Current pattern of ocular trauma as seen in tertiary institutions in south-eastern Nigeria.

BACKGROUND: Ocular trauma is a leading cause of monocular blindness worldwide and in developing countries, are not only more common but also more severe. Industrialization and urbanization may alter or modify prevalent aetiological factors and the presentation of ocular trauma. OBJECTIVE: To determine the current pattern of eye injuries in Teaching Hospitals in Enugu State. METHODS: This prospective cross-sectional descriptive study was carried out at the eye clinics and emergency units of two tertiary institutions in Enugu, Nigeria. Consecutive ocular trauma patients were enrolled over a 5-month period. On presentation, they underwent ocular examination including visual acuity (which was categorized according to the WHO classification of visual impairment and blindness}, anterior and posterior segment examinations. Injuries were grouped using the Birmingham Eye Trauma Terminology system. RESULTS: Within the study period, 2545 new patients presented to the hospitals where the study was conducted. A total of 89 patients presented with ocular trauma, giving an incidence of 3.5%. The male to female ratio was 1.3:1 and patients aged 10 to 19 years formed the majority (24%). Domestic accidents (22%) were the most common cause of ocular injuries while blunt objects (57%) were the most common agents. Closed globe injuries constituted 76% of all injuries. Forty-three per cent of patients presented within 24 h of injury. CONCLUSION: Ocular trauma is still prevalent in South-eastern Nigeria and there has indeed been a change in the pattern as well as the incidence. Assault and road traffic accidents have emerged as important causes of eye injuries. In addition, there has been an improvement in the health-seeking behaviour of people living in Enugu and this may reflect positively on the uptake of recommended preventive strategies.

Refractive Error and Visual Impairment Among School Children: Result of a South-Eastern Nigerian Regional Survey.

PURPOSE: To determine the prevalence refractive errors and causes of visual impairment in school children in the south-eastern region of Nigeria. METHODS: School-based cross-sectional samples of children 5 to 15 of age in both urban and rural areas were profiled through cluster sampling. The main outcome measures were presenting, uncorrected, and best-corrected visual acuity using the Refractive Error in School-age Children (RESC) protocol. RESULTS: A total of 5723 children were examined during the study period comprising 2686 (46.9%) males and 3037 (53.1%) females; (M:F ratio 0.9:1) and aged 10.49±2.74SD of mean (range, 5 to 15 years). The age group 12 to <13 accounted for the highest 776 (13.6%) number of the study participants. The uncorrected visual acuity (VA) of <20/40 (6/12) was seen in 188 (3.4%) of the study participants while the presenting and best-corrected visual acuity of <20/40 (6/12) were noted in 182 (3.4%) children and 14 (0.2%) children, respectively. Refractive error was the principal cause of visual impairment. CONCLUSION: Prevalence of refractive error is low. Myopia is the principal cause of refractive error occurring more in females and in urban schools. The main cause of visual impairment is refractive error, and most children that need spectacle correction did not have them. Program to identify children with refractive error in addition to providing free or affordable optical services remains the key to preventing visual impairment from refractive error particularly in resource-poor settings.

Technical capacities needed to implement the WHO's primary eye care package for Africa: results of a Delphi process.

OBJECTIVE: The aim of the study was to establish the technical capacities needed to deliver the WHO African Region's primary eye care package in primary healthcare facilities. DESIGN: A two-round Delphi exercise was used to obtain expert consensus on the technical complexity of each component of the package and the technical capacities needed to deliver them using Gericke's framework of technical feasibility. The panel comprised nine eyecare experts in primary eyecare in sub-Saharan Africa. In each round panel members used a 4-point Likert scale to indicate their level of agreement. Consensus was predefined as ≥70% agreement on each statement. For round 1, statements on technical complexity were identified through a literature search of primary eyecare in sub-Saharan Africa from January 1980 to April 2018. Statements for which consensus was achieved were included in round 2, and the technical capacities were agreed. RESULTS: Technical complexity statements were classified into four broad categories: intervention characteristics, delivery characteristics, government capacity requirements and usage characteristics. 34 of the 38 (89%) statements on health promotion and 40 of the 43 (93%) statements on facility case management were considered necessary technical capacities for implementation. CONCLUSION: This study establishes the technical capacities needed to implement the WHO Africa Office primary eye care package, which may be generalisable to countries in sub-Saharan Africa.

Dry Eye Disease: Concordance Between the Diagnostic Tests in African Eyes.

OBJECTIVE: To assess the concordance between the diagnostic tests for dry eye disease (DED) in a Nigerian hospital population. METHODS: The study was a hospital-based cross-sectional survey of adults (≥18 years) presenting at the eye clinic of the University of Nigeria Teaching Hospital (UNTH), Enugu; September-December, 2011. Participants' socio-demographic data were collected. Each subject was assessed for DED using the "Ocular Surface Disease Index" (OSDI) questionnaire, tear-film breakup time (TBUT), and Schirmer test. The intertest concordance was assessed using kappa statistic, correlation, and regression coefficients. RESULTS: The participants (n=402; men: 193) were aged 50.1±19.1 standard deviation years (range: 18-94 years). Dry eye disease was diagnosed in 203 by TBUT, 170 by Schirmer test, and 295 by OSDI; the concordance between the tests were OSDI versus TBUT (Kappa, κ=-0.194); OSDI versus Schirmer (κ=-0.276); and TBUT versus Schirmer (κ=0.082). Ocular Surface Disease Index was inversely correlated with Schirmer test (Spearman ρ=-0.231, P<0.001) and TBUT (ρ=-0.237, P<0.001). In the linear regression model, OSDI was poorly predicted by TBUT (ß=-0.09; 95% confidence interval (CI): -0.26 to -0.03, P=0.14) and Schirmer test (ß=-0.35, 95% CI: -0.53 to -0.18, P=0.18). CONCLUSION: At UNTH, there is poor agreement, and almost equal correlation, between the subjective and objective tests for DED. Therefore, the selection of diagnostic test for DED should be informed by cost-effectiveness and diagnostic resource availability, not diagnostic efficiency or utility.

Eye Injuries Among Primary School Children in Enugu, Nigeria: Rural vs Urban.

A cross-sectional survey of the prevalence of eye injuries among primary school children in two noncontiguous local government areas of Enugu State of Nigeria was undertaken. One of the local government areas was urban, while the other one was rural. Children who were <15 years in two randomly selected primary schools in the urban area and three randomly selected schools in the rural area were interviewed and examined with Snellen chart, pen torch, head loupe, and direct ophthalmoscope. The findings were recorded using a semi-structured questionnaire and the World Health Organization Programme for Prevention of Blindness (WHO/PBL) eye examination form. Training on visual acuity measurement was done for each of the class teachers. A total of 1,236 children <15 years of age were studied and analyzed. Slightly more females, 652 (52.8%), than males, 584 (47.2%), constituted the sample population giving a female/male ratio of 1.1:1. A total of 98 (7.93%) children had evidence of injury to the eye or its adnexa. Eyelid scar was the commonest (5.34%) followed by eyebrow scar (2.10%). Canthal scar was the next (0.32%). Two girls had monocular blindness from eye trauma (0.16%). One had leucoma, while the other had a dislocated lens. All the monocular blind children of this study were from the urban area. The home was the commonest environment for an eye injury (69.39%) followed by the school (20.41%). The farm was next in frequency (7.14%), especially among boys in the rural area. The church and the road/street constituted the remainder. Regarding persons causing the injury, the child's playmate was the commonest (55.10%) followed by self (27.55%). Parents and guardians were the next (9.18%). These were injuries associated with corporal punishment. Corporal punishment-related eye injury, according to this study, appears to be common in the rural area and affects boys predominantly. Other human intermediary agents that cause an eye injury include passersby (2.04%), RTA (2.04%), siblings (2.04%), and others (1.02%). The primary agents that caused an eye injury were sticks/wood, 29 (29.60%); stone, 21 (21.43%); pieces of metal, 19 (19.39%); fall, 10 (10.20%); fight/fist blow, 9 (9.918%); plastic, 2 (2.04%); fingernails, 2 (2.04%); farm tools/fruits, 2 (2.04%); and RTA, glass, and headbutt, each 1.02%. Farm implements/fruits as well as fingernails appear to be fairly common primary agents that cause an eye injury in the rural Enugu, Nigeria. In terms of prevalence, there was no significant difference between the urban and rural areas. The findings from this study showed a high prevalence of eye injury among primary school children. In terms of treatment, 58.16% of the children with an eye injury had no form of treatment for it. The children from this study with monocular blindness did not receive adequate medical treatment. Treatment of an eye injury, according to this study, was sought from chemists (19.39%), at hospital/health centers (16.33%), at home (3.06%), and from traditional healers (3.06%). The persons who treated an eye injury, as observed from this study, were doctors (14.29%), nurses (4.08%), chemists (17.35%), and traditional healers and fathers (3.06% each). The frequency of noninjury-related diagnosis made in this study was refractive error, 4.85%; allergic conjunctivitis, 1.94%; oculocutaneous albinism, 0.24%; prepapillary vascular loops, 0.40%; and then ptosis, exotropia, stye, corneal opacity, and retinitis pigmentosa, 0.08% each. The annual incidence of an eye injury according to this study was 3.48%. The majority of the causes of an eye injury, as per this study, were preventable. Appropriate promotion of preventive eye care among children may go a long way in reducing the burden of blindness from eye injuries.

The performance evaluation of a urine malaria test (UMT) kit for the diagnosis of malaria in individuals with fever in south-east Nigeria: cross-sectional analytical study.

BACKGROUND: Accurate rapid diagnosis is one of the important steps in the effort to reduce morbidity and mortality of malaria. Blood-specific malaria rapid diagnostic tests (RDTs) are currently in use but other body fluid specific diagnostic test kits are being developed. The aim of the present study was to evaluate the performance characteristics of a one-step Urine Malaria Test™ (UMT) dipstick in detecting Plasmodium falciparum HRP2, a poly-histidine antigen in urine of febrile patients for malaria diagnosis. METHODS: This was an observational study in which a urine-based malaria test kit was used in malaria diagnosis in a normal field setting. Two hundred and three individuals who presented with fever (≥37.5°C) at seven outpatient clinics in Enugu State during periods of high and low transmission seasons in Southeastern Nigeria were enrolled. Matched samples of urine and blood of consecutively enrolled subjects were tested with UMT and blood smear microscopy. RESULTS: With the blood smear microscopy as standard, the disease prevalence was 41.2% and sensitivity for the UMT was 83.75% (CI: 73.81 to 91.95%, Kappa 0.665, p =0.001). The UMT had an LLD of 120 parasites/µl but the sensitivity at parasite density less than ≤200 parasites/µl was 50% and 89.71% at density ≥201 parasites/µl with specificity of 83.48%. The positive and negative predictive values were 77.91% and 88.07%, respectively. CONCLUSION: The UMT showed moderate level of sensitivity compared with blood smear microscopy. The test kit requires further improvement on its sensitivity in order to be deployable for field use in malaria endemic regions.

Prevalence of presbyopia in a rural African community.

INTRODUCTION: When presbyopia (loss of accommodation of the crystalline lens with increasing age) sets in, doing near work becomes associated with headache and eye strain. Reading and writing become a challenge. Literacy levels may be low in rural communities; nevertheless some work other than reading, like sewing, sorting stone from grain and operating mobile phones, is done with dissatisfaction. This study aims to determine the prevalence of presbyopia, the unmet presbyopia need and the presbyopia correction coverage in a rural African community. METHODS: A population-based cross-sectional study was carried out in a rural population aged 35 years and greater, selected by cluster random sampling. Information was sought on biodata of the participants and they were subsequently examined. Distance visual acuity for each participant was determined. Anterior and posterior segments of the eyes were examined. Objective refraction with subjective refinement was done on all subjects with distant visual acuity less than 6/6. Near visual acuity was assessed at 40 cm with distant correction in place if required. Presbyopia was defined as inability to read N8 at 40 cm or requiring an addition of at least +1.00DS to improve near vision to at least N8. Questionnaires were administered to those identified as presbyopic on source of procurement of spectacles (if they had one) and on reasons for non-procurement of presbyopic spectacles. They were also asked to rate their difficulty with various listed near work. Data entry and analysis were done using Statistical Package for the Social Sciences v16.0 and Program for Epidemiologist v4.01 software. RESULTS: A total of 585 subjects (participation rate 81.1%) aged 35 years and greater were interviewed and examined. The prevalence of presbyopia was 63.4% (95% confidence interval (CI) 62.6-64.2%). There was increasing prevalence with increasing age. The met presbyopia need was 17.6%, unmet need was 45.8% and presbyopic correction coverage was 27.8%. The commonest reasons for not procuring presbyopic correction were 'not a priority' (21.5%) and 'cost' (21.2%). CONCLUSIONS: The prevalence of presbyopia in this rural African community is high. Many who need presbyopic correction do not have corrective spectacles.

Immunogenicity and safety of the candidate RTS,S/AS01 vaccine in young Nigerian children: a randomized, double-blind, lot-to-lot consistency trial.

BACKGROUND: For regulatory approval, consistency in manufacturing of vaccine lots is expected to be demonstrated in confirmatory immunogenicity studies using two-sided equivalence trials. This randomized, double-blind study (NCT01323972) assessed consistency of three RTS,S/AS01 malaria vaccine batches formulated from commercial-scale purified antigen bulk lots in terms of anti-CS-responses induced. METHODS: Healthy children aged 5-17 months were randomized (1:1:1:1) to receive RTS,S/AS01 at 0-1-2 months from one of three commercial-scale purified antigen bulk lots (1600 litres-fermentation scale; commercial-scale lots), or a comparator vaccine batch made from pilot-scale purified antigen bulk lot (20 litres-fermentation scale; pilot-scale lot). The co-primary objectives were to first demonstrate consistency of antibody responses against circumsporozoite (CS) protein at one month post-dose 3 for the three commercial-scale lots and second demonstrate non-inferiority of anti-CS antibody responses at one month post-dose 3 for the commercial-scale lots compared to the pilot-scale lot. Safety and reactogenicity were evaluated as secondary endpoints. RESULTS: One month post-dose-3, anti-CS antibody geometric mean titres (GMT) for the 3 commercial scale lots were 319.6 EU/ml (95% confidence interval (CI): 268.9-379.8), 241.4 EU/ml (207.6-280.7), and 302.3 EU/ml (259.4-352.3). Consistency for the RTS,S/AS01 commercial-scale lots was demonstrated as the two-sided 95% CI of the anti-CS antibody GMT ratio between each pair of lots was within the range of 0.5-2.0. GMT of the pooled commercial-scale lots (285.8 EU/ml (260.7-313.3)) was non-inferior to the pilot-scale lot (271.7 EU/ml (228.5-323.1)). Each RTS,S/AS01 lot had an acceptable tolerability profile, with infrequent reports of grade 3 solicited symptoms. No safety signals were identified and no serious adverse events were considered related to vaccination. CONCLUSIONS: RTS,S/AS01 lots formulated from commercial-scale purified antigen bulk batches induced a consistent anti-CS antibody response, and the anti-CS GMT of pooled commercial-scale lots was non-inferior to that of a lot formulated from a pilot-scale antigen bulk batch.

Dry eye disease: prevalence, distribution and determinants in a hospital-based population.

OBJECTIVES: To determine the prevalence, distribution and risk factors for dry eye disease (DED) in a tertiary ophthalmic outpatient population. METHODS: The study was a cross-sectional descriptive hospital-based survey conducted at the Eye clinic of the University of Nigeria Teaching Hospital (UNTH), Enugu, between September and December, 2011. The participants comprised adult ophthalmic outpatients aged 18 years or older. Participants' sociodemographic data were obtained. Dry eye disease was assessed subjectively with the Ocular Surface Disease Index (OSDI) questionnaire; and objectively with Schirmer's test and Tear-film Break-up Time (TBUT). An OSDI score of ≥ 50 with a TBUT of <10s or Schirmer's test reading of <10mm was considered diagnostic of DED. Descriptive and analytical statistics were performed. In all comparisons, a p<0.05 was considered statistically significant. RESULTS: The participants (n=402) comprised 193 males and 209 females who were aged 50.1 ± 19.06 SD years (range 18-94 years). The majorities of the participants were married - 74.1%, possessed formal education - 86.0% and were civil servants - 33.6%. The prevalence of DED was 19.2%. Dry eye disease was significantly associated with age>40 years (OR 1.88, 95% CI 1.06-3.35, p=0.0004), non-possession of formal education (OR 0.40, 95% CI 0.21-0.74, p=0.001) but not gender (OR 1.48, 95% CI 0.89-2.46, p=0.158). CONCLUSION: The prevalence of DED among ophthalmic outpatients at UNTH, Enugu, is comparatively high. Older age and illiteracy are predictors of DED. There is need for high index of diagnostic suspicion to prevent sight-threatening complications of DED.

Chlorproguanil-dapsone-artesunate versus artemether-lumefantrine: a randomized, double-blind phase III trial in African children and adolescents with uncomplicated Plasmodium falciparum malaria.

BACKGROUND: Chlorproguanil-dapsone-artesunate (CDA) was developed as an affordable, simple, fixed-dose artemisinin-based combination therapy for use in Africa. This trial was a randomized parallel-group, double-blind, double-dummy study to compare CDA and artemether-lumefantrine (AL) efficacy in uncomplicated Plasmodium falciparum malaria and further define the CDA safety profile, particularly its hematological safety in glucose-6-phosphate dehydrogenase (G6PD) -deficient patients. METHODS AND FINDINGS: The trial was conducted at medical centers at 11 sites in five African countries between June 2006 and August 2007. 1372 patients (> or =1 to <15 years old, median age 3 years) with acute uncomplicated P. falciparum malaria were randomized (2:1) to receive CDA 2/2.5/4 mg/kg once daily for three days (N = 914) or six-doses of AL over three days (N = 458). Non-inferiority of CDA versus AL for efficacy was evaluated in the Day 28 per-protocol (PP) population using parasitological cure (polymerase chain reaction [PCR]-corrected). Cure rates were 94.1% (703/747) for CDA and 97.4% (369/379) for AL (treatment difference -3.3%, 95%CI -5.6, -0.9). CDA was non-inferior to AL, but there was simultaneous superiority of AL (upper 95%CI limit <0). Adequate clinical and parasitological response at Day 28 (uncorrected for reinfection) was 79% (604/765) with CDA and 83% (315/381) with AL. In patients with a G6PD-deficient genotype (94/603 [16%] hemizygous males, 22/598 [4%] homozygous females), CDA had the propensity to cause severe and clinically concerning hemoglobin decreases: the mean hemoglobin nadir was 75 g/L (95%CI 71, 79) at Day 7 versus 97 g/L (95%CI 91, 102) for AL. There were three deaths, unrelated to study medication (two with CDA, one with AL). CONCLUSIONS: Although parasitologically effective at Day 28, the hemolytic potential of CDA in G6PD-deficient patients makes it unsuitable for use in a public health setting in Africa. TRIAL REGISTRATION: ClinicalTrials.Gov NCT00344006.