Role and capacity needs of community based surveillance volunteers in the integrated management of skin neglected tropical diseases (skin NTDs): a qualitative study from central Ghana.

BACKGROUND: Community Based Surveillance Volunteers (CBSVs) have been instrumental in the management of Neglected Tropical Diseases (NTDs) but a concern that their services in scale up programmes may be affected due to high attrition rates has been widely acknowledged. We explored the roles and capacity needs of existing CBSVs to inform for a successful integrated NTD management programme in Ghana and similar contexts. METHODS: We conducted qualitative interviews with 50 CBSVs, 21 Community Nurses, 4 Disease control officers, 7 skin NTD researchers, 2 skin NTD patients and a Director of District Health Services in Central Ghana. Interviews were digitally recorded, transcribed and coded prior to translation and thematic analysis. RESULTS: The roles of CBSVs in NTD management were shown to have an impact on disease identification, surveillance, health seeking behaviours and status of CBSVs. Lack of motivation, inadequate structures for engagement of CBSVs within the health system and delayed management of reported cases were identified as gaps that hinder effective delivery of CBSV roles. Provision of incentives as recognition for the unpaid services rendered by CBSVs was seen as a major factor to reduce the rate of CBSV attrition in this scale up programme. Other factors included the formulation of policies by government to guide CBSV engagement, regular training of CBSV in NTD management as well as provision of resources and logistics. CONCLUSION: Measures including continuous training, institution of rewards and incentivization are important for ensuring the sustainability of CBSVs in the provision of skin NTD services in Ghana.

Co-infection of HIV in patients with Buruli ulcer disease in Central Ghana.

BACKGROUND: Previous studies have reported that presence and severity of Buruli ulcer (BU) may reflect the underlying immunosuppression in HIV infected individuals by causing increased incidence of multiple, larger and ulcerated lesions. We report cases of BU-HIV coinfection and the accompanying programmatic challenges encountered in central Ghana. METHODS: Patients with PCR confirmed BU in central Ghana who were HIV positive were identified and their BU01 forms were retrieved and reviewed in further detail. A combined 16S rRNA reverse transcriptase / IS2404 qPCR assay was used to assess the Mycobacterium ulcerans load. The characteristics of coinfected patients (BU+HIV+) were compared with a group of matched controls. RESULTS: The prevalence of HIV in this BU cohort was 2.4% (compared to national HIV prevalence of 1.7%). Eight of 9 BU+HIV+ patients had a single lesion and ulcers were the most common lesion type. The lesions presented were predominantly category II (5/9) followed by category I lesions. The median (IQR) time to healing was 14 (8-28) weeks in the BU+HIV+ compared to 28 (12-33) weeks in the control BU+HIV- group (p = 0.360). Only one BU+HIV+ developed a paradoxical reaction at week 16 but the lesion healed completely at week 20. The median bacterial load (16SrRNA) of BU+HIV+ patients was 750 copies /ml (95% CI 0-398,000) versus 500 copies/ml (95% CI 0-126,855,500) in BU+HIV- group. Similarly, the median count using the IS2404 assay was 500 copies/ml (95% CI 0-500) for BU+HIV+ patients versus 500 copies/ml (95% CI 500-31,000) for BU+HIV- patients. BU+HIV- patients mounted a significantly higher interferon-γ response compared to the BU+HIV+ co-infected patients with respective median (range) responses of [1687(81.11-4399) pg/ml] versus [137.5(4.436-1406) pg/ml, p = 0.03]. There were challenges with the integration of HIV and BU care in this cohort. CONCLUSION: The prevalence of HIV in the BU+ infected population was not significantly increased when compared to the prevalence of HIV in the general population. There was no clear relationship between BU lesion severity and HIV viral load or CD4 counts. Efforts should be made to encourage the integration of care of patients with BU-HIV coinfection.

Seropositivity and associated intrinsic and extrinsic factors for Rift Valley fever virus occurrence in pastoral herds of Nigeria: a cross sectional survey.

BACKGROUND: Rift Valley fever (RVF) is a vector-borne emerging zoonotic disease of animals and humans, characterized by socioeconomic losses to livestock farmers and global public health threat. The study determined RVFV seroprevalence in cattle, assessed pastoralists' knowledge about RVF, and factors that influence its occurrence in pastoral cattle herds of Nigeria. A cross-sectional study was conducted in pastoral herds of North-central Nigeria from 2017 to 2018. Data were collected using serology and questionnaire tools. Descriptive statistics were used to analyze the obtained data. Categorical variables were presented as proportions and their associations determined by Chi-square tests. Associations of risk factors were analyzed by univariable and multivariable logistic regressions analyses at 95% confidence level. RESULTS: The overall IgM seropositivity of RVFV in pastoral cattle herds was 5.6%. This was higher in nomadic herds (7.4%) than in agro-pastoral herds (3.8%). All animal demographic characteristics of age, sex and breeds were not significantly (p > 0.05) associated with RVFV occurrence in pastoral herds. All the 403 pastoralists selected participated in the study, with the majorities of them being male, married and have no formal education. Majority of the pastoralists had low knowledge levels about zoonotic RVFV infection. All identified socio-ecological factors significantly (p < 0.05) influenced RVFV occurrence in herds. Mosquitoes availability in cattle environment (OR = 7.81; 95% CI: 4.85, 12.37), presence of rivers and streams at grazing fields (OR = 10.80; 95% CI: 6.77, 17.34), high rainfall (OR = 4.30; 95% CI: 2.74, 6.59), irrigated rice fields (OR = 5.14; 95% CI: 3.21, 7.79), bushy vegetation (OR = 6.11; 95% CI: 3.96, 9.43), animal movement (OR = 2.2; 95% CI: 1.45, 3.25), and seasons (OR = 2.34; 95% CI: 1.55, 3.51) were more likely to influenced RVFV occurrence in cattle herds. CONCLUSIONS: Results of this study had illustrated recent circulation of RVFV in pastoral cattle herds in Nigeria and needs urgent interventions. The surveyed pastoralists had low knowledge level about RVF while the socio-ecological factors significantly influenced RVFV occurrence in herds. To address these gaps, pastoralists should be educated on clinical manifestations and modes of transmission of the disease in animals and humans, and mitigation measures. Adequate knowledge about RVF epidemiology will assure food security and public health.

Environmental, economic and socio-cultural risk factors of recurrent seasonal epidemics of cerebrospinal meningitis in Kebbi state, northwestern Nigeria: a qualitative approach.

BACKGROUND: Kebbi State remains the epicentre of the seasonal epidemic meningitis in northwestern Nigeria despite interventions. In this setting, no previous study has been conducted to understand the risk factors of the recurrent meningitis epidemics using qualitative approach. Consequently, this study intends to explore and better understand the environmental, economic and socio-cultural factors of recurrent seasonal epidemic meninigitis using a qualitative approach. METHODS: We conducted in-depth interview (40 IDIs) and focus group discussions (6 FGDs) in two local government areas (LGAs) in Kebbi State, Northwestern Nigeria to understand the environmental, economic and socio-cultural factors of recurrent meningitis outbreaks. Routine surveillance data were used to guide the selection of settlements, wards and local government areas based on the frequency of re-occurrences and magnitude of the outbreaks. RESULTS: The discussions revealed certain elements capable of potentiating the recurrence of seasonal meningitis epidemics. These are environmental issues, such as poorly-designed built environment, crowded sleeping and poorly ventilated rooms, dry and dusty weather condition. Other elements were economic challenges, such as poor household living conditions, neighbourhood deprivation, and socio-cultural elements, such as poor healthcare seeking behaviour, social mixing patterns, inadequate vaccination and vaccine hesitancy. CONCLUSION: As suggested by participants, there are potential environmental, socio-cultural and economic factors in the study area that might have been driving recurrent epidemics of cerebrospinal meningitis. In a bid to addressing this perennial challenge, governments at various levels supported by health development partners such as the World Health Organisation (WHO), United Nation Habitat, and United National Development Programme can use the findings of this study to design policies and programmes targeting these factors towards complementing other preventive and control strategies.

Targeting the last polio sanctuaries with Directly Observed Oral Polio Vaccination (DOPV) in northern Nigeria, (2014-2016).

BACKGROUND: The declaration of poliomyelitis eradication as a programmatic emergency for global public health by the 65th World Health Assembly in 2012 necessitated innovations and strategies to achieve results. Review of the confirmed polio cases in 2013 showed that most of the cases were from non-compliant households, where parents connived with vaccinators to finger mark the children without actually vaccinating the children with oral polio vaccine or children were absent from home at the time of the visit of vaccinators. METHODS: We used pre-post design to quantify the outcomes of directly observed vaccination in 90 local government areas from 12 northern Nigeria states at very high risk of polio transmission. The strategy is an intervention, vaccinating children under the direct supervision of an independent supervisor to ensure compliance. Attractive incentives (pluses) were used to make parents willingly submit their children for vaccination or directly attract children to the vaccination teams or post as part of this strategy. RESULTS: There was a steady increase in population immunity in all the 90 DOPV implementing LGAs since the introduction of DOPV in 2013. The number of states in which > 90% of children received > 4 OPV doses increased from 7 in 2013 to 11 states by July 2016. Yobe state reported the highest proportional increase from 75 to 99% by July 2016 (22% increase), while Kano state reported 17% increase, from 82 to 99% by July 2016. CONCLUSION: Directly observed polio vaccination strategy improved uptake of polio vaccines and population immunity in high-risk areas for polio transmission.

Expanding polio surveillance reach beyond vaccination reach in Borno State, Nigeria: The contribution of community informants from insecure areas engaged to conduct polio surveillance in security compromised areas, 2018-2019.

INTRODUCTION: Borno state in north-eastern Nigeria is the epicentre of the >10 years' insurgency activities that have affected the region since 2009, resulting in the destruction of health facilities, killing of health workers, massive population displacement and lack of access to populations to provide health services. This article demonstrates how the involvement of community informants from insecure areas (CIIA) to conduct polio surveillance in security-challenged settlements of Borno state contributed to the expansion of polio surveillance reach beyond polio vaccination reach. METHOD: In each of the 19 security compromised Local Government areas (LGAs) with community informants from insecure areas, Android phones enabled with Vaccination Tracking System (VTS) technology and Open Data Kit (ODK) mobile application were provided to capture geo-coordinates as evidence (geo evidence) for polio surveillance activity conducted. These geo evidence captured were uploaded and mapped to show insecure settlements reached with polio surveillance and those yet to be reached. RESULTS: A total of 3183 security compromised settlements were reached for polio surveillance between March 2018 and October 2019 with valid geo evidence, 542 of these security-compromised settlements had not been previously reached by any other intervention for polio surveillance or polio vaccination. CONCLUSION: The capturing of geo-coordinates as a proxy indicator of polio surveillance activity conducted by informants provided significant evidence of settlements reached for sustained polio surveillance even when a case of Acute Flaccid Paralysis (AFP) had not been reported from these settlements. Using the geo evidence captured by CIIA in insecure settlements, we have demonstrated the expansion of polio surveillance reach beyond polio vaccination reach in Borno state.

Antimicrobial usage and associated residues and resistance emergence in smallholder beef cattle production systems in Nigeria: A One Health challenge.

Livestock intensification has facilitated antimicrobial use (AMU) with consequent antimicrobial resistance (AMR) development. We assessed AMU in beef farms, pathways for residues and resistance dissemination to humans, risk status, residues identification, and drivers for antimicrobial residues and resistance emergence in beef cattle production systems. A cross-sectional survey was conducted in randomly selected beef farms of Northern Nigeria, between 2018 and 2019. Traffic Light model and Disc Diffusion Test were used to assess risk status and determined residues, respectively. Data was analyzed using descriptive statistics and logistic regression models at 95% confidence level. About 92% (n = 608) farmers participated. The majority of farmers managing intensive (78.9%) and semi-intensive (76.6%) farms did not follow antimicrobial dosage instructions. Also, 72.4% and 83.9% of the farmers on intensive and semi-intensive systems, respectively, did not observed withdrawal periods after AMU. Furthermore, 71.5% farmers in intensive and 53.2% in semi-intensive farms used antimicrobials as growth promoters. Antimicrobials frequently used include tetracyclines, sulfonamides and penicillin. Antimicrobial residues and resistance dissemination pathways from beef herds were: consumption of contaminated meat with residues (p = 0.007); contacts with contaminated cattle and fomites (p < 0.001); and contaminated manure and aerosols in farm environment (p = 0.003). Significant drivers of residues and resistance emergence were antimicrobial misuse and overuse (OR = 2.72; 95% CI:1.93-3.83), non-enforcement of laws (OR = 2.98; 95% CI:2.11-4.21), poor education and expertise (OR = 1.52; 95% CI:1.09-2.12), and husbandry management system (OR = 10.24; 95% CI:6.75-15.54). The majority of intensive (63.6%) and semi-intensive (57.63%) farm systems belonged to Class 3 (Red risk) status. Antimicrobial residues were detected in 48.4% intensively and 34.4% semi-intensively managed farms. The study revealed poor practices of AMU in beef cattle production. Many factors were found to influenced antimicrobial residues and resistance occurrence and dissemination. A 'One Health' approach mitigation with adequate sanitation, hygiene, and good biosecurity measures will assure food safety, public and environmental health.

Historical reconstruction of inaccessibility status in Local Government Areas (LGAs) of Borno and Yobe States, Nigeria, 2010-2020.

Introduction: ultimately detected in 2016, wild poliovirus (WPV) transmission continued undetected after 2011 in Northeast Nigeria Borno and Yobe States in security-compromised areas, inaccessible due to armed insurgency. Varying inaccessibility prevented children aged <5 years in these areas from polio vaccination interventions and surveillance, while massive population displacements occurred. We examined progress in access over time to provide data supporting a very low probability of undetected WPV circulation within remaining trapped populations after 2016. Methods: to assess the extent of inaccessibility in security-compromised areas, we obtained empirical historical data in 2020 on a quarterly and annual basis from relevant polio eradication staff for the period 2010-2020. The extent of access to areas for immunization by recall was compared to geospatial data from vaccinator tracking. Population estimates over time in security-compromised areas were extracted from satellite imagery. We compared the historical access data from staff with tracking and population esimates. Results: access varied during 2010-2020, with inaccessibility peaking during 2014-2016. We observed concurrent patterns between historical recalled data on inaccessibility and contemporaneous satellite imagery on population displacements, which increased confidence in the quality of recalled data. Conclusion: staff-recalled access was consistent with vaccinator tracking and satellite imagery of population displacments. Despite variability in inaccessibility over time, innovative immunization initiatives were implemented as access allowed and surveillance initiatives were initiated to search for poliovirus transmission. Along with escape and liberation of residents by the military in some geographic areas, these initiatives resulted in a massive reduction in the size of the unvaccinated population remaining resident.

Determinants of mortality among hospitalized patients with COVID-19 during first and second waves of the pandemic: A retrospective cohort study from an isolation center in Kano, Nigeria.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has emerged as an important cause of morbidity and mortality worldwide. The aim of this study is to identify the clinical predictors of mortality among patients with COVID-19 pneumonia during first and second waves in a treatment center in northwestern Nigeria. METHODS: This was a retrospective cohort study of 195 patients hospitalized with COVID-19 between April 2020 to March 2021 at a designated COVID-19 isolation center in Kano State, Northwest Nigeria. Data were summarized using frequencies and percentages. Unadjusted odds ratios and 95% confidence intervals and p-values were obtained. To determine independent determinants of mortality, we performed a stepwise multivariate logistic regression model. RESULTS: Of 195 patients studied, 21(10.77%) patients died. Males comprised 158 (81.03%) of the study population. In the adjusted stepwise logistic regression analysis, age>64 years (OR = 9.476, 95% CI: 2.181-41.165), second wave of the pandemic (OR = 49.340, 95% CI:6.222-391.247), cardiac complications (OR = 24.984, 95% CI: 3.618-172.508), hypertension (OR = 5.831, 95% CI:1.413-24.065) and lowest systolic blood pressure while on admission greater than or equal to 90mmHg were independent predictors of mortality (OR = 0.111, 95%CI: 0.021-0.581). CONCLUSION: Strategies targeted to prioritize needed care to patients with identified factors that predict mortality might improve patient outcome.

Conducting public health surveillance in areas of armed conflict and restricted population access: a qualitative case study of polio surveillance in conflict-affected areas of Borno State, Nigeria.

This study examined the impact of armed conflict on public health surveillance systems, the limitations of traditional surveillance in this context, and innovative strategies to overcome these limitations. A qualitative case study was conducted to examine the factors affecting the functioning of poliovirus surveillance in conflict-affected areas of Borno state, Nigeria using semi-structured interviews of a purposeful sample of participants. The main inhibitors of surveillance were inaccessibility, the destroyed health infrastructure, and the destroyed communication network. These three challenges created a situation in which the traditional polio surveillance system could not function. Three strategies to overcome these challenges were viewed by respondents as the most impactful. First, local community informants were recruited to conduct surveillance for acute flaccid paralysis in children in the inaccessible areas. Second, the informants engaged in local-level negotiation with the insurgency groups to bring children with paralysis to accessible areas for investigation and sample collection. Third, GIS technology was used to track the places reached for surveillance and vaccination and to estimate the size and location of the inaccessible population. A modified monitoring system tracked tailored indicators including the number of places reached for surveillance and the number of acute flaccid paralysis cases detected and investigated, and utilized GIS technology to map the reach of the program. The surveillance strategies used in Borno were successful in increasing surveillance sensitivity in an area of protracted conflict and inaccessibility. This approach and some of the specific strategies may be useful in other areas of armed conflict.

Risk assessment and preventive health behaviours toward COVID-19 amongst bushmeat handlers in Nigerian wildlife markets: Drivers and One Health challenge.

Over 70% of emerging infectious diseases are zoonotic and 72% of them have wildlife reservoirs with consequent global health impacts. Both SARS-CoV-1 and SARS-CoV-2 emerged certainly through wildlife market routes. We assessed wildlife handlers' zoonotic risk perceptions and preventive health behaviour measures toward COVID-19 during pandemic waves, and its drivers at wildlife markets using Health Belief Model (HBM) constructs. A cross-sectional study was conducted at purposively selected wildlife markets in Nigeria between November 2020 and October 2021. Descriptive, univariate, and multivariable logistic regressions analyses were performed at 95% confidence interval. Of the 600 targeted handlers in 97 wildlife markets, 97.2% (n = 583) participated. Consumers were the majority (65.3%), followed by hunters (18.4) and vendors (16.3%). Only 10.3% hunters, 24.3% vendors and 21.0% consumers associated COVID-19 with high zoonotic risk. Also, only few handlers practiced social/physical distancing at markets. Avoidance of handshaking or hugging and vaccination was significantly (p = 0.001) practiced by few handlers as preventive health behaviours at the markets. All the socio-demographic variables were significantly (p<0.05) associated with their knowledge, risk perceptions, and practice of preventive health behaviours toward COVID-19 at univariate analysis. Poor markets sanitation, hygiene, and biosecurity (OR=3.35, 95% CI: 2.33, 4.82); and poor butchering practices and exchange of wildlife species between shops [(OR=1.87; 95% CI: 1.34, 2.60) and (OR=2.03; 95% CI: 1.43, 2.88), respectively] were more likely to significantly influence COVID-19 emergence and spread at the markets. To tackle the highlighted gaps, collaborations between the public health, anthropologists, and veterinary and wildlife authorities through the One Health approach are advocated to intensify awareness and health education programmes that will improve perceptions and behaviours toward the disease and other emerging diseases control and prevention.

Caregiver burden in Buruli ulcer disease: Evidence from Ghana.

BACKGROUND: Buruli ulcer disease (BUD) results in disabilities and deformities in the absence of early medical intervention. The extensive role of caregiving in BUD is widely acknowledged, however, associated caregiver burden is poorly understood. In this paper we assessed the burden which caregivers experience when supporting patients with BUD in Ghana. METHOD/ PRINCIPAL FINDINGS: This qualitative study was conducted in 3 districts in Ghana between August and October 2019. 13 semi-structured interviews were conducted on caregivers of BUD patients in the local language of Twi. Data was translated into English, coded into broad themes, and direct content analysis approach was used to analyse results. The results show the caregivers face financial, psychological and health issues as a consequence of their caregiving role. CONCLUSION/ SIGNIFICANCE: This study found significant caregiver burden on family members. It also highlighted the psychological burden caregivers experience and the limited knowledge of the disease within endemic communities. Further research is needed to quantify the caregiver burden of BUD at different economic levels in order to better understand the impact of possible caregiver interventions on patient outcomes.

Mental health and quality of life burden in Buruli ulcer disease patients in Ghana.

BACKGROUND: Buruli ulcer disease (BUD) is a necrotic skin neglected tropical disease (NTD) that has both a mental and physical health impact on affected individuals. Although there is increasing evidence suggesting a strong association between neglected tropical diseases (NTDs) and mental illness, there is a relative lack of information on BUD's impact on the mental health and quality of life (QoL) of affected individuals in Ghana. This study is to assess the impact of BUD on mental health and quality of life of patients with active and past BUD infection, and their caregivers. METHODS: We conducted a case control study in 3 BUD endemic districts in Ghana between August and November 2019. Face-to-face structured questionnaire-based interviews were conducted on BUD patients with active and past infection, as well as caregivers of BUD patients using WHO Quality of Life scale, WHO Disability Assessment Schedule, Self-Reporting Questionnaire, Buruli Ulcer Functional Limitation Score and Hospital Anxiety and Depression Scale data tools. Descriptive statistics were used to summarize the characteristics of the study participants. Participant groups were compared using student t test and chi-square (χ2) or Fisher's exact tests. Mean quality of life scores are reported with their respective 95% confidence intervals. Data was analysed using STATA statistical software. RESULTS: Our results show that BUD patients with active and past infection, along with their caregivers, face significant levels of distress and mental health sequelae compared to controls. Depression (P = 0.003) was more common in participants with active (27%) and past BU infection (17%), compared to controls (0%). Anxiety was found in 42% (11/26) and 20% (6/29) of participants with active and past BUD infection compared to 14% (5/36) of controls. Quality of life was also significantly diminished in active BUD infection, compared to controls. In the physical health domain, mean QoL scores were 54 ± 11.1 and 56 ± 11.0 (95% CI: 49.5‒58.5 and 52.2‒59.7) respectively for participants with active infection and controls. Similarly in the psychological domain, scores were lower for active infection than controls [57.1 ± 15.2 (95% CI: 50.9‒63.2) vs 64.7 ± 11.6 (95% CI: 60.8‒68.6)]. Participants with past infection had high QoL scores in both physical [61.3 ± 13.5 (95% CI: 56.1‒66.5)] and psychological health domains [68.4 ± 14.6 (95% CI: 62.7‒74.0)]. CONCLUSIONS: BUD is associated with significant mental health distress and reduced quality of life in affected persons and their caregivers in Ghana. There is a need for integration of psychosocial interventions in the management of the disease.