Effectiveness of self-care interventions for integrated morbidity management of skin neglected tropical diseases in Anambra State, Nigeria.

BACKGROUND: Lymphatic filariasis (LF), Buruli ulcer (BU) and leprosy are neglected tropical diseases (NTDs) of the skin co-endemic in some communities in Nigeria. Not enough is known about the effectiveness of integrated morbidity management and disability prevention in people with these conditions. An integrated self-care intervention was carried out for people with these skin NTDs in two endemic communities of Anambra state, Nigeria. The objective of the study was to assess the effectiveness of self-care practices on costs of care, disability status and health-related quality of life. METHODS: This study utilised a quasi-experimental pre-test/post-test design to assess the effectiveness of the self-care interventions for people affected by NTDs to care for these impairments at home. Data were collected using questionnaires administered at the beginning and at the end of the intervention on monthly cost of morbidity care, and on participants' disability status and their quality of life (QoL). Focus group discussions (FGDs) were held with both the participants and healthcare workers at follow-up. RESULTS: Forty-eight participants were recruited. Thirty participants (62.5%) continued the self-care interventions until the end of the project. Of those, 25 (83%) demonstrated improvement from their baseline impairment status. The mean household costs of morbidity care per participant decreased by 66% after the intervention, falling from US$157.50 at baseline to US$53.24 after 6 months of self-care (p = 0.004). The mean disability score at baseline was 22.3; this decreased to 12.5 after 6 months of self-care (p < 0.001). Among the 30 participants who continued the interventions until the end of the project, 26 (86.7%) had severe disability score (i.e. a score of 10-46) at baseline, and the number with severe disability fell to 18 (60%) of the 30 after the intervention. The mean QoL score increased from 45.7 at baseline to 57.5 at the end of the intervention (p = 0.004). CONCLUSIONS: The 6-month self-care intervention for participants affected by BU, leprosy, or LF led to lower costs of care (including out-of-pocket costs and lost earnings due to morbidity), improved QoL scores, and reduced disability status. TRIAL REGISTRATION: ISRCTN Registry: ISRCTN20317241 ; 27/08/2021, Retrospectively registered.

Support and unmet needs of patients undergoing multidrug-resistant tuberculosis (MDR-TB) treatment in southern Nigeria.

Multidrug-resistant tuberculosis (MDR-TB) is presently a major public health threat. MDR-TB patients face diverse financial and psychosocial difficulties. Researchers conducted in-depth interviews based on interview guides with 42 participants. Data were analyzed using categorization, coding, generation of themes, and thematic memo writing. The key findings were as follows: Out of the 42 patients, 30 (71.4%) were males and 12 (28.6%) were females. All patients received financial stipends for transport and monthly social support. The patients however needed more financial support than they received (suggesting high unmet financial needs). Patients suffered depressive mood before and during treatment but received inadequate mental health/psychosocial care and treatment. Patients developed hearing impairment as a major adverse drug reaction, but the care and treatment they received were inadequate. In conclusion, the programmatic support provided for MDR-TB patients' financial and mental health/psychosocial needs and auditory drug side effects fell short of their need. Programmes for control of MDR-TB should increase budgetary allocations and ramp up mechanisms for provision of mental health/psychosocial support and care/treatment for drug side effects.

Establishing the reliability and construct validity of the Igbo version of Screening Activity Limitation and Safety Awareness scale in persons with Hansen disease.

OBJECTIVE: Leprosy or Hansen's disease is an infectious disease affecting skin and peripheral nerves. The World Health Organization (WHO) Recent Report reveals Africa as having 20,599 new cases, America 36, 178, Eastern Asia 166,445, Western pacific 5,400; totally up to 232,875 new cases. Nigeria as at 2012 had 3,805 new cases. Nerve dysfunction can lead to severe impairments, such as wounds, clawing and shortening of digits, and visual impairments that are often indicated as WHO Grade 2 disabilities. The Screening Activity Limitation Safety Awareness (SALSA) scale however, was developed to-measure self-reported activity limitation in people affected by peripheral neuropathy, and has been translated into several languages world-wide, including two of the three major indigenous languages in Nigeria (i.e. Yoruba and Hausa), leaving the Igbo language yet to be translated. This resulted in the present study, in which the scale was translated into Igbo and the psychometric properties also established to help in data collection and to promote research among the Igbo speaking people living with disabilities from Hansen's disease. DESIGN: The research design was a cross-sectional survey, facility based with 70% RFT and 30% on MDT. Data were analysed using Cronbach's alpha and factor analyses. RESULT: A quantitative exploration of participants' characteristics revealed that of the 40 respondents that participated in the study; 87.5% of them were predominantly from a rural population; 42.5% were males and 57.5% females. Their ages ranged between 15 and 64 years; 55% were uneducated; while 45% were educated. The SALSA Scale was interviewer-administered to the participants. Reliability analysis conducted on the data revealed high Cronbach's alpha co-efficient of 0.93 - 0.94 for the entire items on the scale. Firstly, most of the scale items correlated at least 0.3 with at least one other item on the scale, Secondly, the Kaiser-Meyer-Olkin measure of sampling adequacy was 0.71, Bartlett's test of sphericity was significant (Χ2 (190) = 482.63, P < 0.001). Finally, the communalities were all above 0.3. The principal factor analysis of the scale revealed a five factor scale, having fulfilled all the necessary conditions. CONCLUSION: It can be concluded that the Igbo version of SALSA is reliable and valid for use among the Igbo speaking group in Nigeria.

An audit of first afebrile seizure management in an Irish tertiary pediatric setting.

UNLABELLED: The objective of this study was to compare the first afebrile seizure management with internationally recognized standards in an Irish tertiary pediatric setting. Twenty-one management standards were derived from a combination of British (NICE 2004) and North American (AAN 2003) guidelines. Cases of first afebrile seizure presenting to a pediatric emergency department between July 2007 and June 2010 were assessed against the standards. On completion, the standards developed were presented to the relevant stakeholders, a nurse-developed parental advice sheet was introduced, and a re-audit was performed from July 2010 to June 2011. Forty children were identified in the initial audit period (A1) and 41 over the re-audit (A2). No case achieved full compliance with the devised standards in the audit period. A median compliance score of 15 (range 5-20) was achieved in A1 and 17 (range 11-21) in A2 [mean rank 31.93 versus 49.85; p(1,1) < 0.0001]. Optimal compliance (total score of ≥17) with devised standards was achieved in 6/40 patients in A1 and in 21/41 patients in A2 [χ (2) = 11.95; p(1,1) = 0.001]. CONCLUSION: We demonstrated an initial lack of compliance with international guidelines on management of a common medical presentation, first afebrile seizure, and demonstrated that improvements can be achieved by identification of appropriate standards and critical appraisal of the compliance with these standards through both formal and informal education.

Children and leprosy in southern Nigeria: burden, challenges and prospects.

OBJECTIVES: To describe the trend of leprosy case notification among children from 2002 to 2012 in Southern Nigeria. 2. To identify the challenges faced by the children suffering from leprosy. DESIGN: A retrospective descriptive desk analysis of leprosy case notification data for children from 0 to 14 years in 14 states in Southern Nigeria. Secondly, a cross sectional study of all children currently undergoing leprosy treatment in three selected clusters (referral centres) in Southern Nigeria. A questionnaire-based interview was used to identify the challenges faced by the children with leprosy. RESULTS: Notified cases of leprosy among children in southern Nigeria decreased from 110 cases in 2002 to 64 cases in 2012. The median child proportion and MB proportion were 7.0% and 80.5% respectively. Two children (with WHO Grade 2 Disability) interviewed had great difficulty with their education and social life. Others were able to cope well in school and suffered no discrimination probably because their disease remained undisclosed to and unrecognised by the teachers. The school teachers were reportedly unable to recognise the symptoms/signs of leprosy in seven out of the 10 cases. Eight of the child leprosy cases were initially misdiagnosed at peripheral hospitals. The diagnostic delay ranged from 5 to 48 (with a median of 36) months. Notably, five out of the 10 children interviewed reported a positive household contact history. CONCLUSION: Notwithstanding the decline in leprosy case-notification in southern Nigeria over the past decade, transmission of the infection appears to be on-going as evidenced by the considerable number of child cases. Innovative approaches in case-finding including school-based activities and robust 'family-contact' management are recommended to address long diagnostic delays and lingering stigma.

Improving TB Case Detection Through Active Case-Finding: Results of Multiple Intervention Strategies in Hard-to-Reach Riverine Areas of Southern Nigeria.

BACKGROUND: A major challenge to TB control globally is low case detection, largely due to routine health facility-based passive case-finding employed by national TB control programs. Active case-finding is a risk-population-based screening approach that has been established to be effective in TB control. This intervention aimed to increase TB case detection in hard-to-reach areas in southern Nigeria. METHODS: Using a descriptive cross-sectional design, we conducted implementation research in 15 hard-to-reach riverine local government areas with historically recognized low TB case notification rates. Individuals with TB symptoms were screened using multiple strategies. Data were collected quarterly over a 4-year period using reporting tools and checklists. Descriptive analysis was done with Microsoft Excel spreadsheet 2019. RESULTS: A total of 1,089,129 individuals were screened: 16,576 in 2017; 108,102 in 2018; 697,165 in 2019; and 267,286 in 2020. Of those screened, 24,802 (2.3%) were identified as presumptive TB, of which 88.8% were tested and 10% were diagnosed with TB (0.23% of those screened). TB notifications more than doubled, increasing by 183.3% and 137.5% in the initial implementation and scale-up, respectively. On average, 441 individuals needed to be screened to diagnose 1 TB case. The cases, predominantly males (56.1%) and aged 15 years and older (77.4%), comprised 71.9% bacteriologically confirmed drug-sensitive TB, 25.8% clinically diagnosed drug-sensitive TB, and 2.3% drug-resistant cases. Detection sources included community outreach (1,786), health facilities (505), people living with HIV (57), and household contacts of bacteriologically confirmed TB cases (123). Remarkably, 98.1% of diagnosed TB cases commenced treatment. CONCLUSIONS: We found a significant yield in TB case notifications, more than doubling the baseline figures. Given these successful results, we recommend prioritizing resources to support active case-finding strategies in national programs, especially in hard-to-reach areas with high-risk populations, to address TB more comprehensively.

Understanding the burden of poor mental health and wellbeing among persons affected by leprosy or Buruli ulcer in Nigeria: A community based cross-sectional study.

BACKGROUND: Skin neglected tropical diseases including leprosy and Buruli ulcer (BU)are a group of stigmatizing and disability-inducing conditions and these aspects of the diseases could lead to poor mental health. The study was designed to assess the burden of poor mental health and wellbeing among persons affected by leprosy or BU in Nigeria. METHODS: A community based cross-sectional study design was employed. The study involved persons affected by leprosy or BU. Ten local government areas with the highest number of notified leprosy or BU cases between 2014 and 2018 in southern Nigeria were purposively selected. Information were obtained using Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorders-7 (GAD-7), Warwick-Edinburgh Mental Well-being Scale (WEMWBS) and OSLO Social Support Scale. Outcome measure was poor mental health/wellbeing and was determined by proportion of respondents who had depressive symptoms, anxiety disorder and poor mental wellbeing. RESULTS: A total of 635 persons affected by leprosy or BU participated in the study. The mean age of respondents was 43.8±17.0 years and highest proportion, 22.2% were in age group, 40-49 years. Majority of respondents, 50.7% were males. A higher proportion of respondents, 89.9% had depressive symptoms, 79.4% had anxiety disorders and 66.1% had poor mental wellbeing. Majority, 57.2% had poor mental health/wellbeing. Among the respondents, there was a strong positive correlation between depression and anxiety scores, (r = 0.772, p<0.001). There was a weak negative correlation between depression score and WEMWBS score, (r = -0.457, p<0.001); anxiety score and WEMWBS score, (r = -0.483, p<0.001). Predictors of poor mental health/wellbeing included having no formal education, (AOR = 1.9, 95%CI: 1.1-3.3), being unemployed, (AOR = 3.4, 95%CI: 2.2-5.3), being affected by leprosy, (AOR = 0.2, 95%CI: 0.1-0.4) and having poor social support, (AOR = 6.6, 95%CI: 3.7-11.8). CONCLUSIONS: The burden of poor mental health/wellbeing among persons affected by leprosy or BU is very high. There is need to include mental health interventions in the management of persons affected with leprosy or BU. Equally important is finding a feasible, cost-effective and sustainable approach to delivering mental health care for persons affected with leprosy or BU at the community level. Improving educational status and social support of persons affected by leprosy or BU are essential. Engaging them in productive activities will be of essence.

Participatory Development and Assessment of Audio-Delivered Interventions and Written Material and Their Impact on the Perception, Knowledge, and Attitudes Toward Leprosy in Nigeria: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: In Nigeria, similar to many leprosy-endemic countries, leprosy is highly stigmatized. High levels of stigma among community members as well as internalized stigma among persons affected by leprosy often result in negative psychosocial consequences for those affected. To break this vicious cycle, it is important to conduct context-specific behavioral change activities. Although written material has been successful in improving knowledge and perception, it is not suitable for populations with low educational levels. Audio-delivered interventions are likely to be more suitable for people who are illiterate. This study proposes to assess the impact of an audio-delivered intervention on the perception (knowledge, attitudes, and beliefs) of community members with regard to leprosy in Nigeria. OBJECTIVE: This study aims to assess the impact of audio-delivered and written health education on the perception of leprosy. Specific objectives are to (1) investigate the perception (local beliefs, knowledge, and attitudes) of community members toward leprosy and persons affected by leprosy; (2) investigate whether there is a difference in impact on perception between participants who have received audio-delivered health education and those who have received written health education, with specific reference to gender differences and differences between rural and urban areas; and (3) assess the impact of the participatory development of the audio-delivered and written interventions on empowerment and internalized stigma of persons affected by leprosy who developed the interventions. Additionally, we will translate and cross-culturally validate 4 study instruments measuring outcomes in 2 major Nigerian languages. METHODS: We will use a mixed methods, cross-sectional study design for the intervention development and a 3-arm cluster randomized controlled trial for its implementation and evaluation, comprising (1) baseline assessments of knowledge, attitudes, perceptions, and fears of community members, to develop the audio-delivered content and written material, and the self-esteem and internalized stigma of persons affected by leprosy; and (2) participatory development of the audio-delivered content and written material by persons affected by leprosy and the pilot and implementation of the interventions. This will be done among different groups (selected using cluster randomization) that will be compared (control group, audio-intervention group, and written material group) to evaluate the intervention and the impact of developing the intervention on the persons affected. RESULTS: This study was funded in June 2022, and community member participant recruitment started in January 2023. Baseline data collection was completed by May 2023 (n=811). Participatory cocreation of the audio and written health education content began in July 2023, and the materials are currently under development. Study results are expected in September 2024. CONCLUSIONS: Study findings will contribute to developing evidence-based, context-specific behavioral change interventions, which are critical to addressing stigma in many leprosy-endemic communities where leprosy is highly stigmatized, and contribute toward global triple zero leprosy efforts. TRIAL REGISTRATION: Pan African Clinical Trial Registry PACTR202205543939385; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=23667. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53130.

Leprosy situation in Nigeria.

With an annual new case detection of 4000 people, a Grade 2 disability rate of 12%, and nearly 10% child ratio among new cases, leprosy remains a disease of public health importance in Nigeria. Faced with the reality of low endemicity; a declining budgetary allocation to leprosy control; and a pervasive loss of expertise; it is necessary for Nigeria to re-organise its leprosy control services to further reduce the burden of the disease and ensure quality care to people affected by leprosy.

Is there still yaws in Nigeria? Active case search in endemic areas of southern Nigeria.

BACKGROUND: Yaws is a disease caused by the bacteria Treponema pallidum subspecies pertenue, which is most commonly seen among children below 15 years. In the twentieth century yaws was endemic in Nigeria but eradication strategies markedly reduced the disease burden. Currently there is minimal data on the ongoing transmission of yaws in Nigeria, despite reports of confirmed yaws cases in neighbouring West African countries. METHODS: We conducted both community and school-based active yaws case search among school-aged children in southeast Nigeria. Children were screened by trained community volunteers. Suspected yaws cases were clinically reviewed and tested using rapid diagnostic serological tests. RESULTS: Between February and May 2021, up to 28 trained community volunteers screened a total of 105,015 school children for yaws. Overall, 7,706 children with various skin lesions were identified. Eight (8) suspected cases of yaws were reported, reviewed and screened, but none was confirmed using rapid diagnostic tests. The four most common skin conditions identified were scabies (39%), papular urticaria (29%), tinea corporis (14%) and tinea capitis (12%). CONCLUSIONS: No case of yaws was confirmed in this large population of children in south-east Nigeria. Continuous community awareness and yaws case finding activities have been recommended across Nigeria.

A cluster randomized trial for improving mental health and well-being of persons affected by leprosy or buruli ulcer in Nigeria: A study protocol.

This protocol describes a study in which we would assess the effect of using community lay counselors, self-help groups (SHGs), and trained frontline health workers to reduce mental disorders and improve quality of life (QOL) of persons affected by leprosy or Buruli ulcer (BU). A cluster randomized controlled study design will be employed. The study will involve persons affected by leprosy or BU. Ten local government areas (clusters) with the highest number of notified leprosy or BU cases between 2014 and 2018 in Southern Nigeria will be purposively selected. The clusters will be randomized into intervention and control groups using a computer-generated list of random numbers. At baseline, data were collected using the following validated questionnaires, Patient Health Questionnaire, Generalized Anxiety Disorder questionnaire, Stigma Assessment and Reduction of Impact Scale, World Health Organization QOL BREF and Warwick-Edinburgh Mental Well-being scale among persons affected by leprosy or BU. The intervention will last for 2 years and will involve use of community lay counselors, SHGs, and appropriately trained frontline health workers in reducing mental disorders and improving QOL of persons affected by leprosy or BU. This project postulates that the reduction of burden of mental health problems and improved QOL among persons affected by leprosy or BU could be achieved through a holistic approach involving SHGs, appropriately trained community opinion leaders, and general health-care workers as well as a functional referral system. If successful, the model will be integrated into the activities of the National Tuberculosis and Leprosy Control Programme and scaled up nationwide. Trial registration: ISRCTN Registry: ISRCTN 83649248. https://trialsearch. who.int/Trial2.aspx? TrialID % ISRCTN83649248 Prospectively registered.

Measuring endemicity and burden of leprosy across countries and regions: A systematic review and Delphi survey.

BACKGROUND: Leprosy is a chronic infectious disease caused by Mycobacterium leprae, the annual new case detection in 2019 was 202,189 globally. Measuring endemicity levels and burden in leprosy lacks a uniform approach. As a result, the assessment of leprosy endemicity or burden are not comparable over time and across countries and regions. This can make program planning and evaluation difficult. This study aims to identify relevant metrics and methods for measuring and classifying leprosy endemicity and burden at (sub)national level. METHODS: We used a mixed-method approach combining findings from a systematic literature review and a Delphi survey. The literature search was conducted in seven databases, searching for endemicity, burden and leprosy. We reviewed the available evidence on the usage of indicators, classification levels, and scoring methods to measure and classify endemicity and burden. A two round Delphi survey was conducted to ask experts to rank and weigh indicators, classification levels, and scoring methods. RESULTS: The literature review showed variation of indicators, levels, and cut-off values to measure leprosy endemicity and/or burden. The most used indicators for endemicity include new case detection rate (NCDR), new cases among children and new cases with grade 2 disability. For burden these include NCDR, MB cases, and prevalence. The classification levels 'high' and 'low' were most important. It was considered most relevant to use separate scoring methods for endemicity and burden. The scores would be derived by use of multiple indicators. CONCLUSION: There is great variation in the existing method for measuring endemicity and burden across countries and regions. Our findings contribute to establishing a standardized uniform approach to measure and classify leprosy endemicity and burden at (sub)national level, which would allow effective communication and planning of intervention strategies.

Is there a role for patent medicine vendors in tuberculosis control in southern Nigeria?

Patent medicine vendors (PMVs) are a ubiquitous feature of the informal health sector in Nigeria. A previous study on healthcare-seeking behaviour of persons with chronic cough in southern Nigeria found that over 60% of respondents chose the PMV as a healthcare provider of first instance. This study sought to determine the willingness and capability of PMVs to play a role in the national tuberculosis (TB)-control effort. Study sites were selected through a multi-stage sampling process. In total, 388 PMVs, 17 principal officers of PMV associations, and 17 community leaders were purposively selected. Sets of structured questionnaire were administered to the PMVs while information from the principal officers of PMV associations and community leaders was elicited through in-depth interviews and focus-group discussions (FGDs). Quantitative data were collated using the Epi Info software (version 6.04) and analyzed using the SPSS software (version 15). Most (90%) PMVs indicated that they would be ready to cooperate with the national TB-control programme, if trained. Seventy-three percent attended persons with prolonged cough in the course of their career. However, 48% did not know the cause of TB. Only 3% ever-attended a training session on TB control. Sixty-six percent completed at least 12 years of schooling with secondary school certificate. Eighty percent of the community leaders were happy with the work of PMVs. About two-thirds (65.6%) of the PMVs were male. The PMVs are positively disposed to playing roles in TB control. Given this positive disposition and their widespread acceptance in healthcare-delivery in the communities, they have potentials for playing a role in TB control in southern Nigeria.

Communicating health crisis: a content analysis of global media framing of COVID-19.

Background: This study examines the global media framing of coronavirus disease 2019(COVID-19) to understand the dominant frames and how choice of words compares in the media. Periods of health crisis such as the outbreak of coronavirus pandemic add to the enormous burden of the media in keeping people constantly informed. Extant literature suggests that when a message is released through the media, what matters most is not what is said but how it is said. As such, the media could either mitigate or accentuate the crisis depending on the major frames adopted for the coverage. Methods: The study utilises content analysis. Data were sourced from LexisNexis database and two websites that yielded 6145 items used for the analysis. Nine predetermined frames were used for the coding. Results: Human Interest and fear/scaremongering frames dominated the global media coverage of the pandemic. We align our finding with the constructionist frame perspective which assumes that the media as information processor creates 'interpretative packages' in order to both reflect and add to the 'issue culture' because frames that paradigmatically dominate event coverage also dominate audience response. The language of the coverage of COVID-19 combines gloom, hope, precaution and frustration at varied proportions. Conclusion: We conclude that global media coverage of COVID-19 was high, but the framing lacks coherence and sufficient self-efficacy and this can be associated with media's obsession for breaking news. The preponderance of these frames not only shapes public perception and attitudes towards the pandemic but also risks causing more problems for those with existing health conditions due to fear or panic attack.

Investigating barriers and challenges to the integrated management of neglected tropical skin diseases in an endemic setting in Nigeria.

BACKGROUND: There is a dearth of experience in and evidence for cost-effective integrated community-based management of skin neglected tropical diseases (NTDs). The objective of this study was to assess the knowledge, attitude and care-seeking practices including self-care with a view to introducing appropriate community-based interventions for skin NTDs in an endemic setting in Southern Nigeria. METHODS/PRINCIPAL FINDINGS: This exploratory study adopted a mixed-methods design consisting of cross-sectional surveys of community members and health workers using interviewer-administered questionnaires; and focus group discussions (FGDs) with community members, health care workers and patients with NTDs in Anambra State, Nigeria. The survey was completed by 353 community members (61.8% female) and 15 health care workers (100.0% female). A total of 52 individuals participated in six FGDs. Of the community members, 236 (66.9%) had heard or seen a case of leprosy; 324 (91.8%) and 131 (37.5%) had heard or seen a case of Buruli ulcer and lymphatic filariasis, respectively. Again, 213 (60.3%) of the respondents reported that the diseases were caused by witchcraft or curse. As regards prevention, 241 (68.3%) suggested avoiding handshake with affected persons. Up to 223 (63.2%) of respondents strongly agreed to the seriousness of skin NTDs in their community. Meanwhile, 272 (77.1%) of the respondents believed that the transmission of these skin NTDs can be prevented. Furthermore, 324 (91.7%) desired active community engagement for control of skin NTDs. Regarding community care seeking practices, 197 (55.8%) would first visit the health centre/hospital, followed by 91 (25.8%) traditional healer/herbalist and 35 (9.9%) pharmacy/patent medicine vendor if they develop a skin NTD. Overall, 332 (94.1%) of respondents expressed interest in being taught self-care practices for skin NTDs. Out of 15 healthcare workers, 13 (86.7%) were able to correctly diagnose two of these skin NTDs and 10 (66.7%) would encourage patients to practice self-care. Prominent themes in the FGDs were belief in witchcraft and herbal remedies; as well as the occurrence of physical, social and economic distress. CONCLUSIONS: Our study helped quantify the information gaps that need to be addressed in order to create demand for integrated skin NTDs services in an endemic setting in Nigeria. Individual, structural and socioeconomic challenges to access and delivery of services were identified. Community and health care workers' empowerment and engagement through outreach and regular training, respectively may alleviate these challenges.

Screening diabetes mellitus patients for tuberculosis in Southern Nigeria: A pilot study.

INTRODUCTION: Diabetes mellitus (DM) and tuberculosis (TB) are of great public health importance globally, especially in Sub-Saharan Africa. Tuberculosis is the third cause of death among subjects with non-communicable diseases. DM increases risk of progressing from latent to active tuberculosis. The study aimed to ascertain yield of TB cases and the number needed to screen (NNS) among DM patients. MATERIAL AND METHODS: Across-sectional study was conducted at 10 health facilities with high DM patient load and readily accessible DOTS center in 6 states of southern region of Nigeria over aperiod of 6 months under routine programme conditions. All patients who gave consent were included in the study. Yield and NNS were calculated using an appropriate formula. RESULTS: 3 457 patients were screened with amean age (SD) of 59.9 (12.9) years. The majority were male, 2 277 (65.9%). Overall prevalence of TB was 0.8% (800 per 100 000). Sixteen (0.5%) were known TB cases (old cases). There were 221 presumptive cases (6.4%) out of which 184 (83.3%) were sent for Xpert MTB/Rif assay. Eleven (0.3%) new cases of TB were detected, giving additional yield of 40.7% and the number needed to screen (NNS) of 315. All the 11 patients were placed on anti-TB treatment. CONCLUSIONS: The prevalence of TB among DM patients was higher than in the general population. The yield was also good and comparable to other findings. This underscores the need for institute active screening for TB among DM patients. Further stu-dies are recommended to identify associated factors to guide policy makers in planning and development of TB-DM integrated services.

Assessment of community knowledge, attitude, and stigma of Buruli ulcer disease in Southern Nigeria.

BACKGROUND: Poor knowledge can influence timely care-seeking among persons with Buruli ulcer disease (BUD). OBJECTIVES: To assess community knowledge, attitude and stigma towards persons with BUD in endemic settings of Southern Nigeria. METHODS: This was a cross-sectional survey conducted among adult community members in four States of Southern Nigeria. A semi-structured interviewer-administered questionnaire was administered to all participants. RESULTS: Of 491 adults who completed the survey, 315 (64.2%) belonged to the ≤40 years age group, 257 (52.3%) were males and 415 (84.5%) had some formal education. The overall mean (SD) knowledge score was 5.5±2.3 (maximum 10). Only 172 (35.0%) of the participants had a good knowledge of BUD. A total of 327 (66.6%) considered BUD as a very serious illness. Also, there was a high-level of stigma against BUD patients; 372 (75.8%) of the participants felt compassion for and desire to help them, 77 (15.7%) felt compassion but tended to stay away from them, and 53 (10.8%) feared them because they may infect them with the disease. Having a formal education and ethnicity were independent predictors of good knowledge of BUD. CONCLUSION: There is poor community knowledge of BUD in endemic settings of Southern Nigeria which influenced the attitude and perceptions of community members towards persons with BUD.

Worsening of the disability grade during leprosy treatment: prevalence and its determinants in Southern Nigeria.

Background: In Nigeria, little is known about the development of new or additional physical disability during leprosy treatment. The objective of this study was to determine the prevalence and evaluate factors associated with worsening of physical disability during leprosy treatment in Nigeria. Methods: This was a retrospective cohort study conducted among leprosy patients treated in six referral facilities in six States in Nigeria between January 2011 and December 2015. Multivariable logistic regression analysis was used to identify predictors of worsening disability after treatment. Results: Of 984 leprosy patients who completed treatment, the mean age of the patients was 39.8±17.6 years and 57.4% (565/984) of them were male. Also, 51.6% (508/984) of the patients had either grade 1 or 2 disability at diagnosis, but this declined to 30.8% (303/984) following treatment (p<0.001). Overall, 4.7% (46/984) of the cases developed new or additional disability (or worsening disability) during treatment. The cases with the greatest odds for developing worsening physical disability were patients from the southwest (adjusted odds ratio [aOR] 15.9; 95% CI 3.8-67.4) and southeast zones (aOR 4.7; 95% CI 1.1-19.2), and patients who had a leprosy reaction requiring additional corticosteroid therapy (aOR 11.7; 95% CI 4.4-31.2). Conclusion: Sustained capacity building for health professionals on better monitoring and management of leprosy and its complications is strongly recommended in Nigeria.

Assessment of health care workers' knowledge, attitude and risk perception of Buruli ulcer disease in Southern Nigeria.

Background: Poor knowledge of health care workers may be responsible for the under-diagnosis and low notification of Buruli ulcer (BU) in high-burden settings. This study assessed health care workers' knowledge, attitude and risk perception of BU in Southern Nigeria. Methods: We conducted a cross-sectional survey among 186 health care workers recruited from 58 health facilities in four states of Southern Nigeria. A semi-structured interviewer-administered questionnaire was administered to all participants. Results: The overall mean knowledge score was 8.8±2.7 (maximum 15). Only 29.0% (54/186) of the respondents had a good knowledge of BU. The mean (SD) attitude score was 4.5±1.2 (maximum 6). Also, 61.3% (114/) of the respondents had a good attitude towards BU. The overall mean (SD) risk perception score was 2.6±1.3 (maximum 5). Only 26.3% (49/) of the respondents had a good risk perception of BU disease. Previous training was an independent predictor of good knowledge (aOR 4.6), good attitude (aOR 3.8) and good risk perception (aOR 2.9) to BU. Conclusions: Health care workers in endemic settings of Nigeria have poor knowledge of and poor risk perception of BU disease. Training of health care workers is recommended to address the identified gaps to ensure earlier diagnosis and referral to specialist centres.

Financial burden of health care for Buruli ulcer patients in Nigeria: the patients' perspective.

BACKGROUND: The economic burden of Buruli ulcer for patients has not been well-documented. This study assessed the costs of Buruli ulcer care to patients from the onset of illness to diagnosis and to the end of treatment. METHODS: This was a cross-sectional cost of illness study conducted among patients with Buruli ulcer in four States in Nigeria between July and September 2015. A structured questionnaire was used to collect data on the patients' characteristics, household income and out-of-pocket costs of care. RESULTS: Of 92 patients surveyed, 54 (59%) were older than 15years, 49 (53%) were males, and 86 (93%) resided in a rural area. The median (IQR) direct medical and non-medical cost per patient was US$124 (50-282) and US$3 (3-6); corresponding to 149% and 4% of the patients' median monthly household income, respectively. The overall direct costs per patient was US$135 (58-327), which corresponded to 162% of median monthly household income, with pre-diagnosis costs accounting for 94.8% of the total costs. The direct costs of Buruli ulcer care were catastrophic for 50% of all patients/households - the rates of catastrophic costs for Buruli ulcer care was 66% and 19% for patients belonging to the lowest and highest income quartiles, respectively. CONCLUSIONS: Direct costs of Buruli ulcer diagnosis and treatment are catastrophic to a substantial proportion of patients and their families.