Enablers and barriers to implementing cholera interventions in Nigeria: a community-based system dynamics approach.

Nigeria accounts for a substantial cholera burden globally, particularly in its northeast region, where insurgency is persistent and widespread. We used participatory group model building (GMB) workshops to explore enablers and barriers to implementing known cholera interventions, including water, sanitation, and hygiene (WASH), surveillance and laboratory, case management, community engagement, oral cholera vaccine, and leadership and coordination, as well as explore leverage points for interventions and collaboration. The study engaged key cholera stakeholders in the northeastern states of Adamawa and Bauchi, as well as national stakeholders in Abuja. Adamawa and Bauchi States' GMB participants comprised 49 community members and 43 healthcare providers, while the 23 national participants comprised government ministry, department and agency staff, and development partners. Data were analysed thematically and validated via consultation with selected participants. The study identified four overarching themes regarding the enablers and barriers to implementing cholera interventions: (1) political will, (2) health system resources and structures, (3) community trust and culture, and (4) spill-over effect of COVID-19. Specifically, inadequate political will exerts its effect directly (e.g., limited funding for prepositioning essential cholera supplies) or indirectly (e.g., overlapping policies) on implementing cholera interventions. The healthcare system structure (e.g., centralisation of cholera management in a state capital) and limited surveillance tools weaken the capacity to implement cholera interventions. Community trust emerges as integral to strengthening the healthcare system's resilience in mitigating the impacts of cholera outbreaks. Lastly, the spill-over effects of COVID-19 helped promote interventions similar to cholera (e.g., WASH) and directly enhanced political will. In conclusion, the study offers insights into the complex barriers and enablers to implementing cholera interventions in Nigeria's cholera-endemic settings. Strong political commitment, strengthening the healthcare system, building community trust, and an effective public health system can enhance the implementation of cholera interventions in Nigeria.

Healthcare workers knowledge of cholera multi-stranded interventions and its determining factors in North-East Nigeria: planning and policy implications.

BACKGROUND: Healthcare workers' (HCWs) knowledge of multi-stranded cholera interventions (including case management, water, sanitation, and hygiene (WASH), surveillance/laboratory methods, coordination, and vaccination) is crucial to the implementation of these interventions in healthcare facilities, especially in conflict-affected settings where cholera burden is particularly high. We aimed to assess Nigerian HCWs' knowledge of cholera interventions and identify the associated factors. METHODS: We conducted a cross-sectional study using a structured interviewer-administered questionnaire with HCWs from 120 healthcare facilities in Adamawa and Bauchi States, North-East Nigeria. A knowledge score was created by assigning a point for each correct response. HCWs' knowledge of cholera interventions, calculated as a score, was recoded for ease of interpretation as follows: 0-50 (low); 51-70 (moderate); ≥ 71 (high). Additionally, we defined the inadequacy of HCWs' knowledge of cholera interventions based on a policy-relevant threshold of equal or lesser than 75 scores for an intervention. Multivariable logistic regression was used to identify the factors associated with the adequacy of knowledge score. RESULTS: Overall, 490 HCWs participated in the study (254 in Adamawa and 236 in Bauchi), with a mean age of 35.5 years. HCWs' knowledge score was high for surveillance/laboratory methods, moderate for case management, WASH, and vaccination, and low for coordination. HCWs' knowledge of coordination improved with higher cadre, working in urban- or peri-urban-based healthcare facilities, and secondary education; cholera case management and vaccination knowledge improved with post-secondary education, working in Bauchi State and urban areas, previous training in cholera case management and response to a cholera outbreak-working in peri-urban areas had a negative effect. HCWs' knowledge of surveillance/laboratory methods improved with a higher cadre, 1-year duration in current position, secondary or post-secondary education, previous training in cholera case management and response to a cholera outbreak. However, HCWs' current position had both positive and negative impacts on their WASH knowledge. CONCLUSIONS: HCWs in both study locations recorded a considerable knowledge of multi-stranded cholera interventions. While HCWs' demographic characteristics appeared irrelevant in determining their knowledge of cholera interventions, geographic location and experiences from the current position, training and involvement in cholera outbreak response played a significant role.

Community-Based Surveillance: Knowledge and skills of Community Health Workers in epidemics setting in Ganjuwa LGA, Nigeria.

INTRODUCTION: Community-based surveillance (CBS) is essential for early detection and prompt response to epidemic-prone diseases (EPD). Community Health Workers (CHWs), trained in basic healthcare services, can play a vital role in this process. Like many Local government Areas (LGA) in Nigeria, between January and September 2023, Ganjuwa LGA in Bauchi state was facing a simultaneous outbreak of measles, pertussis, Diphtheria, and Lassa Fever. METHODS: Descriptive cross-sectional study among the CHWs in the Ganjuwa LGA to assess their knowledge and skills in CBS of EPD by using a questionnaire. Exhaustive sampling of CHWs implicated in CBS in Ganjuwa LGA and who gave verbal consent were included. Stata 16.0 software was used for analysis. The final score of knowledge of CHWs on CBS was calculated with the rate of the total best answers given by the CHWs based on five questions fixed. RESULTS: The study enrolled 71 CHWs with a majority being male (61.97%) and an average age of 27 years. The education level of the CHWs varied, with 61.97% having completed secondary school, 29.58% having a university education, and 8.45% having completed primary school. In terms of experience, the majority of CHWs had 1 year of experience (73.24%), followed by 2 years (15.49%). The findings revealed that only a small percentage of CHWs (23.94%) recognized that Ganjuwa LGA was affected by four outbreaks, and 35.21% were aware that EPD could be transmitted through various means in communities. The overall knowledge score of the CHWs was relatively low, with a mean score of 0.4 (ranging from 0 to 1). Most CHWs had a score of 0.2, while only 5.63% achieved a score of 1. On the positive side, a significant majority of CHWs felt comfortable conducting home visits to identify suspected cases of EPD (76.06%) and expressed confidence in their ability to educate community members about disease surveillance and reporting (71.83%). Additionally, a majority of CHWs were familiar with the process of collecting and recording data related to EPD at the community level (64.79%). Most CHWs also expressed willingness to undergo additional training to improve their knowledge and skills in CBS (64.79%) and reported working well with local health facilities and authorities for information sharing and collaboration on disease surveillance efforts (73.24%). CONCLUSION: Overall, these findings highlight both strengths and areas for improvement in the knowledge, skills, and attitudes of CHWs regarding disease surveillance and reporting in the community. Targeted training interventions can help address the gaps identified and further enhance the effectiveness of CHWs in their roles.

Epidemiology, diagnostics and factors associated with mortality during a cholera epidemic in Nigeria, October 2020-October 2021: a retrospective analysis of national surveillance data.

OBJECTIVES: Nigeria reported an upsurge in cholera cases in October 2020, which then transitioned into a large, disseminated epidemic for most of 2021. This study aimed to describe the epidemiology, diagnostic performance of rapid diagnostic test (RDT) kits and the factors associated with mortality during the epidemic. DESIGN: A retrospective analysis of national surveillance data. SETTING: 33 of 37 states (including the Federal Capital Territory) in Nigeria. PARTICIPANTS: Persons who met cholera case definition (a person of any age with acute watery diarrhoea, with or without vomiting) between October 2020 and October 2021 within the Nigeria Centre for Disease Control surveillance data. OUTCOME MEASURES: Attack rate (AR; per 100 000 persons), case fatality rate (CFR; %) and accuracy of RDT performance compared with culture using area under the receiver operating characteristic curve (AUROC). Additionally, individual factors associated with cholera deaths and hospitalisation were presented as adjusted OR with 95% CIs. RESULTS: Overall, 93 598 cholera cases and 3298 deaths (CFR: 3.5%) were reported across 33 of 37 states in Nigeria within the study period. The proportions of cholera cases were higher in men aged 5-14 years and women aged 25-44 years. The overall AR was 46.5 per 100 000 persons. The North-West region recorded the highest AR with 102 per 100 000. Older age, male gender, residency in the North-Central region and severe dehydration significantly increased the odds of cholera deaths. The cholera RDT had excellent diagnostic accuracy (AUROC=0.91; 95% CI 0.87 to 0.96). CONCLUSIONS: Cholera remains a serious public health threat in Nigeria with a high mortality rate. Thus, we recommend making RDT kits more widely accessible for improved surveillance and prompt case management across the country.