Livestock herding and Fulani ethnicity are a combined risk factor for development of early adverse reactions to antivenom treatment: Findings from a cross-sectional study in Nigeria.

BACKGROUND: Adverse reactions to antivenom considerably complicate the clinical management of snakebite envenomed patients because it necessitates a temporary suspension of life-saving antivenom, increases costs and can compromise patient outcomes. This study sought to explore the association between cattle-herding occupation and ethnic group and the occurrence of early adverse reactions to antivenom. METHODS: This cross-sectional study was conducted between the 25th April and 11th July 2011 at the Kaltungo General Hospital in north east Nigeria. The exposure variable of cattle-herding occupation showed a strong correlation with the ethnic group variable, thus these were combined into a new variable with three categories (Fulani and herder, either Fulani or herder, and neither Fulani nor herder). The outcome variable was the occurrence of early adverse reactions, defined as any new symptoms occurring within 6 hours of antivenom administration. Odds Ratios were estimated using multivariable logistic regression models controlling for potential confounders. RESULTS: Among 231 envenomed snakebite victims, the overall incidence of early adverse reactions was 11.9% (95% confidence intervals: 8.0-16.9%). Patients who were Fulani and herders had a higher incidence of early adverse reactions compared to patients who were neither Fulani nor herders (20% vs 5.7%). After adjusting for age and gender, victims who were Fulani and herders were 5.9 times more likely to have an early adverse reaction, compared to victims who were neither Fulani nor herders (95% CI: 1.88-18.59; p = 0.002). INTERPRETATION: To the best of our knowledge, this is the first study to provide evidence of higher odds of early adverse reactions among patients from a particular occupation and/or ethnic group. We recommend that snake envenomed patients of Fulani origin be especially closely monitored for adverse reactions, that hospitals receiving these patients be appropriately resourced to manage both envenoming and adverse reactions and that premedication with adrenaline should be considered. Our findings provide an argument for speculation on the influence of immunological or lifestyle-related differences on the occurrence of early adverse reactions to antivenom.

Mortality Among Confirmed Lassa Fever Cases During the 2015-2016 Outbreak in Nigeria.

OBJECTIVES: To determine factors associated with mortality among confirmed Lassa fever cases. METHODS: We reviewed line lists and clinical records of laboratory-confirmed cases of Lassa fever during the 2016 outbreak in Nigeria to determine factors associated with mortality. We activated an incident command system to coordinate response. RESULTS: We documented 47 cases, 28 of whom died (case fatality rate [CFR] = 59.6%; mean age 31.4 years; SD = ±18.4 years). The youngest and the oldest were the most likely to die, with 100% mortality in those aged 5 years or younger and those aged 55 years or older. Patients who commenced ribavirin were more likely to survive (odds ratio [OR] = 0.1; 95% confidence interval [CI] = 0.03, 0.50). Fatality rates went from 100% (wave 1) through 69% (wave 2) to 31% (wave 3; χ2 for linear trend: P < .01). Patients admitted to a health care center before incident command system activation were more likely to die (OR = 4.4; 95% CI = 1.1, 17.6). The only pregnant patient in the study died postpartum. CONCLUSIONS: Effective, coordinated response reduces mortality from public health events. Attention to vulnerable groups during disasters is essential. Public Health Implications. Activating an incident command system improves the outcome of disasters in resource-constrained settings.

Clinical profile and containment of the Ebola virus disease outbreak in two large West African cities, Nigeria, July-September 2014.

INTRODUCTION: The Ebola virus disease (EVD) outbreak in Nigeria began when an infected diplomat from Liberia arrived in Lagos, the most populous city in Africa, with subsequent transmission to another large city. METHODS: First-, second-, and third-generation contacts were traced, monitored, and classified. Symptomatic contacts were managed at Ebola treatment centers as suspected, probable, and confirmed EVD cases using standard operating procedures adapted from the World Health Organization EVD guidelines. Reverse transcription PCR tests confirmed EVD. Socio-demographic, clinical, hospitalization, and outcome data of the July-September 2014 Nigeria EVD cohort were analyzed. RESULTS: The median age of the 20 EVD cases was 33 years (interquartile range 26-62 years). More females (55%), health workers (65%), and persons <40 years old (60%) were infected than males, non-health workers, and persons aged ≥40 years. No EVD case management worker contracted the disease. Presenting symptoms were fever (85%), fatigue (70%), and diarrhea (65%). Clinical syndromes were gastroenteritis (45%), hemorrhage (30%), and encephalopathy (15%). The case-fatality rate was 40% and there was one mental health complication. The average duration from symptom onset to presentation was 3±2 days among survivors and 5±2 days for non-survivors. The mean duration from symptom onset to discharge was 15±5 days for survivors and 11±2 days for non-survivors. Mortality was higher in the older age group, males, and those presenting late. CONCLUSION: The EVD outbreak in Nigeria was characterized by the severe febrile gastroenteritis syndrome typical of the West African outbreak, better outcomes, rapid containment, and no infection among EVD care-providers. Early case detection, an effective incident management system, and prompt case management with on-site mobilization and training of local professionals were key to the outcome.

Seroprevalence of Hepatitis B Infection in Nigeria: A National Survey.

Hepatitis B virus (HBV) infection accounts for about 1 million deaths worldwide annually. This study was to determine the prevalence, distribution of HBV, and factors associated with infection in an apparently healthy population in Nigeria. A cross-sectional study among the general population was conducted employing a multistage sampling technique. Data on demographic, social, and behavioral indicators were collected using questionnaires and blood samples tested for HBV seromarkers. Descriptive, bivariate, and multivariate analyses were done. Prevalence of hepatitis B infection was 12.2% (confidence interval [CI] = 10.3-14.5). Of the participants, more than half, 527 (54.6%), had evidence of previous exposure to HBV, while 306 (31.7%) showed no serologic evidence of infection or vaccination. Only 76 (7.9%) participants showed serologic evidence of immunity to HBV through vaccination. Factors associated with testing positive for HBV infection were dental procedure outside the health facility (odds ratios [OR] = 3.4, 95% CI = 1.52-7.70), local circumcision (OR = 1.73, 95% CI = 1.17-2.57), and uvulectomy (OR = 1.65, 95% CI = 1.06-2.57). With logistic regression, only dental procedure outside the health facility (adjusted OR = 3.32, 95% CI = 1.38-7.97) remained significant. This first national survey on seroprevalence of hepatitis B describes the epidemiology and high prevalence of HBV infection in Nigeria and highlights the need for improved vaccination against HBV.

Development of a Cost-effective Ovine Polyclonal Antibody-Based Product, EBOTAb, to Treat Ebola Virus Infection.

The highly glycosylated glycoprotein spike of Ebola virus (EBOV-GP1,2) is the primary target of the humoral host response. Recombinant EBOV-GP ectodomain (EBOV-GP1,2ecto) expressed in mammalian cells was used to immunize sheep and elicited a robust immune response and produced high titers of high avidity polyclonal antibodies. Investigation of the neutralizing activity of the ovine antisera in vitro revealed that it neutralized EBOV. A pool of intact ovine immunoglobulin G, herein termed EBOTAb, was prepared from the antisera and used for an in vivo guinea pig study. When EBOTAb was delivered 6 hours after challenge, all animals survived without experiencing fever or other clinical manifestations. In a second series of guinea pig studies, the administration of EBOTAb dosing was delayed for 48 or 72 hours after challenge, resulting in 100% and 75% survival, respectively. These studies illustrate the usefulness of EBOTAb in protecting against EBOV-induced disease.

Epidemiological profile of the Ebola virus disease outbreak in Nigeria, July-September 2014.

INTRODUCTION: In July 2014, Nigeria experienced an outbreak of Ebola virus disease following the introduction of the disease by an ill Liberian Traveler. The Government of Nigeria with the support of Technical and Development Partners responded quickly and effectively to contain the outbreak. The epidemiological profile of the outbreak that majorly affected two States in the country in terms of person, place and time characteristics of the cases identified is hereby described. METHODS: Using field investigation technique, all confirmed and probable cases were identified, line-listed and analysed using Microsoft Excel 2007 by persons, time and place. RESULTS: A total of 20 confirmed and probable cases; 16 in Lagos (including the index case from Liberia) and 4 in Port Harcourt were identified. The mean age was 39.5 ± 12.4 years with over 40% within the age group 30-39 years. The most frequent exposure type was direct physical contact in 70% of all cases and 73% among health care workers. The total case-fatality was 40%; higher among healthcare workers (46%) compared with non-healthcare workers (22%). The epidemic curve initially shows a typical common source outbreak, followed by a propagated pattern. CONCLUSION: Investigation revealed the size and spread of the outbreak and provided information on the characteristics of persons, time and place. Enhanced surveillance measures, including contact tracing and follow- up proved very useful in early case detection and containment of the outbreak.

An evaluation of psychological distress and social support of survivors and contacts of Ebola virus disease infection and their relatives in Lagos, Nigeria: a cross sectional study--2014.

BACKGROUND: By September 2014, an outbreak of Ebola Viral Disease (EVD) in West African countries of Guinea, Liberia, Sierra Leone, Senegal and Nigeria, had recorded over 4500 and 2200 probable or confirmed cases and deaths respectively. EVD, an emerging infectious disease, can create fear and panic among patients, contacts and relatives, which could be a risk factor for psychological distress. Psychological distress among this subgroup could have public health implication for control of EVD, because of potential effects on patient management and contact tracing. We determined the Prevalence, pattern and factors associated with psychological distress among survivors and contacts of EVD and their relatives. METHODS: In a descriptive cross sectional study, we used General Health Questionnaire to assess psychological distress and Oslo Social Support Scale to assess social support among 117 participants who survived EVD, listed as EVD contacts or their relatives at Ebola Emergency Operation Center in Lagos, Nigeria. Factors associated with psychological distress were determined using chi square/odds ratio and adjusted odds ratio. RESULTS: The mean age and standard deviation of participants was 34 +/ - 9.6 years. Of 117 participants, 78 (66.7%) were females, 77 (65.8%) had a tertiary education and 45 (38.5%) were health workers. Most frequently occurring psychological distress were inability to concentrate (37.6%) and loss of sleep over worry (33.3%). Losing a relation to EVD outbreak (OR = 6.0, 95% CI, 1.2-32.9) was significantly associated with feeling unhappy or depressed while being a health worker was protective (OR = 0.4, 95% CI, 0.2-0.9). Adjusted Odds Ratio (AOR) showed losing a relation (AOR = 5.7, 95% CI, 1.2-28.0) was a predictor of "feeling unhappy or depressed", loss of a relation (AOR = 10.1, 95% CI, 1.7-60.7) was a predictor of inability to concentrate. CONCLUSIONS: Survivors and contacts of EVD and their relations develop psychological distress. Development of psychological distress could be predicted by loss of family member. It is recommended that psychiatrists and other mental health specialists be part of case management teams. The clinical teams managing EVD patients should be trained on recognition of common psychological distress among patients. A mental health specialist should review contacts being monitored for EVD for psychological distress or disorders.

Ebola virus disease - gaps in knowledge and practice among healthcare workers in Lagos, August 2014.

OBJECTIVE: Healthcare workers (HCWs) play pivotal roles in outbreak responses. Ebola virus disease (EVD) outbreak spread to Lagos, Nigeria, in July 2014, infecting 11 HCWs (case fatality rate of 45%). This study was conducted during the outbreak to assess HCWs' EVD-related knowledge and practices. METHODS: A health facility-based cross-sectional study was conducted among HCWs across Lagos State using stratified sampling technique. An interviewer-administered questionnaire was administered to elicit respondents' socio-demographic characteristics, knowledge and practices. A checklist assessing health facility's level of preparedness and HCWs' EVD-related training was employed. HCWs' knowledge and practices were scored and classified as either good or poor. Multivariate analysis was performed with confidence interval set at 95%. RESULTS: A total of 112 health facilities with 637 HCWs were recruited. Mean age of respondents was 40.1 ± 10.9 years. Overall, 72.5% had good knowledge; doctors knew most. However, only 4.6% of HCWs reported good practices. 16.6% reported having been trained in identifying suspected EVD patient(s); 12.2% had a triaging area for febrile patients in their facilities. Higher proportions of HCWs with good knowledge and training reported good practices. HCWs with EVD-related training were three times more likely to adopt good practices. CONCLUSION: Lagos State HCWs had good knowledge of EVD without a corresponding level of good practices. Training was a predictor of good practices.

Public knowledge, perception and source of information on ebola virus disease - lagos, Nigeria; september, 2014.

BACKGROUND: The first ever outbreak of Ebola virus disease (EVD) in Nigeria was declared in July, 2014. Level of public knowledge, perception and adequacy of information on EVD were unknown. We assessed the public preparedness level to adopt disease preventive behavior which is premised on appropriate knowledge, perception and adequate information. METHODS: We enrolled 5,322 respondents in a community-based cross-sectional study. We used interviewer-administered questionnaire to collect data on socio-demographic characteristics, EVD-related knowledge, perception and source of information. We performed univariate and bivariate data analysis using Epi-Info software setting p-value of 0.05 as cut-off for statistical significance. RESULTS: Mean age of respondents was 34 years (± 11.4 years), 52.3% were males. Forty one percent possessed satisfactory general knowledge; 44% and 43.1% possessed satisfactory knowledge on mode of spread and preventive measures, respectively. Residing in EVD cases districts, male respondents and possessing at least secondary education were positively associated with satisfactory general knowledge (p-value: 0.01, 0.001 and 0.000004, respectively). Seventy one percent perceived EVD as a public health problem while 61% believed they cannot contract the disease. Sixty two percent and 64% of respondents will not shake hands and hug a successfully treated EVD patient respectively. Only 2.2% of respondents practice good hand-washing practice. Television (68.8%) and radio (55.0%) are the most common sources of information on EVD. CONCLUSIONS: Gaps in EVD-related knowledge and perception exist. Targeted public health messages to raise knowledge level, correct misconception and discourage stigmatization should be widely disseminated, with television and radio as media of choice.

Notifiable disease reporting among public sector physicians in Nigeria: a cross-sectional survey to evaluate possible barriers and identify best sources of information.

BACKGROUND: Since 2001, Nigeria has collected information on epidemic-prone and other diseases of public health importance through the Integrated Disease Surveillance and Response system (IDSR). Currently 23 diseases are designated as "notifiable" through IDSR, including human infection with avian influenza (AI). Following an outbreak of highly pathogenic avian influenza A(H5N1) in Nigerian poultry populations in 2006 and one laboratory confirmed human infection in 2007, a study was carried out to describe knowledge, perceptions, and practices related to infectious disease reporting through the IDSR system, physicians' preferred sources of heath information, and knowledge of AI infection in humans among public sector physicians in Nigeria. METHODS: During November to December 2008, 245 physicians in six Nigerian cities were surveyed through in-person interviews. Survey components included reporting practices for avian influenza and other notifiable diseases, perceived obstacles to disease reporting, methods for obtaining health-related information, and knowledge of avian influenza among participating physicians. RESULTS: All 245 respondents reported that they had heard of AI and that humans could become infected with AI. Two-thirds (163/245) had reported a notifiable disease. The most common perceived obstacles to reporting were lack of infrastructure/logistics or reporting system (76/245, 31%), lack of knowledge among doctors about how to report or to whom to report (64/245, 26%), and that doctors should report certain infectious diseases (60/245, 24%). Almost all participating physicians (>99%) reported having a cell phone that they currently use, and 86% reported using the internet at least weekly. CONCLUSIONS: Although the majority of physicians surveyed were knowledgeable of and had reported notifiable diseases, they identified many perceived obstacles to reporting. In order to effectively identify human AI cases and other infectious diseases through IDSR, reporting system requirements need to be clearly communicated to participating physicians, and perceived obstacles, such as lack of infrastructure, need to be addressed. Future improvements to the reporting system should account for increased utilization of the internet, as well as cell phone and email-based communication.

Training and service in public health, Nigeria Field Epidemiology and Laboratory Training, 2008 - 2014.

The health workforce is one of the key building blocks for strengthening health systems. There is an alarming shortage of curative and preventive health care workers in developing countries many of which are in Africa. Africa resultantly records appalling health indices as a consequence of endemic and emerging health issues that are exacerbated by a lack of a public health workforce. In low-income countries, efforts to build public health surveillance and response systems have stalled, due in part, to the lack of epidemiologists and well-trained laboratorians. To strengthen public health systems in Africa, especially for disease surveillance and response, a number of countries have adopted a competency-based approach of training - Field Epidemiology and Laboratory Training Program (FELTP). The Nigeria FELTP was established in October 2008 as an inservice training program in field epidemiology, veterinary epidemiology and public health laboratory epidemiology and management. The first cohort of NFELTP residents began their training on 20th October 2008 and completed their training in December 2010. The program was scaled up in 2011 and it admitted 39 residents in its third cohort. The program has admitted residents in six annual cohorts since its inception admitting a total of 207 residents as of 2014 covering all the States. In addition the program has trained 595 health care workers in short courses. Since its inception, the program has responded to 133 suspected outbreaks ranging from environmental related outbreaks, vaccine preventable diseases, water and food borne, zoonoses, (including suspected viral hemorrhagic fevers) as well as neglected tropical diseases. With its emphasis on one health approach of solving public health issues the program has recruited physicians, veterinarians and laboratorians to work jointly on human, animal and environmental health issues. Residents have worked to identify risk factors of disease at the human animal interface for influenza, brucellosis, tick-borne relapsing fever, rabies, leptospirosis and zoonotic helminthic infections. The program has been involved in polio eradication efforts through its National Stop Transmission of Polio (NSTOP). The commencement of NFELTP was a novel approach to building sustainable epidemiological capacity to strengthen public health systems especially surveillance and response systems in Nigeria. Training and capacity building efforts should be tied to specific system strengthening and not viewed as an end to them. The approach of linking training and service provision may be an innovative approach towards addressing the numerous health challenges.

Knowledge, care-seeking behavior, and factors associated with patient delay among newly-diagnosed pulmonary tuberculosis patients, Federal Capital Territory, Nigeria, 2010.

INTRODUCTION: Early treatment of Tuberculosis (TB) cases is important for reducing transmission, morbidity and mortality associated with TB. In 2007, Federal Capital Territory (FCT), Nigeria recorded low TB case detection rate (CDR) of 9% which implied that many TB cases were undetected. We assessed the knowledge, care-seeking behavior, and factors associated with patient delay among pulmonary TB patients in FCT. METHODS: We enrolled 160 newly-diagnosed pulmonary TB patients in six directly observed treatment short course (DOTS) hospitals in FCT in a cross-sectional study. We used a structured questionnaire to collect data on socio-demographic variables, knowledge of TB, and care-seeking behavior. Patient delay was defined as > 4 weeks between onset of cough and first hospital contact. RESULTS: Mean age was 32.8 years (± 9 years). Sixty two percent were males. Forty seven percent first sought care in a government hospital, 26% with a patent medicine vendor and 22% in a private hospital. Forty one percent had unsatisfactory knowledge of TB. Forty two percent had patient delay. Having unsatisfactory knowledge of TB (p = 0.046) and multiple care-seeking (p = 0.02) were significantly associated with patient delay. After controlling for travel time and age, multiple care-seeking was independently associated with patient delay (Adjusted Odds Ratio = 2.18, 95% CI = 1.09-4.35). CONCLUSION: Failure to immediately seek care in DOTS centers and having unsatisfactory knowledge of TB are factors contributing to patient delay. Strategies that promote early care-seeking in DOTS centers and sustained awareness on TB should be implemented in FCT.

Determinants of routine immunization coverage in Bungudu, Zamfara State, Northern Nigeria, May 2010.

INTRODUCTION: Immunization is a cost-effective public health intervention to reduce morbidity and mortality associated with infectious diseases. The Nigeria Demographic and Health Survey of 2008 indicated that only 5.4% of children aged 12-23 months in Bungudu, Zamfara State were fully immunized. We conducted this study to identify the determinants of routine immunization coverage in this community. METHODS: We conducted a cross-sectional study. We sampled 450 children aged 12-23 months. We interviewed mothers of these children using structured questionnaire to collect data on socio-demographic characteristics, knowledge on immunization, vaccination status of children and reasons for non-vaccination. We defined a fully immunized child as a child who had received one dose of BCG, three doses of oral polio vaccine, three doses of Diptheria-Pertusis-Tetanus vaccine and one dose of measles vaccine by 12 months of age. We performed bivariate analysis and logistic regression using Epi-info software. RESULTS: The mean age of mothers and children were 27 years (standard error (SE): 0.27 year) and 17 months (SE: 0.8 month) respectively. Seventy nine percent of mothers had no formal education while 84% did not possess satisfactory knowledge on immunization. Only 7.6% of children were fully immunized. Logistic regression showed that possessing satisfactory knowledge (Adjusted OR=18.4, 95% CI=3.6-94.7) and at least secondary education (Adjusted OR=3.6, 95% CI=1.2-10.6) were significantly correlated with full immunization. CONCLUSION: The major determinants of immunization coverage were maternal knowledge and educational status. Raising the level of maternal knowledge and increasing maternal literacy level are essential to improve immunization coverage in this community.

Polio eradication in Nigeria and the role of the National Stop Transmission of Polio program, 2012-2013.

To strengthen the Nigeria polio eradication program at the operational level, the National Stop Transmission of Polio (N-STOP) program was established in July 2012 as a collaborative effort of the National Primary Health Care Development Agency, the Nigerian Field Epidemiology and Laboratory Training Program, and the US Centers for Disease Control and Prevention. Since its inception, N-STOP has recruited and trained 125 full-time staff, 50 residents in training, and 50 ad hoc officers. N-STOP officers, working at national, state, and district levels, have conducted enumeration outreaches in 46,437 nomadic and hard-to-reach settlements in 253 districts of 19 states, supported supplementary immunization activities in 236 districts, and strengthened routine immunization in 100 districts. Officers have also conducted surveillance assessments, outbreak response, and applied research as needs evolved. The N-STOP program has successfully enhanced Global Polio Eradication Initiative partnerships and outreach in Nigeria, providing an accessible, flexible, and culturally competent technical workforce at the front lines of public health. N-STOP will continue to respond to polio eradication program needs and remain a model for other healthcare initiatives in Nigeria and elsewhere.

Outreach to underserved communities in northern Nigeria, 2012-2013.

BACKGROUND: Persistent wild poliovirus transmission in Nigeria constitutes a major obstacle to global polio eradication. In August 2012, the Nigerian national polio program implemented a strategy to conduct outreach to underserved communities within the context of the country's polio emergency action plans. METHODS: A standard operating procedure (SOP) for outreach to underserved communities was developed and included in the national guidelines for management of supplemental immunization activities (SIAs). The SOP included the following key elements: (1) community engagement meetings, (2) training of field teams, (3) field work, and (4) acute flaccid paralysis surveillance. RESULTS: Of the 46,437 settlements visited and enumerated during the outreach activities, 8607 (19%) reported that vaccination teams did not visit their settlements during prior SIAs, and 5112 (11.0%) reported never having been visited by polio vaccination teams. Fifty-two percent of enumerated settlements (23,944) were not found in the existing microplan used for the immediate past SIAs. CONCLUSIONS: During a year of outreach to >45,000 scattered, nomadic, and border settlements, approximately 1 in 5 identified were missed in the immediately preceding SIAs. These missed settlements housed a large number of previously unvaccinated children and potentially served as reservoirs for persistent wild poliovirus transmission in Nigeria.

Assessment of blood lead levels among children aged ≤ 5 years--Zamfara State, Nigeria, June-July 2012.

Since 2010, Nigerian state and federal governments and the international community have been responding to an outbreak of lead poisoning caused by the processing of lead-containing gold ore in Zamfara State, Nigeria, that resulted in the deaths of approximately 400 children aged ≤ 5 years. Widespread education, surveys of high-risk villages, testing of blood lead levels (BLLs), medical treatment, and environmental cleanup all have been implemented. To evaluate the success of these remediation efforts in reducing the prevalence of lead poisoning and dangerous work practices, a population-based assessment of children's BLLs and ore processing techniques was conducted during June-July 2012. The assessment found few children in need of medical treatment, significantly lower BLLs, and substantially less exposure of children to dangerous work practices. Public health strategies designed to identify and treat children with lead poisoning, clean up existing environmental hazards, and prevent children from being exposed to dangerous ore processing techniques can produce a sustained reduction in BLLs.

Association of blood lead level with neurological features in 972 children affected by an acute severe lead poisoning outbreak in Zamfara State, northern Nigeria.

BACKGROUND: In 2010, Médecins Sans Frontières (MSF) investigated reports of high mortality in young children in Zamfara State, Nigeria, leading to confirmation of villages with widespread acute severe lead poisoning. In a retrospective analysis, we aimed to determine venous blood lead level (VBLL) thresholds and risk factors for encephalopathy using MSF programmatic data from the first year of the outbreak response. METHODS AND FINDINGS: We included children aged ≤5 years with VBLL ≥45 µg/dL before any chelation and recorded neurological status. Odds ratios (OR) for neurological features were estimated; the final model was adjusted for age and baseline VBLL, using random effects for village of residence. 972 children met inclusion criteria: 885 (91%) had no neurological features; 34 (4%) had severe features; 47 (5%) had reported recent seizures; and six (1%) had other neurological abnormalities. The geometric mean VBLLs for all groups with neurological features were >100 µg/dL vs 65.9 µg/dL for those without neurological features. The adjusted OR for neurological features increased with increasing VBLL: from 2.75, 95%CI 1.27-5.98 (80-99.9 µg/dL) to 22.95, 95%CI 10.54-49.96 (≥120 µg/dL). Neurological features were associated with younger age (OR 4.77 [95% CI 2.50-9.11] for 1-<2 years and 2.69 [95%CI 1.15-6.26] for 2-<3 years, both vs 3-5 years). Severe neurological features were seen at VBLL <105 µg/dL only in those with malaria. INTERPRETATION: Increasing VBLL (from ≥80 µg/dL) and age 1-<3 years were strongly associated with neurological features; in those tested for malaria, a positive test was also strongly associated. These factors will help clinicians managing children with lead poisoning in prioritising therapy and developing chelation protocols.

HIV counseling and testing and access-to-care needs of populations most-at-risk for HIV in Nigeria.

Mobile HIV counseling and testing (mHCT) is an effective tool to access hard-to-reach most-at-risk populations (MARPs), but identifying which populations are not accessing services is often a challenge. We compared correlates of human immunodeficiency virus (HIV) infection and awareness of HIV care services among populations tested through mHCT and at testing facilities in Nigeria. Participants in a cross-sectional study completed a questionnaire and HCT between May 2005 and March 2010. Of 27,586 total participants, 26.7% had been previously tested for HIV; among mHCT clients, 14.7% had previously been tested. HIV prevalence ranged from 6.6% among those tested through a facility to 50.4% among brothel-based sex workers tested by mHCT. Among mHCT participants aged 18-24, women were nine times more likely to be infected than men. Women aged 18-24 were also less likely than their male counterparts to know that there were medicines available to treat HIV (63.2 vs. 68.1%; p=0.03). After controlling for gender, age, and other risk factors, those with current genital ulcer disease were more likely to be HIV-infected (OR(mHCT)=1.65, 1.31-2.09; OR(facility)=1.71, 1.37-2.14), while those previously tested were less likely to be HIV-infected (OR(mHCT)=0.75, 0.64-0.88; OR(facility)=0.27, 0.24-0.31). There is an urgent need to promote strategies to identify those who are HIV-infected within MARPs, particularly young women, and to educate and inform them about availability of HIV testing and care services. mHCT, ideally coupled with sexually transmitted infection management, may help to ensure that MARPs access HIV prevention support, and if infected, access care, and treatment.

Breaking community barriers to polio vaccination in Northern Nigeria: the impact of a grass roots mobilization campaign (Majigi).

This paper examines the impact of a community-based intervention on the trends in the uptake of polio vaccination following a community mobilization campaign for polio eradication in northern Nigeria. Uptake of polio vaccination in high-risk communities in this region has been considerably low despite routine and supplemental vaccination activities. Large numbers of children are left unvaccinated because of community misconceptions and distrust regarding the cause of the disease and the safety of the polio vaccine. The Majigi polio campaign was initiated in 2008 as a pilot trial in Gezawa, a local council with very low uptake of polio vaccination. The average monthly increase in the number of vaccinated children over the subsequent six months after the pilot trial was 1,047 [95% confidence interval (CI): 647-2045, P = 0·001]. An increasing trend in uptake of polio vaccination was also evident (P = 0·001). The outcome was consistent with a decrease or no trend in the detection of children with zero doses. The average monthly decrease in the number of children with zero doses was 6·2 (95% CI: -21 to 24, P = 0·353). Overall, there was a relative increase of approximately 310% in the polio vaccination uptake and a net reduction of 29% of never vaccinated children. The findings of this pilot test show that polio vaccination uptake can be enhanced by programs like Majigi that promote effective communication with the community.