Meeting Report: WHO Workshop on modelling global mortality and aetiology estimates of enteric pathogens in children under five. Cape Town, 28-29th November 2018.

Investment in vaccine product development should be guided by up-to-date and transparent global burden of disease estimates, which are also fundamental to policy recommendation and vaccine introduction decisions. For low- and middle-income countries (LMICs), vaccine prioritization is primarily driven by the number of deaths caused by different pathogens. Enteric diseases are known to be a major cause of death in LMICs. The two main modelling groups providing mortality estimates for enteric diseases are the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, Seattle and the Maternal Child Epidemiology Estimation (MCEE) group, led by Johns Hopkins Bloomberg School of Public Health. Whilst previous global diarrhoea mortality estimates for under five-year-olds from these two groups were closely aligned, more recent estimates for 2016 have diverged, particularly with respect to numbers of deaths attributable to different enteric pathogens. This has impacted prioritization and investment decisions for vaccines in the development pipeline. The mission of the Product Development for Vaccines Advisory Committee (PDVAC) at the World Health Organisation (WHO) is to accelerate product development of vaccines and technologies that are urgently needed and ensure they are appropriately targeted for use in LMICs. At their 2018 meeting, PDVAC recommended the formation of an independent working group of subject matter experts to explore the reasons for the difference between the IHME and MCEE estimates, and to assess the respective strengths and limitations of the estimation approaches adopted, including a review of the data on which the estimates are based. Here, we report on the proceedings and recommendations from a consultation with the working group of experts, the IHME and MCEE modelling groups, and other key stakeholders. We briefly review the methodological approaches of both groups and provide a series of proposals for investigating the drivers for the differences in enteric disease burden estimates.

Family planning practices of rural community dwellers in cross River State, Nigeria.

BACKGROUND: Nigeria is the most populous nation in Africa and the seventh most populous in the world. Despite a high fertility rate of 5.5 per woman and a high population growth rate of 3.2%, Nigeria's contraceptive prevalence is 15%, which is one of the lowest in the world. The objective of this study was to determine the knowledge of family planning and family planning preferences and practices of rural community women in Cross River State of Nigeria. MATERIALS AND METHODS: This was a cross-sectional study involving 291 rural women. Convenience sampling method was used. The women were assembled in a hall and a semi-structured questionnaire was administered to every consenting woman until the sample size was attained. Data obtained from the study were analyzed using the Statistical Package for the Social Sciences version 20 and presented in tables as frequencies and percentages as well as figures. Association between categorical variables was explored using chi-square test. Binary logistic regression was also performed to determine predictors of use of at least one family planning method at some point in time. RESULTS: Fifty (17.2%) respondents were using at least one family planning method. One hundred and ninety-eight (68.3%) respondents had used at least one family planning method at some point in time. Reasons given for not using any family planning method included "Family planning is against my religious beliefs" (56%); "it is against our culture" (43.8%); "I need more children" (64.9%); "my partner would not agree" (35.3%); "family planning does not work" (42.9%); "it reduces sexual enjoyment" (76%); and "it promotes unfaithfulness/infidelity" (59%). Binary logistic regression conducted to predict the use of at least one family planning method at some point in time using some independent variables showed that who makes the decision regarding family planning use was the strongest predictor of family planning use (OR = 0.567; 95% CI = 0.391-0.821). This suggests that family planning uptake is more likely when couples make a joint decision. CONCLUSION: The proportion of respondents who were currently using at least one family planning method was low. The findings of this study suggest that family planning uptake would increase if couples make joint decisions in this regard.

Trauma death in a resource constrained setting: mechanisms and contributory factors, the result of analysing 147 cases.

AIMS AND OBJECTIVES: The objective of the following study is to analyze the trauma type (causes), injury pattern and factors that may have contributed to death within 72 h of admission into our emergency department (E.D). MATERIALS AND METHODS: An 18 month prospective observational study, done from April 2009 to September 2010. All the patients were that admitted for 72 h following a full assessment by the attending clinician were enlisted for the study. The demographic data of each patient, time of arrival at the E.D, type of injury sustained, time of incident, previous care at any peripheral hospital, clinical state of the patient, Glasgow coma scale (GCS), Injury severity score (ISS) and treatment offered before death were entered into a Proforma. DATA ANALYSIS: This was done using EPI-Info statistical programme version 3.4.3 of 2007(by CDC Atlanta Georgia , USA). RESULTS: A total of 4011 patients were seen in the E.D during the period. 1943 (48.4%), were trauma emergencies, with a (147; 41.4%) mortality. Their ages ranged from 4 to 87 years, with an average of 34.5 years. The male:female ratio was 7:1. The assessed GCS ranged from 6 to 15, with an average of 9.1, the ISS ranged from 9 to 75 with an average of 31.3. Road traffic accidents (RTAs) accounted for 118 (80.3%) of the deaths, assaults 14.3%, falls from height 4.0% and gunshot injuries 1.4%. The overall mortality was 17.1%. CONCLUSION: The major source of trauma death was RTA; The most frequently injured part of the body was head, with death resulting clinically hemorrhage. The 17.1% mortality is multifactorial: The late presentation (in some cases occasioned by interference by persons not knowledgeable in the basics of trauma care) lack of trained personnel and the systemic deficiencies.

Epidemiology of death in the emergency department of a tertiary health centre south-south of Nigeria.

BACKGROUND: The emergency department (E.D) of any hospital is an important entry point of critically ill patients. The initial management of these patients is often challenging, and for valuable lives to be saved, the in fracture and manpower should be up to date. OBJECTIVE: To analyze the epidemiology of death in our Emergency Department within 72hours after admission, the death rate, and to establish any contributory factors. METHOD: Demographic data, time of arrival at the ED, physical finding, the Glasgow coma scale(GCS), the injury severity score(ISS), the diagnosis, investigations done, treatment offered, the time of death and the autopsy report, were entered into a Proforma. These data was analyzed using EPI-Info statistical programme version 3.4.3 of 2007. RESULTS: Four thousand and eleven (4,011) patients were seen in the E.D during the period. A total of three hundred and fifty five (355) mortalities were recorded. Their ages ranged from 4-87years, with an average of 34.5years. The male: female ratio was 2.1:1. The overall mortality in the hospital during the period was 859: the E.D mortality figure representing 41.3%. Fifteen patients were brought in dead. The 355 deaths fell into two categories: trauma and non-trauma. One hundred and forty-seven (41.4%) persons died from trauma; road traffic accidents (RTAs) accounting for 118 (80.3%). Two hundred and eight (58.6%) persons died from nontrauma related causes, with chronic cardiovascular disorders been the most frequent cause of death 52[25.0]. Majority of the mortalities were between 26-50 years age range. 86.2% of the mortalities presented late, greater than 6hours after the incidence. Within the 72 hours period, only 129(36.3%) were able to do the requested tests. Out of the 355 deaths, only 4[1.1%] were autopsied. An in-hospital 72hours death rate of 8.6 was recorded. CONCLUSION: Road traffic accidents and cardiovascular disorders are the common causes of emergency death in UCTH. A recorded death rate of 8.6% is high, suspected contributory factors include systemic deficiencies such as the lack of a trauma system, prehospital care; late presentation, the role of chemist operators, traditional healers, and delayed referral systems.

Lower limb amputation in diabetic foot disease: experience in a tertiary hospital in southern Nigeria

The diabetic foot is characterised by the triad of neuropathy, infection, and ischaemia, which may ultimately lead to limb amputation. It is important to understand the factors that place diabetic patients at increased risk of amputation in our society, hence the need for this study. The medical records of all patients admitted and treated for diabetic foot complications over a 3-year period (January 2007 to December 2009) were retrieved. Relevant information was obtained from the case notes. Thirty-six (36) patients entered the study, 25 males and 11 females (M:F ratio 2.3:1.0). Mean age was 54 years (range 24­74). Patients presented with foot gangrene (58%), ulceration (31%) and infection (11%) with trauma being the most common precipitating factor (53%). Nineteen patients (53%) had lower limb amputation, the commonest of which was below knee. Of the patients that had amputation, 18 (95%) had type 2 diabetics. Adequate diabetic foot disease preventive strategies need to be designed and implemented to reduce the incidence of lower limb amputations

Social determinants of alcohol use among drivers in Calabar.

OBJECTIVE: Hazardous use of alcohol is a public health problem which accounts for 4.0% of global disease burden. Although the prevalence of alcohol use among drivers of commercial vehicles in Nigeria has been documented, not much is known about its social determinants. This study was, therefore, aimed at assessing the social determinants of alcohol use among drivers of commercial vehicles in Calabar. MATERIALS AND METHODS: A cross-sectional descriptive study was conducted among 360 male commercial drivers. A semistructured questionnaire, which included the World Health Organization Alcohol Use Disorders Identification Test, was administered at interview. Binary and multinomial logistic regression analyses were used to identify social determinants of any and hazardous alcohol use. RESULTS: Determinants of any alcohol use (binary logistic) were history of use by parents (adjusted odds ratios (AOR)=2.7; 95% CI=1.1-6.3), friends (AOR=3.2; 95% CI=1.3-7.8) and ready availability (AOR=4.1; 95% CI=1.9-8.8) while determinants of hazardous use (multinomial logistic) were history of use by parents (AOR=5.8; 95% CI=2.0-16.9), siblings (AOR=7.0; 95% CI=2.6-16.9), friends (AOR=6.6; 95% CI=1.8-24.4), hostile upbringing environment (AOR=3.8; 95% CI=1.3-11.1), use of other drugs (AOR=55.6, 95% CI=14.5-200), and respondents who had fathers with a maximum of primary or no formal education (AOR=4.6; 95% CI=1.8-11.8). CONCLUSION: Alcohol use was associated with family use, friends' use, and use of other drugs. Multiple health education interventions are needed to tackle these challenges.

Differential enrichment of simple sequence repeats in selected Alzheimer-associated genes.

The involvement of beta-amyloid (Abeta) in the pathogenesis of Alzheimer's disease (AD) has been well documented. In addition, a significant degree of information has been documented regarding the genetics of Abeta production and aggregation in familial forms of AD (FADs). However, the information regarding the causes or mechanism(s) responsible for Abeta accumulation in non-FADs is not as extensive and requires further elucidation. Simple sequence repeat (SSR)-mediated molecular misreading has recently been implicated in Abeta accumulation, via neuronal expression of mutant forms of the Abeta precursor (APP+1) and ubiquitin-B (UBB+1) proteins. Also, additional studies have demonstrated that the enrichment or representation of SSRs correlates with the rate of such molecular misreading. Therefore, we have analyzed the representation of SSRs in the DNA sequences of selected AD genes (ADGs) and non-ADGs. SSRs of various motifs were found to be differentially enriched in both ADGs and non-ADGs. More importantly, all known AD-associated SSRs (ADSSRs) were found to be highly enriched in the APP and UBB genes. Since molecular misreading is believed to be a widespread phenomenon during aging, the high enrichment of ADSSRs in the APP and UBB genes suggests that older individuals may exhibit relatively high rates of neuronal expression of mutant APP+1 and UBB+1 peptides. This is consistent with the proposed involvement of these peptides in the pathogenesis of non-FADs.

Sexuality; Contraception and Unintended Pregnancy among Female Student Nurses in Calabar; Nigeria

Background - There has been increased concern on human sexuality; especially with respect to contraception and the control of sexually transmissible infections. There is need to identify the sociodemographic characteristics that influence sexual behaviour and contraceptive use among young women. Methods - A descriptive cross sectional study that focused on the socio-demographic characteristics; sexuality; knowledge and use of modern contraceptive technology as well as interventions taken in the event of inadvertent pregnancy was conducted. A structured; close- ended questionnaire was randomly administered to 195 female nursing students with 60; 65 and 70 of them in their first; second and third year respectively. Results - Majority (76.7) of the students were in the age bracket of 20 - 24years. While 65.6of them were sexually active; only 54.9had knowledge of family planning. Condom was the commonest contraceptive used (37.4) and the main reasons were that of effectiveness (31.8) and safety (30.3). There was a significant relationship between respondents with multiple sexual partners and incidence of unwanted pregnancies (p=0.003). The majority (51.2) of those with unwanted pregnancies resorted to induced abortion

Factors associated with missed opportunities to immunise with tetanus toxoid at a tertiary health institution in Nigeria.

OBJECTIVE: To determine the magnitude of and the reasons for missed opportunities to immunise with tetanus toxoid at a tertiary health institution in Nigeria. The information obtained would be used in developing an intervention strategy for eliminating missed opportunities in the future. DESIGN: Missed opportunity was assessed by using the Revised WHO/EPI protocol (WHO/EPI/MLM/91.7). Exit interviews were carried out on pregnant women visiting the antenatal (prenatal) clinic to register the present pregnancy. SETTING: A tertiary health institution in Nigeria. SUBJECTS: Pregnant women who attended the antenatal clinic for the purpose of registering the present pregnancy during the last two booking days in February, 1997 and the first booking day in March, 1997. MAIN OUTCOME MEASURES: Missed opportunities and contributory factors. RESULTS: The prevalence of missed opportunity was 66%. The factors responsible for missed opportunity were poor history taking, lack of knowledge of the current schedule of immunisation, dependence on physician referral for immunisation and inefficient immunisation record keeping system. CONCLUSION: The findings establish the need for providing physicians in antenatal settings with an update on current immunisation policy and practice and for improved documentation of immunisation histories.

PIP: This report presents the magnitude of the problem and the reason for missed opportunities for tetanus toxoid (TT) immunization at the University of Calabar Teaching Hospital (UCTH) in Nigeria. The information obtained will be used in developing a strategy for eliminating missed opportunities in the future. The subjects were all pregnant women who attended the antenatal clinic for the purpose of registering pregnancy during the last two booking days in February 1997 and the first booking day in March 1997. Information were collected from 54 pregnant women by means of exit interview conducted by trained by data collectors. Information obtained includes: dose(s) of TT received and when; record of offer of TT; and acceptance or decline of TT offered. Results of the exit interview showed a 66% prevalence rate of missed opportunity. Factors contributing to this high prevalence of missed opportunity were poor history taking, lack of knowledge of current schedule of immunization, dependence on physician referral for immunization, and an inefficient immunization record keeping system. The findings point out the need to provide physicians in antenatal settings with an update on current immunization policy and practice and for improved documentation of immunization histories.