Maternal mortality review in a major tertiary referral hospital in Liberia, 2018-2021.

Objectives: Anecdotal evidence showed increased maternal deaths at the major tertiary hospital over the past two years (2020-2021). We reviewed the maternal death audit data, identified the main causes of maternal death, and associated risk factors. Findings were shared with policymakers to help reduce maternal mortality. Study design: We conducted a secondary data review and descriptive analysis of maternal death at the tertiary hospital located in Monrovia. Method: The maternal death data were extracted from patient medical records, including death certificates and maternal audit records. The record of live births was obtained from the delivery register. Data were analyzed using Epi Info version 7.2 Maternal mortality ratio (MMR) was estimated, the leading direct and indirect causes of maternal death were identified, and the factors associated with maternal death were explored using logistic regression at a 5% level of significance. Results: There are a total of 233 maternal deaths and 14, 879 live births giving a maternal mortality ratio (MMR) of 1565 per 100,000 live births during the period under review. The median age of the mothers at death was 29 (14-45) years. About 40.3% (94/233) of cases died within <1 day of admission, referrals accounted for 59% (137/233) of the cases. Direct causes of death accounted for 66% (147/223). Hemorrhage [30.6% (45/147)], Eclampsia [(30/147) 20.6%] and Sepsis [(30/147) 20.6%] were the main direct causes of death while cardiovascular-related [18.4% (14/76)] and HIV/AIDS [16% (12/76)] were the leading indirect cause of death. Patients from referred other facilities were 7.9 times more likely to die as compared to non-referral (pOR:7.9, 95%CI: 5.9-10.6, p < 0.001). Conclusion: The maternal mortality ratio remained high. Referrals were done late. The Liberia Ministry of Health should equip more secondary-level health facilities and tertiary hospitals to handle maternal emergencies and sensitize the populace and healthcare workers on prompt identification and referral of obstetric emergencies. The MoH also needs to improve the blood transfusion services to help in the management of postpartum hemorrhage.

Trend of Lassa fever cases and factors associated with mortality in Liberia, 2016 - 2021: a secondary data analysis.

Introduction: Lassa fever (LF) is endemic in Liberia and is immediately reportable. Suspected cases are confirmed at the National Public Health Reference Laboratory. However, there is limited information on the trend and factors associated with mortality. We described the epidemiological characteristics of LF cases and determined factors associated with mortality in Liberia from 2016 to 2021. Methods: we reviewed 867 case-based LF surveillance data from 2016 to 2021 obtained from the National Public Health Institute of Liberia (NPHIL). The cases that met the suspected LF case definition were tested with RT-PCR. Using Epi Info 7.2.5.0. We conducted univariate, bivariate, and multivariate and analysis. We calculated frequencies, proportions. Positivity rate, case fatality rate, and factors associated with LF mortality using chi-square statistics and logistics regression at 5% level of significance. Results: eighty-five percent (737/867) of the suspected cases were tested and 26.0% (192/737) were confirmed LF positive. The median age of confirmed LF cases was 21(IQR: 12-34) years. Age 10-19 years accounted for 24.5% (47/192) and females 54.2% (104/192). Bong 33.9% (65/192), Grand Bassa 31.8% (61/192), and Nimba counties, 21.9% (42/192) accounted for most of the cases. The median duration from symptom onset to hospital admission was 6 (IQR: 3-9) days. A majority, 66% (126/192) of the cases were reported during the dry season (October-March) and annual incidence was highest at 12 cases per 1,000,000 population in 2019 and 2020. The overall case fatality rate was 44.8%. Non-endemic counties, Margibi, 77.8% and Montserrado, 66.7% accounted for the highest case fatality rate (CFR), while 2018, 66.7% and 2021, 60.0% recorded the highest CFR during the period. Age ≥30 years (aOR=2.1,95% CI: 1.08-4.11, p=0.027) and residing in Grand Bassa County (aOR=0.3, 95% CI: 0.13-0.73, p=0.007) were associated with LF mortality. Conclusion: Lassa fever was endemic in three of the fifteen counties of Liberia, case fatality rate remained generally high and widely varied. The high fatality of LF has been reported to the NPHIL and is currently being further investigated. There is a need to continuously train healthcare workers, especially in non-endemic counties to improve the LF treatment outcome.

COVID-19 vaccine hesitancy among adults in Liberia, April-May 2021.

BACKGROUND: Vaccination is one of the most cost-effective public health interventions used to prevent diseases in susceptible populations. Despite the established efficacy of vaccines, there are many reasons people are hesitant about vaccination, and these reasons could be complex. This rapid survey estimated the prevalence of COVID-19 vaccine hesitancy and potentially contributing factors in Montserrado and Nimba counties in Liberia. METHODS: A cross-sectional study was conducted among adults living in Liberia. The relationship between vaccine non-acceptance and sociodemographic characteristics was examined using chi-square statistics. The variables with a p-value less than 0.2 at the bivariate analysis were modelled in a binary logistic regression at a 5% level of significance. The adjusted odds ratio and 95% confidence interval are reported. RESULTS: There were 877 participants in the study. Majority were 25-34 years of age (30.4%, 272/877), females (54.05%, 474/877), and Christians (85.2%, 747/877). Most of the participants were aware of the COVID-19 vaccine (75%, 656/877), single (41.4%, 363/877), self-employed (37.51%, 329/877), and live-in rural communities (56.1%, 492/877). Vaccine hesitancy was (29.1%, 255/877; 95% CI:26.2-32.2). Vaccine hesitancy was greater among adults living in urban areas (41%) compared to persons living in rural communities (59%) (aOR; 1.5, 95% CI: 1.1-2.1) and respondents aged 45-54 years (aOR:0.5; 95% CI: 0.2-0.9; p = 0.043) were 50% less likely to be hesitant to COVID-19 vaccination compared to those more than 55 years. The most common source of information was the media (53%, 492/877) and the main reason for being hesitant was a need for more information about the vaccine and its safety (84%, 215/255). CONCLUSIONS: The majority of study participants were aware of the COVID-19 vaccines and their most common source of information was the media (television, radio). Vaccine hesitancy was moderate. This could pose a challenge to efforts to control the spread of the COVID-19 pandemic. Therefore, the health authorities should provide more health education on the importance of vaccines and their safety to the populace.

The influence of first wave of COVID-19 outbreak on routine healthcare services, Liberia, August 2020: a mixed study approach.

BACKGROUND: The COVID-19 pandemic left countries to rapidly implement diverse and stringent public health measures without recourse to mitigate its effect on the sustenance of routine healthcare services. This study described routine health service disruption and restoration strategies at 6 months into the epidemic in Liberia. METHODS: Liberia, with 15 counties, has 839 health facilities, with one-third in Montserrado County. A cross-sectional study using a mixed approach - quantitative and qualitative research with concurrent triangulation was conducted using a structured guide for group discussions among key health workers at 42 secondary and most patronized health facilities in 14 counties and 7 Montserrado districts. Additionally, routine health data between January and June 2019 and 2020 were extracted from the source documents to the electronic checklist. We performed a descriptive analysis of quantitative data and plotted the line graph of the relative percentage change. Transcribed audio recording notes were synthesized using ATLAS ti for content analysis to identify the themes and subthemes in line with the study objectives and excerpts presented in the results. RESULTS: Liberia declared COVID-19 outbreak on March 16, 2020. From conducted interviews at 41 health facilities, 80% reported disruption in routine health services. From January to June 2020, scheduled routine immunization outreaches conducted decreased by 47%. Using a relative percentage change, outpatient attendance decreased by 32% in May, inpatient admission by 30% in April, malaria diagnosis and treatment by 40% in April, and routine antenatal obstetric care by 28% in April. The fear of contacting COVID-19 infection, redeployment of healthcare workers to COVID-19 response, restriction of movement due to lockdown, inadequate or lack of PPE for healthcare workers, lack of drugs and vaccine supplies for clients, and partial closure of routine healthcare services were common perceived reasons for disruptions. Massive community health education and strict compliance with COVID-19 nonpharmacological measures were some of the health facility recovery strategies. CONCLUSIONS: The COVID-19 outbreak in Liberia caused a disruption in routine healthcare services, and strategies to redirect the restoration of routine healthcare services were implemented. During epidemics or global health emergencies, countries should sustain routine health services and plan for them.

Rural-urban disparities and factors associated with delayed care-seeking and testing for malaria before medication use by mothers of under-five children, Igabi LGA, Kaduna Nigeria.

BACKGROUND: Fever in under-five children (U5) is the commonest presenting complaint in general practice and mothers' recognition is an entry point for fever treatment, including malaria. This study describes rural-urban disparity in fever prevalence in U5, mothers' malaria knowledge, care-seeking, testing for malaria before anti-malarial medication and the associated factors. METHODS: A cross-sectional survey was conducted among 630 mother-child pairs [rural (300) and urban (330)] selected randomly using a multi-stage sampling from 63 villages in Igabi LGA, Kaduna State, Nigeria. Trained female data collectors administered a pre-tested structured questionnaire to collect information on mother-child demographic profiles, malaria knowledge, fever episodes in birth order last child in two weeks prior to survey, blood testing before anti-malarial use, and delayed care-seeking defined as care sought for fever > 48 h of onset. Malaria knowledge was categorized into good, average, and poor if the final scores were ≥ 75th, 50th-74th, and < 50th percentiles, respectively. Frequency, proportions, and odds ratio were calculated. Statistically significant was set at p-value < 0.05. RESULTS: The median age (interquartile range) of rural mothers was 30 (IQR, 10) years compared to 27 (IQR, 6) years in urban. Of the 70.0% (441/629) U5 children with fever, 58.5% (258/441) were in rural settlements. A third of the mothers whose child had fever sought care. Mothers in rural settlements were 2.8 (adjusted OR: 2.8, CI 1.8-4.2, p < 0.01) times more likely to delay care-seeking for fever. Other significant factors were poor or no knowledge of malaria transmission, poor perception of malaria as a major health problem, and household size > 5. Also, mothers who had no formal education were four times more likely to receive anti-malarial medications without testing for malaria compared to their educated counterpart (adjusted OR: 4.0, 95% CI 1.6-9.9, p < 0.000). CONCLUSIONS: Rural-urban disparities existed between fever prevalence in U5 children, care-seeking practices by their mothers, and factors associated with delayed care-seeking and testing the fever for malaria before anti-malarial medication. Fever treatment for high impact malaria elimination in Nigeria needs a context-specific intervention rather than 'one-size-fits-all' approach.

Factors associated with utilization of LLINs among women of child-bearing age in Igabi, Kaduna State, Nigeria.

BACKGROUND: The long-lasting insecticidal nets (LLIN) are effective against prevention of malaria and its utilization has been proven to save lives. Despite the mass distribution of LLIN, Nigeria remains the country with the highest malaria burden in Africa. The awareness of LLIN in Nigeria is high, but the utilization is low. The aim of this work is to describe factors associated with the utilization of LLIN among women of child-bearing age (WCBA) in Igabi, Kaduna, Nigeria. METHODS: A cross-sectional survey was conducted among 630 WCBA selected using a multi-stage sampling at 63 randomly selected villages in Igabi Local Government Area of Kaduna State. Trained female data collectors administered pre-tested structured questionnaires adapted from the Malaria Indicator Survey. Information collected were demographic profile, knowledge of LLIN as a preventive strategy for malaria, and LLIN ownership and utilization. LLIN utilization was assessed by identifying household members that slept under the hanged LLIN the night before the survey. Questions on the awareness of LLIN, ability to define what it is, use of LLIN, what differentiates LLIN from other bed nets, and duration of use before replacement, were scored and categorized as good, average and poor knowledge of LLIN. RESULTS: A total of 629 WCBA was sampled, their mean age (± SD) was 29.3 (± 6.2) years, 22.0% were pregnant, 40.5% had no formal education, 41.1% were employed, and 47.7% lived in rural communities. Awareness and good knowledge about LLINs for the prevention of malaria was 96.0% and 24.0%, respectively. The proportion of women who slept under a LLIN the night before the survey (utilization) was 70.0% and slightly higher (74.0%) among pregnant WCBA. Women who lived in rural communities were more likely to utilize LLINs compared to their urban counterparts (OR 3.4; 95% CI 2.3-4.9). Younger women (aged < 30 years) were less likely to utilize LLINs compared to the older women (OR 0.7; 95% CI 0.5-0.9). CONCLUSIONS: The knowledge of LLIN among WCBA was poor, but LLIN utilization was moderate. Living in rural communities and older WCBA were significant characteristics associated with LLIN utilization. Strategies that will improve the utilization of LLIN among the young and urban WCBA should be the focus of the Malaria Elimination Programme (MEP).

Measles outbreak investigation in an urban slum of Kaduna Metropolis, Kaduna State, Nigeria, March 2015.

INTRODUCTION: Despite availability of an effective vaccine, the measles epidemic continue to occur in Nigeria. In February 2015, we investigated a suspected measles outbreak in an urban slum in Rigasa, Kaduna State, Nigeria. The study was to confirm the outbreak, determine the risk factors and implement appropriate control measures. METHODS: We identified cases through active search and health record review. We conducted an unmatched case-control (1:1) study involving 75 under-5 cases who were randomly sampled, and 75 neighborhood controls. We interviewed caregivers of these children using structured questionnaire to collect information on sociodemographic characteristics and vaccination status of children. We collected 15 blood samples for measles IgM using Enzyme Linked Immunosorbent Assay. Descriptive, bivariate and logistic regression analyses were performed using Epi-info software. Confidence interval was set at 95%. RESULTS: We recorded 159 cases with two deaths {case fatality rate = 1.3%}. 50.3% (80) of the cases were male. Of the 15 serum samples, 11(73.3%) were confirmed IgM positive for measles. Compared to the controls, the cases were more likely to have had no or incomplete routine immunization (RI) [adjusted odds ratio (AOR) (95% confidence interval (CI)]: 28.3 (2.1, 392.0), contact with measles cases [AOR (95% CI)]: 7.5 (2.9, 19.7), and having a caregiver younger than 20 years [AOR (95% CI)]: 5.2 (1.2, 22.5). Measles serum IgM was positive in 11 samples. CONCLUSION: We identified low RI uptake and contact with measles cases as predictors of measles outbreak in Rigasa, Kaduna State. We recommended strengthening of RI and education of care-givers' on completing RI schedule.

Setting a Nigeria national malaria operational research agenda: the process.

BACKGROUND: Employing malaria operational research (MOR) findings in planning national malaria control programmes is gaining increased attention. The malaria control foci are diverse, resources are limited; therefore, agreeing on priority areas is critical. Hitherto, the process of prioritising MOR questions in Nigeria has been limited to few stakeholders. In support of the National Malaria Elimination Programme's (NMEP) effort at setting a MOR agenda, the Nigeria Field Epidemiology and Laboratory Training Programme (NFELTP) in collaboration with NMEP conducted preliminary exploratory study to identify key malaria research gaps and needs, and provide data to inform setting a robust national MOR agenda. The process of generating data is presented in this paper. METHODS: A twelve-member task-team comprising NFELTP, university researchers and NMEP officers was commissioned. Following an inaugural meeting the task-team developed a framework of activities and held five planning meetings, conducted five-week online and self-administered paper-based surveys, key informant interview (KII), two-day desk review workshop, seven-day qualitative data analysis, ten-day result and five-day report writing workshops. Paired group members conducted the interviews across six geopolitical zones of Nigeria. Abridged study report was used for a two-day MOR setting agenda stakeholders' workshop. RESULTS: A structured framework, study protocol and data collection instruments were developed and submitted for ethical approval. The instruments included survey questionnaire for detailed information on researchers and other stakeholders' experience with MOR, the gaps and needs in thematic MOR areas; KII and Delphi guides. After an initial scoping review, primary data were collected from purposively selected survey participants using mixed methods: - online survey (n = 100), self-administered paper-based survey (n = 85), KII (n = 40), desk review workshop (n = 22) and Delphi interviews (n = 8). Comprehensive lists of research gaps/bottlenecks and needs were generated for each thematic area in malaria control. These were used at a two-day national MOR setting stakeholder workshop (n = 54) to guide the development of national MOR agenda document. CONCLUSIONS: A systematic approach involving broad stakeholder engagement provided data and evidence-based information for development of a robust national MOR agenda. The processes involved are recommended for use in malaria endemic settings.

A qualitative exploration of malaria operational research situation in Nigeria.

BACKGROUND: Malaria, remains one of the leading causes of high morbidity and mortality in Nigeria despite implementation of several public health interventions for its control. Operational limitations and methodological gaps have been associated with malaria control interventions and research, and these have necessitated the need for a well-tailored Malaria Operational Research (MOR) agenda. However, there is paucity of evidence-based information on relevant stakeholders' experience, awareness, perceptions and use of MOR and suggestions on setting MOR agenda. As part of a larger study to provide data for national MOR agenda setting, we assessed the MOR research situation from the perspectives of key stakeholders in Nigeria and contribution of MOR to the malaria elimination agenda. METHODS: We conducted key informant interviews among 40 purposively selected stakeholders from the six geo-political zones in Nigeria. Data was collected using a pre-tested key informant interview guide which comprised issues related to experience, awareness, use of MOR and MOR needs, and suggestions for MOR. We conducted a detailed content analysis. RESULTS: Half of the participants had participated in MOR. Participants perceived MOR as important. Only few were aware of existing framework for MOR in Nigeria while above half expressed that MOR is yet to be used to inform policy in Nigeria. Participants identified several MOR needs such as development of improved diagnostic techniques, and interventions for promoting early diagnosis, prompt treatment and quality programmatic data. Participants opined the need for country-specific prioritised MOR agenda that cut across malaria thematic areas including malaria prevention and case management. Participants suggested the involvement of various stakeholders and multi-disciplinary approach in setting MOR. CONCLUSION: Although some stakeholders have been involved in MOR, it is still rarely used to inform policy and several needs exist across thematic areas. A broad-based stakeholder involvement, multi-disciplinary approach to agenda setting and its wide dissemination have been suggested.

Social consequences of epilepsy: a study of 231 Nigerian patients.

BACKGROUND: Epilepsy is the commonest neurological disorder and majority of the sufferers are found in the developing countries. It is associated with psychological and social problems. The aim of this study was to determine the social difficulties experienced by epileptic patients and the factors that are associated with these difficulties. METHODS: Two hundred and thirty-one consecutive epileptic patients who were of age 10 years and above, and who had no co-morbid major psychiatric disorder, seen over a 6-month period at the outpatient clinic of Federal Neuro-psychiatric Hospital, Kaduna, were interviewed. We used an instrument designed for the purpose of this study, which focused on people's attitudes to epilepsy, relationship/marital, employment and academic problems. RESULTS: The mean age of the subjects was 28 +/- 13.2 years; 59.3% were males; 44.6% said people make negative remarks about their illness; 14.1% have been denied leadership role; 36.4% were irregular at work; 37.3% performed poorly at work; 22.5% have had their marriage proposals rejected; 19.5% have been abandoned by spouse. At least 39.4% had poor academic performance while 19.5% were withdrawn from school because of epilepsy. Short seizure-free period, long duration of seizure disorder and family history of epilepsy were significantly associated with social problems. CONCLUSION: Social difficulties are common among epileptics. Effort should be made to educate the society about epilepsy, and physicians treating patients with epilepsy should aim at achieving a good seizure control.

The burden experienced by family caregivers of patients with epilepsy attending the government psychiatric hospital, Kaduna, Nigeria.

BACKGROUND: Caring for patients with chronic medical and psychiatric disorders is associated with significant burden. However little is known about the burden experience by caregivers of patients with epilepsy in Nigeria. The objective of this study, therefore, was to assess the level and correlates of burden among caregivers of patients with epilepsy. METHODS: It was a cross-sectional study carried out among 231 eligible caregivers of patients with epilepsy attending the psychiatric clinic of government psychiatric hospital in Kaduna, Northern Nigeria. Sociodemographic/clinical characteristics of patients and socio-demographic characteristics of caregivers were recorded, and the Zarit Burden Interview administered to caregivers to assess their experience of burden. RESULTS: The mean age of the caregivers was 43.6 ± 9.5 years, 52.4% lived outside Kaduna and the mean seizure-free period for the patients was 26.4 ± 36.5 weeks. One hundred and twenty (51.9%) caregivers had high burden. High burden was significantly associated with patients aged less than 20 years, patient's unemployment, long duration of epilepsy, short seizure-free period, family history of epilepsy and living outside Kaduna (p value<0.05). CONCLUSION: Caregivers of patients with epilepsy experience significant burden while caring for their relatives and this is mainly associated with patient's factors and location of residence. Therefore efforts should be made control seizure and make health care available and affordable to all citizens irrespective of where they live.