Epidemiology of physical inactivity in Nigeria: a systematic review and meta-analysis.

BACKGROUND: Physical activity is crucial to preventing noncommunicable diseases. This study aimed to provide up-to-date evidence on the epidemiology of insufficient physical activity across Nigeria to increase awareness and prompt relevant policy and public health response. METHODS: A systematic literature search of community-based studies on physical inactivity was conducted. We constructed a meta-regression epidemiologic model to determine the age-adjusted prevalence and number of physically inactive persons in Nigeria for 1995 and 2020. RESULTS: Fifteen studies covering a population of 13 814 adults met our selection criteria. The pooled crude prevalence of physically inactive persons in Nigeria was 52.0% (95% CI: 33.7-70.4), with prevalence in women higher at 55.8% (95% CI: 29.4-82.3) compared to men at 49.3% (95% CI: 24.7-73.9). Across settings, prevalence of physically inactive persons was significantly higher among urban dwellers (56.8%, 35.3-78.4) compared to rural dwellers (18.9%, 11.9-49.8). Among persons aged 20-79 years, the total number of physically inactive persons increased from 14.4 million to 48.6 million between 1995 and 2020, equivalent to a 240% increase over the 25-year period. CONCLUSIONS: A comprehensive and robust strategy that addresses occupational policies, town planning, awareness and information, and sociocultural and contextual issues is crucial to improving physical activity levels in Nigeria.

Electronic reporting of integrated disease surveillance and response: lessons learned from northeast, Nigeria, 2019.

BACKGROUND: Electronic reporting of integrated disease surveillance and response (eIDSR) was implemented in Adamawa and Yobe states, Northeastern Nigeria, as an innovative strategy to improve disease reporting. Its objectives were to improve the timeliness and completeness of IDSR reporting by health facilities, prompt identification of public health events, timely information sharing, and public health action. We evaluated the project to determine whether it met its set objectives. METHOD: We conducted a cross-sectional study to assess and document the lessons learned from the project. We reviewed the performance of the local government areas (LGAs) on timeliness and completeness of reporting, rumors identification, and reporting on the eIDSR and the traditional paper-based system using a checklist. Respondents were interviewed online on the relevance, efficiency, sustainability, project progress and effectiveness, the effectiveness of management, and potential impact and scalability of the strategy using structured questionnaires. Data were cleaned, analyzed, and presented as proportions using an MS Excel spreadsheet. Responses were also presented as direct quotes. RESULTS: The number of health facilities reporting IDSR increased from 103 to 228 (117%) before and after implementation of the eIDSR respectively. The timeliness of reporting was 43% in the LGA compared to 73% in health facilities implementing eIDSR. The completeness of IDSR reports in the last 6 months before the evaluation was ≥85%. Of the 201 rumors identified and verified, 161 (80%) were from the eIDSR pilot sites. The majority of the stakeholders interviewed believed that eIDSR met its predetermined objectives for public health surveillance. The benefits of eIDSR included timely reporting and response to alerts and disease outbreaks, improved timeliness, and completeness of reporting, and supportive supervision to the operational levels. The strategy helped stakeholders to appreciate their roles in public health surveillance. CONCLUSION: The eIDSR has increased the number of health facilities reporting IDSR, enabled early identification, reporting, and verification of alerts, improved timeliness and completeness of reports, and supportive supervision of staff at the operational levels. It was well accepted by the stakeholder as a system that made reporting easy with the potential to improve the public health surveillance system in Nigeria.

Estimating the prevalence of overweight and obesity in Nigeria in 2020: a systematic review and meta-analysis.

BACKGROUND: Targeted public health response to obesity in Nigeria is relatively low due to limited epidemiologic understanding. We aimed to estimate nationwide and sub-national prevalence of overweight and obesity in the adult Nigerian population. METHODS: MEDLINE, EMBASE, Global Health, and Africa Journals Online were systematically searched for relevant epidemiologic studies in Nigeria published on or after 01 January 1990. We assessed quality of studies and conducted a random-effects meta-analysis on extracted crude prevalence rates. Using a meta-regression model, we estimated the number of overweight and obese persons in Nigeria in the year 2020. RESULTS: From 35 studies (n = 52,816), the pooled crude prevalence rates of overweight and obesity in Nigeria were 25.0% (95% confidence interval, CI: 20.4-29.6) and 14.3% (95% CI: 12.0-15.5), respectively. The prevalence in women was higher compared to men at 25.5% (95% CI: 17.1-34.0) versus 25.2% (95% CI: 18.0-32.4) for overweight, and 19.8% (95% CI: 3.9-25.6) versus 12.9% (95% CI: 9.1-16.7) for obesity, respectively. The pooled mean body mass index (BMI) and waist circumference were 25.6 kg/m2 and 86.5 cm, respectively. We estimated that there were 21 million and 12 million overweight and obese persons in the Nigerian population aged 15 years or more in 2020, accounting for an age-adjusted prevalence of 20.3% and 11.6%, respectively. The prevalence rates of overweight and obesity were consistently higher among urban dwellers (27.2% and 14.4%) compared to rural dwellers (16.4% and 12.1%). CONCLUSIONS: Our findings suggest a high prevalence of overweight and obesity in Nigeria. This is marked in urban Nigeria and among women, which may in part be due to widespread sedentary lifestyles and a surge in processed food outlets, largely reflective of a trend across many African settings.KEY MESSAGESAbout 12 million persons in Nigeria were estimated to be obese in 2020, with prevalence considerably higher among women. Nutritional and epidemiological transitions driven by demographic changes, rising income, urbanization, unhealthy lifestyles, and consumption of highly processed diets appear to be driving an obesity epidemic in the country.

Prevalence, awareness, treatment, and control of hypertension in Nigeria in 1995 and 2020: A systematic analysis of current evidence.

Improved understanding of the current burden of hypertension, including awareness, treatment, and control, is needed to guide relevant preventative measures in Nigeria. A systematic search of studies on the epidemiology of hypertension in Nigeria, published on or after January 1990, was conducted. The authors employed random-effects meta-analysis on extracted crude hypertension prevalence, and awareness, treatment, and control rates. Using a meta-regression model, overall hypertension cases in Nigeria in 1995 and 2020 were estimated. Fifty-three studies (n = 78 949) met our selection criteria. Estimated crude prevalence of pre-hypertension (120-139/80-89 mmHg) in Nigeria was 30.9% (95% confidence interval [CI]: 22.0%-39.7%), and the crude prevalence of hypertension (≥140/90 mmHg) was 30.6% (95% CI: 27.3%-34.0%). When adjusted for age, study period, and sample, absolute cases of hypertension increased by 540% among individuals aged ≥20 years from approximately 4.3 million individuals in 1995 (age-adjusted prevalence 8.6%, 95% CI: 6.5-10.7) to 27.5 million individuals with hypertension in 2020 (age-adjusted prevalence 32.5%, 95% CI: 29.8-35.3). The age-adjusted prevalence was only significantly higher among men in 1995, with the gap between both sexes considerably narrowed in 2020. Only 29.0% of cases (95% CI: 19.7-38.3) were aware of their hypertension, 12.0% (95% CI: 2.7-21.2) were on treatment, and 2.8% (95% CI: 0.1-5.7) had at-goal blood pressure in 2020. Our study suggests that hypertension prevalence has substantially increased in Nigeria over the last two decades. Although more persons are aware of their hypertension status, clinical treatment and control rates, however, remain low. These estimates are relevant for clinical care, population, and policy response in Nigeria and across Africa.

The reactive vaccination campaign against cholera emergency in camps for internally displaced persons, Borno, Nigeria, 2017: a two-stage cluster survey.

INTRODUCTION: In 2017, amidst insecurity and displacements posed by Boko Haram armed insurgency, cholera outbreak started in the Muna Garage camp for Internally Displaced Persons (IDPs) in Borno State, Nigeria. In response, the Borno Ministry of Health and partners determined to provide oral cholera vaccine (OCV) to about 1 million people in IDP camps and surrounding communities in six Local Government Areas (LGAs) including Maiduguri, Jere, Konduga, Mafa, Dikwa, and Monguno. As part of Monitoring and Evaluation, we described the coverage achieved, adverse events following immunisation (AEFI), non-vaccination reasons, vaccination decisions as well as campaign information sources. METHODS: We conducted two-stage probability cluster surveys with clusters selected without replacement according to probability-proportionate-to-population-size in the six LGAs targeted by the campaign. Individuals aged ≥1 years were the eligible study population. Data sources were household interviews with vaccine card verification and memory recall, if no card, as well as multiple choice questions with an open-ended option. RESULTS: Overall, 12 931 respondents participated in the survey. Overall, 90% (95% CI: 88 to 92) of the target population received at least one dose of OCV, range 87% (95% CI: 75 to 94) in Maiduguri to 94% (95% CI: 88 to 97) in Monguno. The weighted two-dose coverage was 73% (95% CI: 68 to 77) with a low of 68% (95% CI: 46 to 86) in Maiduguri to a high of 87% (95% CI: 74 to 95) in Dikwa. The coverage was lower during first round (76%, 95% CI: 71 to 80) than second round (87%, 95% CI: 84 to 89) and ranged from 72% (95% CI: 42 to 89) and 82% (95% CI: 82 to 91) in Maiduguri to 87% (95% CI: 75 to 95) and 94% (95% CI: 88 to 97) in Dikwa for the respective first and second rounds. Also, coverage was higher among females of age 5 to 14 and ≥15 years than males of same age groups. There were mild AEFI with the most common symptoms being fever, headache and diarrhoea occurring up to 48 hours after ingesting the vaccine. The most common actions taken after AEFI symptoms included 'did nothing' and 'self-medicated at home'. The top reason for taking vaccine was to protect from cholera while top reason for non-vaccination was travel/work. The main source of campaign information was a neighbour. An overwhelming majority (96%, 95% CI: 95% to 98%) felt the campaign team treated them with respect. While 43% (95% CI: 36% to 50%) asked no questions, 37% (95% CI: 31% to 44%) felt the team addressed all their concerns. CONCLUSION: The campaign achieved high coverage using door-to-door and fixed sites strategies amidst insecurity posed by Boko Haram. Additional studies are needed to improve how to reduce non-vaccination, especially for the first round. While OCV provides protection for a few years, additional actions will be needed to make investments in water, sanitation and hygiene infrastructure.

A rapid assessment of the implementation of integrated disease surveillance and response system in Northeast Nigeria, 2017.

BACKGROUND: Integrated disease surveillance and response (IDSR) is the strategy adopted for public health surveillance in Nigeria. IDSR has been operational in Nigeria since 2001 but the functionality varies from state to state. The outbreaks of cerebrospinal meningitis and cholera in 2017 indicated weakness in the functionality of the system. A rapid assessment of the IDSR was conducted in three northeastern states to identify and address gaps to strengthen the system. METHOD: The survey was conducted at the state and local government areas using standard IDSR assessment tools which were adapted to the Nigerian context. Checklists were used to extract data from reports and records on resources and tools for implementation of IDSR. Questionnaires were used to interview respondents on their capacities to implement IDSR. Quantitative data were entered into an MS Excel spreadsheet, analysed and presented in proportions. Qualitative data were summarised and reported by thematic area. RESULTS: A total of 34 respondents participated in the rapid survey from six health facilities and six local government areas (LGAs). Of the 2598 health facilities in the three states, only 606 (23%) were involved in reporting IDSR. The standard case definitions were available in all state and LGA offices and health facilities visited. Only 41 (63%) and 31 (47.7%) of the LGAs in the three states had rapid response teams and epidemic preparedness and response committees respectively. The Disease Surveillance and Notification Officers (DSNOs) and clinicians' knowledge were limited to only timeliness and completeness among over 10 core indicators for IDSR. Review of the facility registers revealed many missing variables; the commonly missed variables were patients' age, sex, diagnosis and laboratory results. CONCLUSIONS: The major gaps were poor documentation of patients' data in the facility registers, inadequate reporting tools, limited participation of health facilities in IDSR and limited capacities of personnel to identify, report IDSR priority diseases, analyze and interpret IDSR data for decision making. Training of surveillance focal persons, provision of IDSR reporting tools and effective supportive supervisions will strengthen the system in the country.

What are the drivers of recurrent cholera transmission in Nigeria? Evidence from a scoping review.

BACKGROUND: The 2018 cholera outbreak in Nigeria affected over half of the states in the country, and was characterised by high attack and case fatality rates. The country continues to record cholera cases and related deaths to date. However, there is a dearth of evidence on context-specific drivers and their operational mechanisms in mediating recurrent cholera transmission in Nigeria. This study therefore aimed to fill this important research gap, with a view to informing the design and implementation of appropriate preventive and control measures. METHODS: Four bibliographic literature sources (CINAHL (Plus with full text), Web of Science, Google Scholar and PubMed), and one journal (African Journals Online) were searched to retrieve documents relating to cholera transmission in Nigeria. Titles and abstracts of the identified documents were screened according to a predefined study protocol. Data extraction and bibliometric analysis of all eligible documents were conducted, which was followed by thematic and systematic analyses. RESULTS: Forty-five documents met the inclusion criteria and were included in the final analysis. The majority of the documents were peer-reviewed journal articles (89%) and conducted predominantly in the context of cholera epidemics (64%). The narrative analysis indicates that social, biological, environmental and climatic, health systems, and a combination of two or more factors appear to drive cholera transmission in Nigeria. Regarding operational dynamics, a substantial number of the identified drivers appear to be functionally interdependent of each other. CONCLUSION: The drivers of recurring cholera transmission in Nigeria are diverse but functionally interdependent; thus, underlining the importance of adopting a multi-sectoral approach for cholera prevention and control.

Identifying and quantifying the factors associated with cholera-related death during the 2018 outbreak in Nigeria.

INTRODUCTION: cholera outbreaks in Nigeria are often associated with high case fatality rates; however, there is a dearth of evidence on context-specific factors associated with the trend. This study therefore aimed to identify and quantify the factors associated with cholera-related deaths in Nigeria. METHODS: using a cross-sectional design, we analysed surveillance data from all the States that reported cholera cases during the 2018 outbreak, and defined cholera-related death as death of an individual classified as having cholera according to the Nigeria Centre for Disease Control case definition. Factors associated with cholera-related death were assessed using multivariable logistic regression and findings presented as adjusted odds ratios (ORs) with 95% Confidence Intervals (95% CIs). RESULTS: between January 1 and November 19, 2018, 41,394 cholera cases were reported across 20 States, including 815 cholera-related deaths. In the adjusted multivariable model, older age, male gender, living in peri-urban areas or in flooded states, infection during the rainy season, and delay in seeking health care by >2 days were positively associated with cholera-related death; whereas living in urban areas, hospitalisation in the course of illness, and presentation to a secondary hospital were negatively associated with cholera-related death. CONCLUSION: cholera-related deaths during the 2018 outbreak in Nigeria appeared to be driven by multiple factors, which further reemphasises the importance of adopting a multisectoral approach to the design and implementation of context-specific interventions in Nigeria.

Current prevalence pattern of tobacco smoking in Nigeria: a systematic review and meta-analysis.

BACKGROUND: National smoking cessation strategies in Nigeria are hindered by lack of up-to-date epidemiologic data. We aimed to estimate prevalence of tobacco smoking in Nigeria to guide relevant interventions. METHODS: We conducted systematic search of publicly available evidence from 1990 through 2018. A random-effects meta-analysis and meta-regression epidemiologic model were employed to determine prevalence and number of smokers in Nigeria in 1995 and 2015. RESULTS: Across 64 studies (n = 54,755), the pooled crude prevalence of current smokers in Nigeria was 10.4% (9.0-11.7) and 17.7% (15.2-20.2) for ever smokers. This was higher among men compared to women in both groups. There was considerable variation across geopolitical zones, ranging from 5.4% (North-west) to 32.1% (North-east) for current smokers, and 10.5% (South-east) to 43.6% (North-east) for ever smokers. Urban and rural dwellers had relatively similar rates of current smokers (10.7 and 9.1%), and ever smokers (18.1 and 17.0%). Estimated median age at initiation of smoking was 16.8 years (IQR: 13.5-18.0). From 1995 to 2015, we estimated an increase in number of current smokers from 8 to 11 million (or a decline from 13 to 10.6% of the population). The pooled mean cigarettes consumption per person per day was 10.1 (6.1-14.2), accounting for 110 million cigarettes per day and over 40 billion cigarettes consumed in Nigeria in 2015. CONCLUSIONS: While the prevalence of smokers may be declining in Nigeria, one out of ten Nigerians still smokes daily. There is need for comprehensive measures and strict anti-tobacco laws targeting tobacco production and marketing.

Descriptive epidemiology of cholera outbreak in Nigeria, January-November, 2018: implications for the global roadmap strategy.

BACKGROUND: The cholera outbreak in 2018 in Nigeria reaffirms its public health threat to the country. Evidence on the current epidemiology of cholera required for the design and implementation of appropriate interventions towards attaining the global roadmap strategic goals for cholera elimination however seems lacking. Thus, this study aimed at addressing this gap by describing the epidemiology of the 2018 cholera outbreak in Nigeria. METHODS: This was a retrospective analysis of surveillance data collected between January 1st and November 19th, 2018. A cholera case was defined as an individual aged 2 years or older presenting with acute watery diarrhoea and severe dehydration or dying from acute watery diarrhoea. Descriptive analyses were performed and presented with respect to person, time and place using appropriate statistics. RESULTS: There were 43,996 cholera cases and 836 cholera deaths across 20 states in Nigeria during the outbreak period, with an attack rate (AR) of 127.43/100,000 population and a case fatality rate (CFR) of 1.90%. Individuals aged 15 years or older (47.76%) were the most affected age group, but the proportion of affected males and females was about the same (49.00 and 51.00% respectively). The outbreak was characterised by four distinct epidemic waves, with higher number of deaths recorded in the third and fourth waves. States from the north-west and north-east regions of the country recorded the highest ARs while those from the north-central recorded the highest CFRs. CONCLUSION: The severity and wide-geographical distribution of cholera cases and deaths during the 2018 outbreak are indicative of an elevated burden, which was more notable in the northern region of the country. Overall, the findings reaffirm the strategic role of a multi-sectoral approach in the design and implementation of public health interventions aimed at preventing and controlling cholera in Nigeria.

Integrated Disease Surveillance and Response (IDSR) strategy: current status, challenges and perspectives for the future in Africa.

In 1998, the WHO African region adopted a strategy called Integrated Disease Surveillance and Response (IDSR). Here, we present the current status of IDSR implementation; and provide some future perspectives for enhancing the IDSR strategy in Africa. In 2017, we used two data sources to compile information on the status of IDSR implementation: a pretested rapid assessment questionnaire sent out biannually to all countries and quarterly compilation of data for two IDSR key performance indicators (KPI). The first KPI measures country IDSR performance and the second KPI tracks the number of countries that the WHO secretariat supports to scale up IDSR. The KPI data for 2017 were compared with a retrospective baseline for 2014. By December 2017, 44 of 47 African countries (94%) were implementing IDSR. Of the 44 countries implementing IDSR, 40 (85%) had initiated IDSR training at subnational level; 32 (68%) had commenced community-based surveillance; 35 (74%) had event-based surveillance; 33 (70%) had electronic IDSR; and 32 (68%) had a weekly/monthly bulletin for sharing IDSR data. Thirty-two countries (68%) had achieved the timeliness and completeness threshold of at least 80% of the reporting units. However, only 12 countries (26%) had the desired target of at least 90% IDSR implementation coverage at the peripheral level. After 20 years of implementing IDSR, there are major achievements in the indicator-based surveillance systems. However, major gaps were identified in event-based surveillance. All African countries should enhance IDSR everywhere.

Estimating morbidity due to stroke in Nigeria: a systematic review and meta-analysis.

BACKGROUND: The response to stroke in Nigeria is impaired by inadequate epidemiologic information. We sought to collate available evidence and estimate the incidence of stroke and prevalence of stroke survivors in Nigeria. METHODS: Using random effects meta-analysis, we pooled nationwide and regional incidence and prevalence of stroke from the estimates reported in each study. RESULTS: Eleven studies met our selection criteria. The pooled crude incidence of stroke in Nigeria was 26.0 (12.8-39.0) /100,000 person-years, with this higher among men at 34.1 (9.7-58.4) /100,000, compared to women at 21.2 (7.4-35.0) /100,000. The pooled crude prevalence of stroke survivors in Nigeria was 6.7 (5.8-7.7) /1000 population, with this also higher among men at 6.4 (5.1-7.6) /1000, compared to women at 4.4 (3.4-5.5) /1000. In the period 2000-2009, the incidence of stroke in Nigeria was 24.3 (95% CI: 11.9-36.8) per 100,000, with this increasing to 27.4 (95% CI: 2.2-52.7) per 100,000 from 2010 upwards. The prevalence of stroke survivors increased minimally from 6.0 (95% CI: 4.6-7.5) per 1000 to 7.5 (95% CI: 5.8-9.1) per 1000 over the same period. The prevalence of stroke survivors was highest in the South-south region at 13.4 (9.1-17.8) /100,000 and among rural dwellers at 10.8 (7.5-14.1) /100,000. CONCLUSION: Although study period does not appear to contribute substantially to variations in stroke morbidity in Nigeria, an increasing number of new cases compared to survivors may be due in part to limited door-door surveys, or possibly reflects an increasing mortality from stroke in the country.

Epidemiology of harmful use of alcohol in Nigeria: a systematic review and meta-analysis.

Background: Nigeria, the most populous country in Africa, has reported relatively high levels of alcohol misuse, yet limited resources to guide effective population-wide response. There is a need to integrate existing empirical information in order to increase the power and precision of estimating epidemiological evidence necessary for informing policies and developing prevention programs. Objectives: We aimed to estimate nationwide and zonal prevalence of harmful use of alcohol in Nigeria to inform public health policy and planning. Methods: Epidemiologic reports on alcohol use in Nigeria from 1990 through 2018 were systematically searched and abstracted. We employed random-effects meta-analysis and meta-regression model to determine the number of harmful alcohol users. Results: 35 studies (n = 37,576 Nigerians) were identified. Pooled crude prevalence of harmful use of alcohol was 34.3% (95% CI: 28.6-40.1); twice as high among men (43.9%, 31.1-56.8) compared to women (23.9%, 16.4-31.4). Harmful alcohol use was higher in rural settings (40.1%, 24.2-56.1) compared to urban settings (31.2%, 22.9-39.6). The number of harmful alcohol users aged ≥15 years increased from 24 to 34 million from 1995 to 2015. However, actual age-adjusted prevalence of harmful use of alcohol in Nigeria decreased from 38.5% to 32.6% over the twenty-year period. Conclusions: While the prevalence of the total population that drinks harmfully appears to be dropping, absolute number of individuals that would be classified as harmful drinkers is increasing. This finding highlights the complexity of identifying and advocating for substance abuse policies in rapidly changing demographic settings common in Africa, Asia, and other developing countries.

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.

The role of supportive supervision using mobile technology in monitoring and guiding program performance: a case study in Nigeria, 2015-2016.

BACKGROUND: Supportive supervision is one of the interventions that fosters program improvement by way of imparting knowledge and skills to health workers. The basic challenge in supportive supervision is the availability of data in real time for timely and effective feedback. Thus, the main objective of this study was to determine the contribution of real-time data collection during supportive supervision for timely feedback and generation of evidence for health intervention planning. METHODS: We analyzed supportive supervision records collected through handheld devices employing the open data kit (ODK) platform from July 2015 to June 2016. Supervision was conducted across the country by 592 World Health Organization (WHO) officers. The availability of real-time data and the distance of health facilities to the community were analyzed. RESULTS: During the study period, 90,396 health facilities were supervised. The average time spent during supervision varied from 1.53 to 3.78 h across the six geopolitical zones of the country. The average interval between completion of the supervisory checklist and synchronization with the server varied from 3.9 h to 7.5 h. The average distance between the health facility and a ward varied from 5 to 24 km. CONCLUSION: The use of handheld devices for supportive supervision provided real-time data from health facilities to state and zonal levels for analysis and feedback. Program officers used the findings to rectify process indicators in time for a better outcome.

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.

Institutionalizing documentation for WHO Nigeria country office visibility and improved donor relations, 2013-2016.

BACKGROUND: The mandate and unique experience of the World Health Organization (WHO) globally, enables over 190 countries, Nigeria inclusive, to depend on the technical support provided by the organization to define and mitigate the threats to public health. With other emerging health actors competing for scarce donors' resources, the demand for visibility has invariably equaled expectations on WHO's expertise and technical support. However, the inability to systematically document activities conducted by WHO personnel before 2013 overshadowed most of its invaluable contributions due to poor publicity. The inauguration of the Communications Group in December 2013 with a visibility plan necessitated a paradigm shift towards building a culture of documentation to engender visibility. METHODS: We used a pre-post design of activities to evaluate the effectiveness of specific interventions implemented to improve visibility from 2013 to 2016. The paper highlights how incorporating communication strategies into the accountability framework of staff contributed in changing the landscape as well as showcasing the activities of WHO in Nigeria for improved donor relations. RESULTS: With the specific interventions implemented to improve WHO's visibility in Nigeria, we found that donor relations improved between 2013 and 2015. It is not a mere coincidence that the period corresponds with the era of incorporation of documentation into the accountability framework of technical staff for visibility as locally mobilized resources increased to record 112% in 2013 and 2014. The intervention assisted in the positive projection of WHO and its donors by the Nigeria media. CONCLUSION: Despite several interventions, which worked, made WHO ubiquitous and added awareness and visibility for donors who funded various projects, other factors could have contributed towards achieving results. Notwithstanding, incorporating documentation component into the accountability framework of field staff and clusters has significantly improved communication of WHO's work and promoted healthy competition for increased visibility.

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.

Assessment of unmet needs to address noncompliant households during polio supplemental immunization activities in Kaduna state, 2014-2016.

BACKGROUND: Despite concerted global efforts being made to eradicate poliomyelitis, the wild poliovirus still circulates in three countries, including Nigeria. In addition, Nigeria experiences occasional outbreaks of the circulating vaccine-derived poliovirus type 2 (cVDPV2). Vaccine rejection by caregivers persists in some parts of northern Nigeria, which compromises the quality of supplemental immunization activities (SIAs). In 2013, the Expert Review Committee (ERC) on polio recommended innovative interventions in all high-risk northern states to improve the quality of SIA rounds through innovative interventions. The study assessed the impact of using unmet needs data to develop effective strategies to address noncompliant households in 13 high-risk Local government areas (LGAs) in Kaduna state, Nigeria. METHODS: A retrospective study was conducted in noncompliant communities using unmet needs data collated from 2014 to 2016. Household-based noncompliance data collated from tally sheets between 2013 and 2016 was also analyzed to assess the impact of unmet needs data in addressing noncompliance households in high-risk communities in Kaduna state. A structured interview was used to interview caregivers by the application of an unmet needs questionnaire, a quantitative study that assesses caregiver perception on immunization and other unmet needs which, if the gaps were addressed, would allow them to accept immunization services. Interventions include siting of temporary health camps in noncompliant communities to provide free medical consultations, treatment of minor ailments, provision of free antimalaria drugs and other essential drugs, and also referral of serious cases; intervention of religious and traditional leaders, youth against polio intervention, and the use of attractive bonuses (sweets, balloons, milk) during SIAs were all innovations applied to reduce noncompliance in households in affected communities as the need for eradication of polio was declared as a state of emergency. Outcomes from the analyses of unmet needs data were used to direct specific interventions to certain areas where they will be more effective in reducing the number of noncompliant households recorded on the tally sheet in each SIA round. Hence, seven immunization parameters were assessed from the unmet needs data. RESULTS: Overall, 54% of the noncompliant caregivers interviewed were ready to support immunization services in their communities. The majority of caregivers were also willing to vaccinate their children publicly following unmet needs interventions that were conducted in noncompliant communities. The trend of noncompliant households decreased by 79% from 16,331 in September 2013 to 3394 in May 2016. CONCLUSIONS: Unmet needs interventions were effective in reducing the number of noncompliant households recorded during SIA rounds in Kaduna State. Hence, unmet needs intervention could be adapted at all levels to address challenges faced in other primary healthcare programs in Nigeria.