Abstract
Background
Lymphatic filariasis (LF), Buruli ulcer (BU) and leprosy are neglected tropical diseases (NTDs) of the skin co-endemic in some communities in Nigeria. Not enough is known about ...the effectiveness of integrated morbidity management and disability prevention in people with these conditions. An integrated self-care intervention was carried out for people with these skin NTDs in two endemic communities of Anambra state, Nigeria. The objective of the study was to assess the effectiveness of self-care practices on costs of care, disability status and health-related quality of life.
Methods
This study utilised a quasi-experimental pre-test/post-test design to assess the effectiveness of the self-care interventions for people affected by NTDs to care for these impairments at home. Data were collected using questionnaires administered at the beginning and at the end of the intervention on monthly cost of morbidity care, and on participants’ disability status and their quality of life (QoL). Focus group discussions (FGDs) were held with both the participants and healthcare workers at follow-up.
Results
Forty-eight participants were recruited. Thirty participants (62.5%) continued the self-care interventions until the end of the project. Of those, 25 (83%) demonstrated improvement from their baseline impairment status. The mean household costs of morbidity care per participant decreased by 66% after the intervention, falling from US$157.50 at baseline to US$53.24 after 6 months of self-care (
p
= 0.004). The mean disability score at baseline was 22.3; this decreased to 12.5 after 6 months of self-care (
p
< 0.001). Among the 30 participants who continued the interventions until the end of the project, 26 (86.7%) had severe disability score (i.e. a score of 10–46) at baseline, and the number with severe disability fell to 18 (60%) of the 30 after the intervention. The mean QoL score increased from 45.7 at baseline to 57.5 at the end of the intervention (
p
= 0.004).
Conclusions
The 6-month self-care intervention for participants affected by BU, leprosy, or LF led to lower costs of care (including out-of-pocket costs and lost earnings due to morbidity), improved QoL scores, and reduced disability status.
Trial registration
ISRCTN Registry:
ISRCTN20317241
; 27/08/2021, Retrospectively registered.
There is a dearth of experience in and evidence for cost-effective integrated community-based management of skin neglected tropical diseases (NTDs). The objective of this study was to assess the ...knowledge, attitude and care-seeking practices including self-care with a view to introducing appropriate community-based interventions for skin NTDs in an endemic setting in Southern Nigeria.
This exploratory study adopted a mixed-methods design consisting of cross-sectional surveys of community members and health workers using interviewer-administered questionnaires; and focus group discussions (FGDs) with community members, health care workers and patients with NTDs in Anambra State, Nigeria. The survey was completed by 353 community members (61.8% female) and 15 health care workers (100.0% female). A total of 52 individuals participated in six FGDs. Of the community members, 236 (66.9%) had heard or seen a case of leprosy; 324 (91.8%) and 131 (37.5%) had heard or seen a case of Buruli ulcer and lymphatic filariasis, respectively. Again, 213 (60.3%) of the respondents reported that the diseases were caused by witchcraft or curse. As regards prevention, 241 (68.3%) suggested avoiding handshake with affected persons. Up to 223 (63.2%) of respondents strongly agreed to the seriousness of skin NTDs in their community. Meanwhile, 272 (77.1%) of the respondents believed that the transmission of these skin NTDs can be prevented. Furthermore, 324 (91.7%) desired active community engagement for control of skin NTDs. Regarding community care seeking practices, 197 (55.8%) would first visit the health centre/hospital, followed by 91 (25.8%) traditional healer/herbalist and 35 (9.9%) pharmacy/patent medicine vendor if they develop a skin NTD. Overall, 332 (94.1%) of respondents expressed interest in being taught self-care practices for skin NTDs. Out of 15 healthcare workers, 13 (86.7%) were able to correctly diagnose two of these skin NTDs and 10 (66.7%) would encourage patients to practice self-care. Prominent themes in the FGDs were belief in witchcraft and herbal remedies; as well as the occurrence of physical, social and economic distress.
Our study helped quantify the information gaps that need to be addressed in order to create demand for integrated skin NTDs services in an endemic setting in Nigeria. Individual, structural and socioeconomic challenges to access and delivery of services were identified. Community and health care workers' empowerment and engagement through outreach and regular training, respectively may alleviate these challenges.
Introduction In 2019, 10.0 million people developed tuberculosis (TB) yet 2.9 million were not notified to National TB programmes (NTPs).1 This is largely due to limited accessibility to healthcare ...services, underdeveloped health reporting systems, insufficient human resources and poor linkages between private providers and national authorities.2 There are various global initiatives to address this challenge, including the Find.Treat.All #EndTB initiative and the End TB strategy which aims to reduce TB incidence by 90% between 2015 and 2035.3 To support innovative programmes, approaches and technologies aiming to increase the number of people detected with TB in low-and-middle income countries (LMICs), the TB REACH initiative was launched in 2010. ...to provide a holistic view, we also incorporated the perspectives of monitoring and evaluation (M&E) consultants and members of the TB REACH secretariat who are key stakeholders in the TB REACH initiative.Table 1 Characteristics of ACF implementors Country Year Organisation category Intervention type* Intervention Afghanistan 2017–2018 Non-governmental organisation Community outreach School girls were trained to screen women and girls in rural villages. South Africa 2013–2014 Non-governmental organisation Community outreach, key population Engaged community health workers and health workers to conduct household screening for TB and contact tracing. *Community outreach=conducting house to house screening within the community or mass screening events; contact tracing=screening contacts of people who had TB; systematic screening=screening a particular targeted population; key populations=those identified as vulnerable or targeted populations within the respective country/region. Previously documented successful ACF projects have overcome these issues by hiring local field staff, who live within the communities.6 9–12 Also, leveraging pre-existing systems and/or communities to assist with implementation in hard-to-reach areas and encouraging sustainability by strengthening current health systems and health infrastructure.13 14 For example, using renewable energy such as solar power to power facilities lacking electricity in rural areas.15 Lesson 2: project management Implementing project management skills enables ACF implementors to not only ensure execution of activities in the field, but to also recognise the need for an agile working environment where data-driven decision-making assists in risk mitigation and conflict management.
Diabetes mellitus (DM) and tuberculosis (TB) are of great public health importance globally, especially in Sub-Saharan Africa. Tuberculosis is the third cause of death among subjects with ...non-communicable diseases. DM increases risk of progressing from latent to active tuberculosis. The study aimed to ascertain yield of TB cases and the number needed to screen (NNS) among DM patients.
Across-sectional study was conducted at 10 health facilities with high DM patient load and readily accessible DOTS center in 6 states of southern region of Nigeria over aperiod of 6 months under routine programme conditions. All patients who gave consent were included in the study. Yield and NNS were calculated using an appropriate formula.
3 457 patients were screened with amean age (SD) of 59.9 (12.9) years. The majority were male, 2 277 (65.9%). Overall prevalence of TB was 0.8% (800 per 100 000). Sixteen (0.5%) were known TB cases (old cases). There were 221 presumptive cases (6.4%) out of which 184 (83.3%) were sent for Xpert MTB/Rif assay. Eleven (0.3%) new cases of TB were detected, giving additional yield of 40.7% and the number needed to screen (NNS) of 315. All the 11 patients were placed on anti-TB treatment.
The prevalence of TB among DM patients was higher than in the general population. The yield was also good and comparable to other findings. This underscores the need for institute active screening for TB among DM patients. Further stu-dies are recommended to identify associated factors to guide policy makers in planning and development of TB-DM integrated services.
Mycolactones, secreted by Mycobacterium ulcerans, were previously believed to prevent super infection in Buruli ulcer lesions. However, little is known about secondary bacterial infections in these ...lesions. This study evaluated contaminating bacterial flora and their antibiotic susceptibility patterns in cases of previously untreated Buruli ulcer disease from three states in Southern Nigeria.
A prospective analysis was conducted between January and June of 2015 using wound swabs from eligible patients with Buruli ulcer disease, confirmed by quantitative-polymerase chain reaction, with active ulcers. Microbiological analyses including isolation of bacteria, species identification of isolates, and drug susceptibility tests were performed.
Of 51 patients, 27 (52.9%) were female. One or more bacterial species of clinical importance was isolated from each patient. A total of 17 different microbial species were isolated; 76.4% were Gram-negative and 23.6% were Gram-positive isolates. The most common bacterial species detected was Staphylococcus aureus (24%), followed by Aeromonas hydrophila (13%), Pseudomonas aeruginosa (13%), and Klebsiella pneumoniae (11%). Drug susceptibility tests showed a particularly high frequency of resistance to commonly used antimicrobials in Nigeria for Staphylococcus aureus.
Super bacterial infections occur in Buruli ulcer lesions in Nigeria, and these infections are associated with high rates of resistance to commonly used antibiotics in the country.
A major challenge to TB control globally is low case detection, largely due to routine health facility-based passive case-finding employed by national TB control programs. Active case-finding is a ...risk-population-based screening approach that has been established to be effective in TB control. This intervention aimed to increase TB case detection in hard-to-reach areas in southern Nigeria.
Using a descriptive cross-sectional design, we conducted implementation research in 15 hard-to-reach riverine local government areas with historically recognized low TB case notification rates. Individuals with TB symptoms were screened using multiple strategies. Data were collected quarterly over a 4-year period using reporting tools and checklists. Descriptive analysis was done with Microsoft Excel spreadsheet 2019.
A total of 1,089,129 individuals were screened: 16,576 in 2017; 108,102 in 2018; 697,165 in 2019; and 267,286 in 2020. Of those screened, 24,802 (2.3%) were identified as presumptive TB, of which 88.8% were tested and 10% were diagnosed with TB (0.23% of those screened). TB notifications more than doubled, increasing by 183.3% and 137.5% in the initial implementation and scale-up, respectively. On average, 441 individuals needed to be screened to diagnose 1 TB case. The cases, predominantly males (56.1%) and aged 15 years and older (77.4%), comprised 71.9% bacteriologically confirmed drug-sensitive TB, 25.8% clinically diagnosed drug-sensitive TB, and 2.3% drug-resistant cases. Detection sources included community outreach (1,786), health facilities (505), people living with HIV (57), and household contacts of bacteriologically confirmed TB cases (123). Remarkably, 98.1% of diagnosed TB cases commenced treatment.
We found a significant yield in TB case notifications, more than doubling the baseline figures. Given these successful results, we recommend prioritizing resources to support active case-finding strategies in national programs, especially in hard-to-reach areas with high-risk populations, to address TB more comprehensively.
In Nigeria, little is known about the development of new or additional physical disability during leprosy treatment. The objective of this study was to determine the prevalence and evaluate factors ...associated with worsening of physical disability during leprosy treatment in Nigeria.
This was a retrospective cohort study conducted among leprosy patients treated in six referral facilities in six States in Nigeria between January 2011 and December 2015. Multivariable logistic regression analysis was used to identify predictors of worsening disability after treatment.
Of 984 leprosy patients who completed treatment, the mean age of the patients was 39.8±17.6 years and 57.4% (565/984) of them were male. Also, 51.6% (508/984) of the patients had either grade 1 or 2 disability at diagnosis, but this declined to 30.8% (303/984) following treatment (p<0.001). Overall, 4.7% (46/984) of the cases developed new or additional disability (or worsening disability) during treatment. The cases with the greatest odds for developing worsening physical disability were patients from the southwest (adjusted odds ratio aOR 15.9; 95% CI 3.8-67.4) and southeast zones (aOR 4.7; 95% CI 1.1-19.2), and patients who had a leprosy reaction requiring additional corticosteroid therapy (aOR 11.7; 95% CI 4.4-31.2).
Sustained capacity building for health professionals on better monitoring and management of leprosy and its complications is strongly recommended in Nigeria.
Implementation studies are recommended to assess the feasibility and effectiveness of programmes. In Nigeria, little is known about the burden of diabetes mellitus (DM) among tuberculosis (TB) ...patients. The objective of this study was to determine screening efficacy, prevalence of DM and determinants of DM among TB patients. We report on a multi-centre implementation study carried-out in 13 health facilities in six States of Southern Nigeria. All newly diagnosed TB patients registered from March to October 2015 were screened for DM using current World Health Organisation guidelines. Overall, 2094 TB patients were evaluated, 196 (9.4%) were found to have DM. The prevalence of newly diagnosed DM was 5.5% (115/2094). DM prevalence varied according to age group; occurring in 2.2% of patients aged ≤ 25 years and 16.9% in patients aged (56-65) years. The additional yield of DM was 59% while the number needed to screen to detect a new case of DM was 18. Factors associated with DM were; age >40 years (aOR2.8, CI 2.1-3.9), rural residence (aOR2.3, 1.6-3.2), private health facility care (aOR2.0, 1.4-2.7), and having an occupation that engages in vigorous activity (aOR0.6, 0.4-0.9). The burden of DM among TB patients is high. Prioritization of DM screening for TB patients is indicated.
Poor knowledge can influence timely care-seeking among persons with Buruli ulcer disease (BUD).
To assess community knowledge, attitude and stigma towards persons with BUD in endemic settings of ...Southern Nigeria.
This was a cross-sectional survey conducted among adult community members in four States of Southern Nigeria. A semi-structured interviewer-administered questionnaire was administered to all participants.
Of 491 adults who completed the survey, 315 (64.2%) belonged to the ≤40 years age group, 257 (52.3%) were males and 415 (84.5%) had some formal education. The overall mean (SD) knowledge score was 5.5±2.3 (maximum 10). Only 172 (35.0%) of the participants had a good knowledge of BUD. A total of 327 (66.6%) considered BUD as a very serious illness. Also, there was a high-level of stigma against BUD patients; 372 (75.8%) of the participants felt compassion for and desire to help them, 77 (15.7%) felt compassion but tended to stay away from them, and 53 (10.8%) feared them because they may infect them with the disease. Having a formal education and ethnicity were independent predictors of good knowledge of BUD.
There is poor community knowledge of BUD in endemic settings of Southern Nigeria which influenced the attitude and perceptions of community members towards persons with BUD.
Background
Delayed diagnosis of Buruli ulcer can worsen clinical presentation of the disease, prolong duration of management, and impose avoidable additional costs on patients and health providers. ...We investigated the profile, delays in diagnosis, duration of hospitalisation, and associated factors among patients with Buruli ulcer in Nigeria.
Methods
This was a prospective cohort study of patients with Buruli ulcer who were identified from a community-based survey. Data on the patients’ clinical profile, delays in diagnosis and duration of hospitalisation were prospectively collected.
Results
Of 145 patients notified, 125 (86.2%) were confirmed by one or more laboratory tests (81.4% by PCR). The median age of the patients was 20 years, 88 (60.7%) were >15years old and 85 (58.6%) were females. In addition, 137 (94.5%) were new cases, 119 (82.1%) presented with ulcers and 110 (75.9%) had lower limb lesions. The mean time delay to diagnosis was 50.6 (±101.9) weeks. The mean duration of hospitalisation was 108 (±60) days. Determinants of time delay to diagnosis were higher disease category (p=0.001) and laboratory confirmation of disease (p=0.02). Determinants of longer hospitalisation were; multiple lesions (p=0.035), and having functional limitation at diagnosis and undertaking surgery (p=0.003).
Conclusions
Patients with Buruli ulcer have very long time delays to diagnosis and long hospitalisation during treatment. This calls for early case-finding and improved access to Buruli ulcer services in Nigeria.
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