spent in the antenatal clinic was 4.1 hours ± 1.2 hours (range 2-7 hours). Being married and multiparous significantly affected satisfaction with the quality of antenatal care services as represented by P-value of 0.015 and 0.005 respectively. CONCLUSION: majority of pregnant women were satisfied with the care they received. Health providers should, however, improve the state of sanitary facilities and ensure the provision of adequate information on cervical cancer screening during health talks.

Comparative outcome of overhead and total body phototherapy for treatment of severe neonatal jaundice in Nigeria.

Background: In Nigeria, neonatal jaundice is commonly treated by overhead phototherapy with neonates lying supine, often with effective exposure of less than one half of the body surface. Total body exposure in phototherapy has been in use for less than 2 years in Nigeria, but is available in only five neonatal centres.Aim: To compare the effectiveness of total body exposure (TBPE) with the conventional partial exposure (COPT) for treatment of hyperbilirubinaemia.Methods: Eleven datasets from 10 neonatal units across Nigeria were retrieved. They included neonates with severe hyperbilirubinaemia treated with TBPE using the Firefly® device (MTTS Asia) as a test group. The remainder of the patients, the controls, were treated with COPT. Any requirement for exchange blood transfusion (EBT) in either group was documented. Total serum bilirubin (TSB) >213.8 µmol/L (12.5 mg/dL) was treated as severe hyperbilirubinaemia. The efficiency of the intervention was determined according to the time taken for a severe case to be downgraded to mild at ≤213.8 µmol/L.Results: A total of 486 patients were studied, 343 controls and 143 cases. Mean (SD) postnatal age was 6 days (0.7) for cases and 5 (0.9) for controls, for gestational age (GA) in completed weeks was 36 (0.5) for cases and 37 (0.7) for controls and for birthweight was 2.7 kg (0.25) for cases and 2.7 (0.22) for controls. Mean (SD) pre-intervention TSB was 299.3 (35.7) µmol/L for cases and 327.3 (13.9) for controls. Severity downgrade day was Day 2 (0.4) for cases and Day 5 (1.1) for controls. Overall relative EBT rate was 6% for cases and 55% for controls (p= 0.0001), and early preterm relative EBT rate was 0% for cases and 68% for controls (p < 0.01).Conclusion: TBPE was quicker and safer for reduction of hyperbilirubinaemia and patients rarely required EBT. TBPE is recommended for rapid reduction of serum bilirubin levels and the reduction of treatment costs, morbidity and mortality in low- and middle-income countries.Abbreviations: EBT, exchange blood transfusion; TBPE, total body exposure technique; COPT, conventional partial exposure; TSB, total serum bilirubin; SB, serum bilirubin; NNJ, neonatal jaundice; SCNU, special care neonatal unit; LMIC, low- and middle-income countries; HIC, high-income countries; LED, light-emitting diode.

Knowledge and Practices of Health-Care Waste Management among Health Workers in Lassa Fever Treatment Facility in Southeast Nigeria.

BACKGROUND: The threat of endemic, emerging, and reemerging infectious diseases, especially the viral hemorrhagic fevers demands effective health-care waste management (HCWM) among health-care workers. The study was intended to assess the knowledge and practices of HCWM among the cleaning staff in a Lassa fever (LF) treatment facility. MATERIALS AND METHODS: This was a cross-sectional descriptive study of 234 cleaning staff of Federal Teaching Hospital Abakaliki recruited by systematic random sampling. Data collection was with semi-structured questionnaires. Knowledge and practices of respondents were assessed using cutoff score of 75%; score of 75% and above being interpreted as good and <75% as poor. Data were analyzed using Epi™ Info Version 7.2. RESULTS: There were 177 (75.6%) female and 57 (24.4%) male cleaning staff with a mean age of 33.4 years (±8.3). Among all the respondents, 18 (7.7%) had no formal education, while others had varying levels of education (primary, 43 [18.4%]; secondary, 133 [56.8%]; tertiary, 40 [17.1%]). Only 134 (57.3%) of the respondents had ever been trained on HCWM, of which 77 (57.5%) of them were trained in 2018. The proportion of respondents with good knowledge of HCWM was 41.5%. In addition, only 83 (35.5%) properly categorized the body parts, body fluids, and fetuses as pathological waste. About one-third, 77 (33.3%), had knowledge of steps in HCWM and 45.3% knew of diseases transmitted through health-care waste with 171 (62.8%) identifying LF as one of the diseases. The proportion of respondents with good practices of HCWM was 53.9% with only 131 (56.0%) segregating waste in specified color-coded containers. Among the factors examined, none was significantly associated with knowledge and practice of participants on HCWM. CONCLUSION: The proportions of the cleaning staff with good knowledge and practices of HCWM were low. There is a need to train and retrain hospital staff on proper HCWM as well as need for proper supervision and monitoring.

A cluster of nosocomial Lassa fever cases in a tertiary health facility in Nigeria: Description and lessons learned, 2018.

BACKGROUND: Lassa fever is an acute viral haemorrhagic disease endemic in Nigeria. The 2018 Lassa fever outbreak in Nigeria was unprecedented, with 8% of all cases occurring among healthcare workers (HCWs). A disproportionately high number of these infections occurred in HCWs working in a tertiary health facility in Nigeria. This paper describes the cluster of Lassa fever infections among HCWs in a treatment centre and the lessons learnt. METHODS: We analysed clinical, epidemiological and laboratory data from surveillance and laboratory records kept during the 2018 outbreak. Interviews were conducted with surviving HCWs using a questionnaire developed specifically for the investigation of Lassa fever infections in HCWs. Descriptive analysis of the data was performed in Microsoft excel. RESULTS: The index case was a 15-year-old male who presented at the health facility with fever and uncontrolled nasopharyngeal bleeding, following a recent uvulectomy by a traditional healer. Overall, 16 HCWs were affected (15 confirmed and 1 probable) with five deaths (CFR-31.6%). Of the 15 confirmed cases, five (33.3%) were asymptomatic. Nine HCWs were direct contacts of the index case; the remaining six HCWs had no direct contact with the index case. HCW interviews identified a low index of suspicion for Lassa fever leading to inadequate infection prevention and control (IPC) practices as possible contributing factors to nosocomial transmission. CONCLUSION: Maintaining a high index of suspicion for Lassa fever in all patients, especially in endemic areas, is essential in adhering to adequate IPC practices in health facilities in order to prevent nosocomial transmission of Lassa fever among HCWs. There is a need to continually train and sensitise HCWs on strict adherence to IPC measures while providing care, irrespective of a patient's provisional diagnosis.

Knowledge, Attitude and Practice of Healthcare Managers to Medical Waste Management and Occupational Safety Practices: Findings from Southeast Nigeria.

INTRODUCTION: Awareness of appropriate waste management procedures and occupational safety measures is fundamental to achieving a safe work environment, and ensuring patient and staff safety. AIM: This study was conducted to assess the attitude of healthcare managers to medical waste management and occupational safety practices. MATERIALS AND METHODS: This was a cross-sectional study conducted among 54 hospital administrators in Ebonyi state. Semi-structured questionnaires were used for qualitative data collection and analyzed with SPSS statistics for windows (2011), version 20.0 statistical software (Armonk, NY: IBM Corp). RESULTS: Two-fifth (40%) of healthcare managers had received training on medical waste management and occupational safety. Standard operating procedure of waste disposal was practiced by only one hospital (1.9%), while 98.1% (53/54) practiced indiscriminate waste disposal. Injection safety boxes were widely available in all health facilities, nevertheless, the use of incinerators and waste treatment was practiced by 1.9% (1/54) facility. However, 40.7% (22/54) and 59.3% (32/54) of respondents trained their staff and organize safety orientation courses respectively. Staff insurance cover was offered by just one hospital (1.9%), while none of the hospitals had compensation package for occupational hazard victims. Over half (55.6%; 30/54) of the respondents provided both personal protective equipment and post exposure prophylaxis for HIV. CONCLUSION: There was high level of non-compliance to standard medical waste management procedures, and lack of training on occupational safety measures. Relevant regulating agencies should step up efforts at monitoring and regulation of healthcare activities and ensure staff training on safe handling and disposal of hospital waste.

Evaluation of Clinical Diagnosis of Fetal Distress and Perinatal Outcome in a Low Resource Nigerian Setting.

INTRODUCTION: Fetal distress has been shown to contribute to the increasing caesarean section rate. There has been controversy on the usefulness of clinical diagnosis of fetal distress using only the intermittent counting of the fetal heart rate and/or passage of meconium-stained liquor. AIM: To evaluate the clinical diagnosis of fetal distress and the perinatal outcome. MATERIALS AND METHODS: This was a retrospective study in which the case records of the patients, who were diagnosed of fetal distress at Federal Teaching Hospital, Abakaliki, Nigeria, from January 1, 2008 to December 31, 2014, were collated. The statistical analysis was done using the Statistical Package for Social Sciences version 17 software (SPSS Inc., Chicago IL, USA). RESULTS: Out of the 15,640 deliveries carried out within the study period, 3,761 (24.05%) deliveries were through caesarean section. A total of 326 (8.9%) of the 3,761 caesarean sections were due to fetal distress within the study period. More so, a total of 227 (70.9%) babies were born with ≥ 7 Apgar score at the 1(st) minute of delivery. The perinatal mortality rate was 31.25 per 1000 deliveries. Though birth asphyxia was recorded more on babies of mothers that had fresh meconium-stained liquor and whose decision-intervention interval was more than 30 minutes when compared with those without any of the two conditions, there was no statistical significant difference between them. CONCLUSION: The clinical diagnosis of fetal distress is accurate in 29.1% of the cases. However, it has led to an unnecessary caesarean section in the remaining 70.9% of the parturients. In order to reduce this high trend of unnecessary caesarean sections due to clinical diagnosis of fetal distress in this environment, antepartum fetal assessment with non-stress test or biophysical profile and intrapartum use of continuous electronic fetal monitoring should be used to confirm or refute the fetal distress before any surgical intervention. Fetal blood sampling and fetal pulse oximetry should be performed in event of non- re-assuring or abnormal cardiotocography.