Pattern of Clinical and Laboratory Presentation of Cerebral Malaria among Children in Nigeria.

Introduction: Cerebral malaria (CM) is the most lethal form of severe malaria with high case fatality rates. Overtime, there is an inherent risk in changing pattern of presentation of CM which, if the diagnosis is missed due to these changing factors, may portend a poor outcome. Variations in the pattern of clinic-laboratory presentations also make generalization difficult. This study was, therefore, set out to report the pattern of clinical and laboratory presentation of CM. Methods: This was a cross-sectional study among children aged 6 months to 14 years admitted with a diagnosis of CM as defined by the World Health Organization criteria. A pretested pro forma was filled, and detailed neurological examination and laboratory (biochemical, microbiology, and hematology) investigations were done. P <5% was considered statistically significant. Results: Sixty-four children were recruited with a mean age of 34.9 ± 24.9 months and a male-to-female ratio of 1.9:1. There were 87.5% of under-five children. Fever (96.9%) was the major presenting feature closely followed by convulsions (92.2%). Convulsions were mainly generalized (94.9%) and multiple (76.5%). Profound coma (Blantyre coma score of 0) was present in 12.5% of cases, and the leading features on examination were fever (84.4%) and pallor (75.0%). Retinal vessel whitening (48.4%) was the most common funduscopic abnormality. Metabolic acidosis (47.9%), severe anemia (14.1%), hyperglycemia (17.2%), and hypoglycemia (7.8%) were seen among the children. Few (1.6%) had hyperparasitemia and bacteremia (3.2%). Conclusion: Early recognition of the clinical presentation and prompt management may improve the outcome of cerebral malaria.

High blood lead levels of children in a gold mining community in Osun State, Nigeria: an urgent call for action.

BACKGROUND: Environmental exposure from artisanal gold mining activities is a major risk for high blood lead levels (BLLs) in children. Over the last decade, artisanal gold mining activities have been on a sharp increase in some parts of Nigeria. This study compared BLLs of children in the mining community of Itagunmodi and a 50-km distant non-mining community of Imesi-Ile, Osun State, Nigeria. METHODS: This community-based study investigated 234 apparently healthy children, with 117 each from Itagunmodi and Imesi-Ile. Relevant history, examination and laboratory findings including BLLs were recorded and analysed. RESULTS: All participants had BLLs above the cut-off value of 5 µg/dl. However, the mean BLL of subjects living in the gold-mining community (24.2±5.3 µg/dl) was significantly higher than for children in the non-mining area of Imesi-Ile (19.5±6.4 µg/dl; p<0.001). Children in the gold mining community were 3.07 times more likely to have a BLL ≥20 µg/dl than those in the non-mining environment (odds ratio [OR] 3.07 [95% confidence interval {CI} 1.79 to 5.2], p<0.001). Similarly, the odds of having a BLL ≥30 µg/dl was 7.84 times more likely among children living in gold mining Itagunmodi than in Imesi-Ile (OR 7.84 [95% CI 2.32 to 26.46], p<0.0001). BLL was not associated with socio-economic and nutritional status of the participants. CONCLUSIONS: In addition to introduction and enforcement of safe mining practices, regular screening for lead toxicity is advocated for children in these communities.

Relationship between ultrasound-measured spleen, liver and anthropometry of children living in a rural community in southwest Nigeria: a cross-sectional study.

BACKGROUND: Ultrasonography is noninvasive, relatively inexpensive and useful for resource-poor settings. US spleen and liver sizes have been observed to differ among populations, so there is a need for reference values for different geographic populations. OBJECTIVE: To describe the sizes of the spleen and liver of children living in a rural community in southwest Nigeria and assess the relationship between these measurements and the children's anthropometry. MATERIALS AND METHODS: We conducted a community-based cross-sectional study among 358 apparently healthy children ages 1-14 years. We obtained the participants' weights, heights, body mass index and body surface area. They underwent US imaging to obtain longitudinal measurements of their spleen and liver. We used independent t-test to compare means, and linear regression analysis to assess relationships between continuous data. The significance level was set as P < 0.05. RESULTS: There were more girls (181; 50.6%). Most children were ages 1-5 years (172; 48.0%). The body surface area had significantly strong positive relationships with US spleen size (r = 0.769; R2 = 0.592; P < 0.0001) and US liver size (r = 0.819; R2 = 0.671; P < 0.0001) but body mass index had weak positive relationships. CONCLUSION: This study contributes to data on US spleen and liver sizes of Nigerian children. The findings buttress observations that body surface area strongly correlates with US spleen and liver measurements. It is recommended that more studies be conducted among Nigerian children to generate a robust pool of data that are useful for creating homogeneous formulae to ease interpretation of US measurements of these intraabdominal organs.

A comparative study on the prevalence and intensity of urinary schistosomiasis among primary (formal) and almajiri (informal) school pupils in kura local government area of Kano State, Nigeria.

BACKGROUND: Urinary schistosomiasis remains one of the most prevalent neglected tropical diseases in the world today, particularly in developing countries including Nigeria. Chronic infection can affect the genitourinary system. School pupils, particularly the informal Almajiri school pupils are at increased risk of the infection. STUDY OBJECTIVES: The objective of this study was to determine and compare the prevalence and intensity of urinary schistosomiasis among primary and Almajiri school pupils in Kura Local Government Area (LGA) aged 5-15 years. We also aim to determine the presence of haematuria and proteinuria among these pupils. SUBJECTS AND METHODS: It was a cross-sectional comparative study involving 200 primary and 200 Almajiri school pupils aged 5-15 years in Kura LGA who met the inclusion criteria. Urine samples were analysed by the dipstick urinalysis and microscopically examined for the egg S. haematobium. RESULTS: The Almajiri school pupils had a significantly higher infection (55.5%) than the primary school pupils (43.0%). The infection was predominantly of light intensity in both school types (67%). The overall mean egg intensity was 51.6 ± 35 EPC. The infection was higher among boys and those aged 10 years and above. Majority of the pupils had microhaematuria (88.3%) and and proteinuria (71.1%), which were statistically significantly associated with the infection with P < 0.1 and P < 0.001, respectively. CONCLUSION: The prevalence of urinary schistosomiasis is higher among the Almajiri school pupils compared to the primary school pupils. Control programmes should focus on these Almajiri pupils in addition to the primary school pupils.

Towards malaria control in Nigeria: implications of the malaria parasite rate and spleen rate among children living in a rural community in southwest Nigeria.

BACKGROUND: The World Health Organization prioritizes malaria surveillance for accurate tracking of progress of intervention programmes. The malaria parasite rate (PR) and spleen rate (SR) are economical surveillance tools. There has been a global decline in the burden of malaria over the last decade, but most African countries, like Nigeria, have a slow rate of decline. There is a need for adequate malaria surveillance to guide malaria control strategies and policymaking. METHODS: A community-based cross-sectional study was conducted among 363 children ages 1-15 y in rural southwest Nigeria. The participants' PR was determined by microscopy and the SR was determined by palpation and ultrasonography. The associations between PR and SR and other covariates were assessed. RESULTS: The PR was 26.7% and the SR was 12.9%. There was no significant association between PR or SR across age groups, but low social class was significantly associated with PR (55 [33.5%], p=0.004) and SR (29 [17.3%], p=0.013). The odds of having splenomegaly doubled with malaria parasitaemia (odds ratio 2.03 [95% confidence interval 1.06 to 3.88). CONCLUSIONS: The PR and SR suggest that the study area is meso-endemic. The PR in the study area was almost equal across age groups; our findings suggest there may be a need for policy review to plan malaria intervention programmes and include older children, not just children <5 y of age. Routine malaria surveillance using simple tools such as the PR and SR are necessary for reviewing malaria control programmes in the community.

A comparative study of the prevalence of zinc deficiency among children with acute diarrhoea in SouthWestern Nigeria.

BACKGROUND: Zinc deficiency has been associated with increased incidence, severity and duration of childhood diarrhoea. OBJECTIVE: The objective of the study was to determine the prevalence of zinc deficiency among under-five children with acute diarrhoea. METHODS: The study was a comparative cross-sectional study in which serum zinc levels were determined using atomic absorption spectrometry in under-five children with acute diarrhoea and in apparently healthy contols. Two hundred and fifty children with acute diarrhoea and 250 controls were studied at the Wesley Guild Hospital, Ilesa, Nigeria. RESULTS: The diarrhoea patients had a mean ± SD serum zinc level of 78.8 ± 35.6 µg/dl, while the controls had a mean of 107.3 ± 46.8 µg/dl. The mean serum zinc level was significantly lower in the patients than the controls (t = -7.66; p < 0.001). Furthermore, the prevalence of zinc deficiency was significantly higher among the patients (30.4% versus 12.4% in the controls; OR = 3.09; 95% CI = 1.94 - 4.90; χ2 = 24.08; p < 0.001). Low social class was associated with a significantly higher prevalence of zinc deficiency among the patients (p = 0.013). CONCLUSION: Zinc deficiency is significantly associated with diarrhoea among under-five children in the study community. Hence, routine zinc supplementation should be encouraged for the treatment of diarrhoea, and availability should be ensured.

Prevalence of Vitamin A deficiency among under-five children in South-Western Nigeria.

BACKGROUND AND AIM: Vitamin A deficiency (VAD) constitutes a major nutritional concern in developing countries. It contributes significantly to the morbidity and mortality of under-five children and can result in impaired resistance to infection as well as increased risk of death. The aim of this study was to determine the prevalence of VAD among Southwestern Nigerian children. METHODS: Apparently healthy children aged between 6 months and 5 years were recruited for the study. Their serum retinol levels were determined by high-performance liquid chromatography. RESULTS: Of the 170 children studied, nine (5.3%) had VAD, although none had severe VAD. The prevalence of VAD did not show statistically significant variation with age (P = 0.159), sex (P = 1.000), social class (P = 0.740), immunisation status (P = 0.197) or nutritional status (P = 0.090). CONCLUSION: The prevalence of VAD among Nigerian children appears to have reduced, compared with previous reports; however, further studies are required to assess the current national prevalence, so as to design programmes that can achieve further reduction in the proportion of children affected.

Sickle cell disease in southwestern Nigeria: assessment of knowledge of primary health care workers and available facilities.

Background: Patients with sickle cell disease (SCD) benefit optimally from comprehensive care. In Nigeria, despite the huge burden, involvement of community health workers (CHWs) in the management of SCD is poor. Methods: This community-based study assessed SCD-related knowledge of 182 CHWs from the 46 primary health care (PHC) centres in Ilesa, southwestern Nigeria. Available facilities and management practices for SCD care at these centres were also evaluated using pretested self-administered questionnaires and observational checklists. Results: The majority of CHWs (167/182 [91.8%]) knew that SCD is an inheritable blood disorder. However, only 32.4% and 26.4% knew that SCD can be diagnosed in the prenatal and neonatal periods, respectively. Also 37.4%, 49.5% and 67.6% knew about the role of chemoprophylaxis (folic acid/penicillin), adequate fluids and malaria prevention, respectively, in SCD care. Overall, 37.9% had good knowledge on the nature and care of the disease. Just 2/46 (4.3%) PHC centres treat patients with SCD. SCD-targeted nutritional counselling and referral to secondary/tertiary hospitals were poor and unorganized. No centre offered SCD screening, home visits or recordkeeping. Conclusions: The level of SCD care and knowledge of CHWs at PHC centres in southwestern Nigeria of early SCD diagnosis and crisis prevention is poor. CHWs should be regularly trained and equipped for basic SCD management, including early detection, crisis prevention, prompt referral and provision of basic genetic counselling, to dispel associated myths and stigma.

Serum vitamin D profile of Nigerian children with asthma: Association with asthma severity and control.

OBJECTIVE: Childhood asthma is a chronic inflammatory airway disorder with increasing prevalence even in Africa. Vitamin D, with anti-inflammatory and immune-modulatory properties, may have effects on the severity and level of symptoms control in childhood asthma. We aimed to assess the serum vitamin D levels in children with asthma as related to disease severity and control in a tropical region. METHODS: A hospital based comparative cross sectional study was conducted in western Nigeria. Serum vitamin D (25-OH-D) levels of all the children, assayed using high-performance liquid chromatography (HPLC), were compared to the various disease severity and levels of asthma control as well as between the asthmatic and non-asthmatic children. RESULTS: A total of 206 children (103 asthmatics and 103 non-asthmatics) were recruited with a mean (SD) age of 6.6 (3.7) years. The majority (82.5%) of the children with asthma had mild intermittent form, 63.1% had well controlled symptoms while 33.0% and 3.9% had partly controlled and uncontrolled symptoms, respectively. None of the children were deficient in vitamin D. The mean (SD) serum vitamin D levels of the children with asthma (49.2 [7.2] ng/mL) was significantly lower than those without asthma (51.2 [6.9] ng/mL, P = 0.043). Varying degrees of asthma severity and levels of symptoms control were not affected by serum vitamin D levels. CONCLUSION: Children with asthma in Nigeria had marginally but significantly lower mean serum vitamin D levels when compared with their counterparts without asthma. However, serum vitamin D level does not seem to be associated with childhood asthma severity and control in these children with normal serum vitamin D levels.

Low serum vitamin A is prevalent in underfive children with severe malaria and is associated with increased risk of death.

INTRODUCTION: Micronutrient deficiencies are prevalent in developing countries and may influence vulnerability to diseases particularly malaria and its severity. This study investigated serum vitamin A profile of under-five children with severe malaria (SM) in South-western, Nigeria and to determine its association with degree of malaria parasitaemia, types of SM and eventual outcome. METHODOLOGY: Using HPLC, serum vitamin A concentrations of 170 under-five children with SM and 170 age- and gender-matched controls were determined. Parasite species identification and density were also determined. Association between serum vitamin A levels and the degree of parasitaemia, type of SM and patients' outcome were examined by both bivariate and logistic regression analyses. RESULTS: Thirty-five (20.6%) of the children with SM compared with 3 (1.8%) of the controls had hypovitaminosis A, p <0.001, OR = 14.4, 95% Confidence Interval = 4.4 - 47.8. The mean serum vitamin A concentration was also lower in the patients (45.23µg/dL vs. 87.28µg/dL; p <0.001). There was inverse correlation between serum vitamin A levels and malaria parasite density (r = - 0.103, p = 0.027). Higher proportions of children with SM and hypovitaminosis A presented with metabolic acidosis and cerebral malaria (p <0.001 and 0.032 respectively). Children with SM and hypovitaminosis A were 9.1 times more likely to die compared to those without low serum vitamin A levels, OR = 9.1, 95% Confidence Interval = 2.2-38.1, p = 0.002. CONCLUSION: Children with SM had reduced serum vitamin A and significantly contributed to increased morbidity and mortality.

Vitamin A deficiency among under-five Nigerian children with diarrhoea.

BACKGROUND: Vitamin A deficiency (VAD) and diarrhoea are still important contributors to childhood deaths in Africa, and vitamin A deficient children are at increased risk as well as severity of diarrhoea. OBJECTIVES: To determine the prevalence of VAD and identify the associated factors among children with diarrhoea. METHODS: The study was a hospital-based cross-sectional descriptive study. Consecutive children with diarrhoea were recruited, provided they met the inclusion criteria. Serum retinol levels were determined by high performance liquid chromatography (HPLC) in one hundred and seventy under-five children who presented with diarrhoea at the Wesley Guild Hospital, Ilesa, Nigeria. RESULTS: The serum retinol levels of the children ranged from 0.29 - 2.35 µmol/L with a mean ± SD of 1.07 ± 0.42 µmol/L. Twenty seven (15.9%) were vitamin A deficient with three (1.8%) of these having severe VAD. Wasting was significantly associated with a higher prevalence of VAD [p = 0.023, OR (95% CI) = 3.08 (1.21 - 7.79)]. A significantly greater proportion of the subjects who had VAD were hospitalized, compared with the non-deficient ones [p = 0.001, OR (95% CI) = 4.40 (1.82 - 10.66)]. The only subject who died was vitamin A deficient. CONCLUSION: Wasting and hospitalization are factors that may indicate the presence of VAD in a child with diarrhoea. Vitamin A supplements should therefore be given, as part of the treatment for diarrhoea, to children who have wasting, especially when they require hospitalization.

Efficacy of artemisinin combination therapy for the treatment of uncomplicated falciparum malaria in Nigerian children.

INTRODUCTION: The development and spread of Plasmodium falciparum resistance to most commonly used antimalarials remain a major challenge in the control of malaria. Constant monitoring of drug efficacy is an important tool in establishing rational antimalarial drug policies. METHODOLOGY: A randomized comparative study was conducted at the Wesley Guild Hospital, Ilesa, Nigeria between February 2010 and September 2011 comparing the efficacy and safety of artemether-lumefantrine (Coartem) and fixed dose of artesunate plus amodiaquine (Larimal) in the treatment of uncomplicated P. falciparum malaria in children betweem 6 and 144 months of age. P. falciparum malaria parasitemia was assessed by microscopy and rapid diagnostic test. Drugs were administered according to age for three days under supervision. The primary efficacy endpoint was a day 28 PCR-corrected parasitological cure. RESULTS: A total of 182 patients were enrolled in the two treatment groups, Coartem (n = 101) and Larimal (n = 81), and tested after 28 days. In the intention-to-treat population, Coartem (n = 101) and Larimal (n = 81) had a PCR-corrected cure rate of 98% and 100% respectively, while in the per-protocol population, Coartem (n = 89) and Larimal (n = 71) both had a PCR-corrected cure rate of 100% at day 28. Although parasite and fever clearance time was faster in the Larimal group, no significant difference was observed between the two drugs. No serious adverse effects  were reported. CONCLUSION: Five years after being introduced in Nigeria, both Coartem and Larimal have been shown to be safe and highly effective in the treatment of uncomplicated P. falciparum malaria in children.

Efficacy of Artemisinin Combination Therapy for the Treatment of Uncomplicated Falciparum Malaria in Nigerian Children

Introduction: The development and spread of Plasmodium falciparum resistance to most commonly used antimalarials remain a major challenge in the control of malaria. Constant monitoring of drug efficacy is an important tool in establishing rational antimalarial drug policies.Methodology: A randomized comparative study was conducted at the Wesley Guild Hospital; Ilesa; Nigeria between February 2010 and September 2011 comparing the efficacy and safety of artemether-lumefantrine (Coartem) and fixed dose of artesunate plus amodiaquine (Larimal) in the treatment of uncomplicated P. falciparum malaria in children betweem 6 and 144 months of age. P. falciparum malaria parasitemia was assessed by microscopy and rapid diagnostic test. Drugs were administered according to age for three days under supervision. The primary efficacy endpoint was a day 28 PCR-corrected parasitological cure. Results: A total of 182 patients were enrolled in the two treatment groups; Coartem (n = 101) and Larimal (n = 81); and tested after 28 days. In the intention-to-treat population; Coartem (n= 101) and Larimal (n= 81) had a PCR-corrected cure rate of 98 and 100 respectively; while in the per-protocol population; Coartem (n = 89) and Larimal (n = 71) both had a PCR-corrected cure rate of 100 at day 28. Although parasite and fever clearance time was faster in the Larimal group; no significant difference was observed between the two drugs. No serious adverse effects were reported. Conclusion: Five years after being introduced in Nigeria; both Coartem and Larimal have been shown to be safe and highly effective in the treatment of uncomplicated P. falciparum malaria in children

Preliminary trial of aloe vera gruel on HIV infection.

BACKGROUND: Ten (10) young women diagnosed with human immunodeficiency virus (HIV) infection in the Wesley Guild Hospital Ilesa, a unit of Obafemi Awolowo University Teaching Hospital, Ile Ife, Osun State, Nigeria who did not meet the national criteria for the use of antiretroviral drugs were managed with 30-40 mL of aloe vera (Aloe barbadensis miller) gruel daily. METHODS: Their CD4 counts, general improvement, and physical well-being (including weight gain) were monitored over a 1-year period. The findings were compared with those of 20 age- matched controls who were on antiretroviral drugs. One (1) patient who reacted badly to antiretroviral drug switched over to aloe vera. RESULTS: The average weight gain among those on aloe vera was 4.7 kg compared to 4.8 kg by those on antiretroviral drug (p=0.916). The average rise in CD4 count among them was 153.7 cells/µL compared to 238.85 cells/µL among the controls (p=0.087). There was no significant side effect(s) in either group except in the 1 patient who switched over from antiretroviral drugs to aloe vera gruel. CONCLUSIONS: These preliminary data suggest that consumption of aloe vera may be of help to HIV-infected individuals in the tropics, given its availability and inexpensiveness.

Effectiveness of dried Carica papaya seeds against human intestinal parasitosis: a pilot study.

The tropical fruit Carica papaya and its seeds have proven antihelminthic and anti-amoebic activities. To determine the effectiveness of air-dried C. papaya seeds on human intestinal parasitosis, 60 asymptomatic Nigerian children with stool microscopic evidence of intestinal parasites received immediate doses (20 mL) of either an elixir composed with air-dried C. papaya seeds and honey (CPH) or honey alone (placebo) in two randomized treatment groups. Repeat stool microscopic examinations were conducted 7 days postintervention for intestinal parasites. Significantly more subjects given CPH elixir than those given honey had their stools cleared of parasites [23 of 30 (76.7%) vs. five of 30 (16.7%); z = 4.40, P = .0000109]. There were no harmful effects. The stool clearance rate for the various types of parasites encountered was between 71.4% and 100% following CPH elixir treatment compared with 0-15.4% with honey. Thus, air-dried C. papaya seeds are efficacious in treating human intestinal parasites and without significant side effects. Their consumption offers a cheap, natural, harmless, readily available monotherapy and preventive strategy against intestinal parasitosis, especially in tropical communities. Further and large-scale intervention studies to compare C. papaya with standard antiparasitic preparation are desirous.

Maternal factors in the etiology of fetal malnutrition in Nigeria.

BACKGROUND: The main objective of the study was to determine the role of maternal factors in the etiology of fetal malnutrition (FM) in Nigeria. Neonatal and Maternity Units of the Wesley Guild Hospital Ilesa, Nigeria, a unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife was the setting for the study. METHODS: This was a prospective study of consecutive, singleton, term live babies delivered between January and August 2001. Fetal malnutrition was diagnosed using Clinical Assessment of Fetal Nutritional Status (CANS) and the score (CANSCORE) adapted by Metcoff. The maternal prenatal record was checked and additional history was obtained from the mother. This included history of maternal illness and drugs taken during pregnancy. The socioeconomic class of the parents was also documented. Nutritional status of the mother was determined using mid arm circumference (MAC) and the body mass index (BMI). Babies were stratified into babies with FM and babies without FM. The two groups of babies were compared. RESULTS: Of the 473 studied, 89 [18.8%] had FM. Maternal factors found associated with FM were: lack of antenatal care, young mother (<18 years), primiparity, maternal undernutrition (BMI < 18.5 kg/m(2) and MAC < 23.5 cm), low socioeconomic status, pregnancy-induced hypertension, antepatum hemorrhage, and maternal infections especially malaria, urinary tract infections and HIV (P < 0.05). CONCLUSION: Improvement in the socioeconomic status of women and good antenatal care will reduce most of the maternal factors associated with FM in Nigeria. Therefore, antenatal should be made cheap and accessible to all pregnant mothers.

Comparison of healing of incised abscess wounds with honey and EUSOL dressing.

OBJECTIVE: To clinically compare the healing of abscess wounds dressed with either crude undiluted honey or Edinburgh University solution of lime (EUSOL). DESIGN: A prospective clinical randomized study. LOCATION: The Isolation Children's Ward of the Wesley Guild Hospital, Ilesa, an affiliate of the Obafemi Awolowo University, Ile-Ife, Nigeria. SUBJECTS: Thirty-two (32) Nigerian children with 43 pyomyositis abcesses. INTERVENTIONS: All subjects had fresh surgical incision and drainage of the abcesses and a 21-day course of ampicillin plus cloxacillin (Ampiclox) and gentamicin; the wounds were left to close spontaneously with twice-daily wound dressing with packing of the abscess cavity with either honey- or EUSOL-soaked gauze in two randomized treatment groups. OUTCOME MEASURES: The clinical conditions of the wound sites were documented on days 1, 3, 7, and 21 as either clean or dirty, dry or wet, granulation tissue present or absent, and epithelialization present or absent; the length of hospital stay was also measured. RESULTS: Honey-treated wounds demonstrated quicker healing and the length of hospital stay was significantly shorter in patients with honey-treated wounds than those treated with EUSOL (t = 2.45, p = 0.019). CONCLUSIONS: Honey is a superior wound dressing agent to EUSOL. Honey is recommended for the dressing of infected wounds, more so in tropical countries, where it is most readily available.