HIV-TB co-infection in children: associated factors and access to HIV services in Lagos,Nigeria

Background: Human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading causes of death from infectious disease worldwide. The World Health Organization estimates that the prevalence of HIV among children with TB in moderate to high prevalence countries ranges between 10% and 60%. This study aimed to determine the access to HIV services of HIV-TB co-infected children.Methods: A retrospective review of data of children diagnosed with TB in Lagos State, Nigeria from 1 January 2012 to 31 December 2013.Results: A total of 1199 children aged between 0 and 14 years were diagnosed with TB. Of 1095 (91.3%) who underwent testing for HIV, 320 (29.2%) were HIV seropositive. The male-to-female ratio of HIV-TB positive outcomes was 1:0.9. Of the 320 HIV-TB co-infected children, 57 (17.8%) were aged <1 year, 86 (26.9%) 1–4 years and 186 (58.1%) 5–14 years; 186/320 (58.1%) began cotrimoxazole preventive therapy (CPT), and 151 (47.2%) were put on antiretroviral treatment (ART). ART uptake was not significantly higher in facilities where HIV-TB services were co-located (P > 0.05).Conclusion: The uptake of CPT and ART was low. There is a need to intensify efforts to improve access to HIV services in Lagos State, Nigeria.     

Plasmid profile analysis and antimicrobial susceptibility patterns of Shigella isolates from Nigeria

In an epidemiological survey, plasmid profiles and antimicrobial susceptibility testing of 100 shigella isolates in Lagos, Nigeria was done. All the isolates were sensitive to nalidixic acid, nitrofurantoin and ciprofloxacin. The commonest antimicrobial susceptibility pattern was resistance to ampicillin, colistin sulphate, co-trimoxazole, streptomycin and tetracycline. All but 4 of 100 isolates screened contained one or more plasmids. Plasmid profile analysis distinguished more strains than did antimicrobial susceptibility patterns. A total of 36 isolates was able to transfer resistance plasmids to Escherichia coli K-12 by conjugation. Using in vitro transformation, seven isolates transferred resistance. These plasmids specified resistance to tetracycline, streptomycin, sulphonamide, trimethoprim and ampicillin.     

Evaluation of nutritional status and incidence of anaemia among primary school children in Lagos, Nigeria

A list of 53 primary schools was obtained from Ikorodu Local Government of Lagos State, Nigeria. Five primary schools were chosen from the list by numerical series which had a total of 4,515 pupils representing 13.6#pc of the total primary school population. Two hundred and fifty pupils were chosen randomly using Fisher#shYates random sample table. The following information enumerated from the study.

Chi-square value [P#lt.05] showed relationship between the PCV level and nutritional status of the children. Similar association also showed between the MCHC and nutritional status. Twenty four had their PCV less than 30 while 21 had the MCHC less than 33 which is an indicator of iron deficiency anaemia.

The stool examination showed a total of 180 [72#pc] pupils comprising of 89 [70.6#pc] males and 91 [73.4#pc] females had intestinal parasites. Ascaris and Trischuris and hookworm were commonly identified among the children. This also indicated a chi-square value [P#lt.05] association between the nutritional status and worm infestation.     

Career aspirations of house officers in Lagos, Nigeria

OBJECTIVE: To identify the career aspirations of interns (house officers) working in two hospitals in Lagos, Nigeria. METHODS: All house officers working in the Lagos University Teaching Hospital and the General Hospital, Ikeja were invited to participate in a cross sectional survey. A self-administered questionnaire was used to collect data. RESULTS: Specialization choice was evident in 97.1% of the interns while they were undergraduates but this declined to 82.9% on qualifying, though chosen specialties did not vary much between both periods. The preferred specialties were surgery (18.1%), obstetrics and gynaecology (18.1%), paediatrics (9.5%) and dental sciences (10.5%). Doctors who were below the age of 26 years were significantly more likely to want to specialize than others (P=0.017). Furthermore, respondents who had no regrets about selecting medicine as a career were significantly more willing to specialize than others (P=0.013). The major reasons for wanting to specialize were interest in specialty (72.4%), job satisfaction (67.6%) and bright prospects in selected field (54.3%). However, 14.4% no longer wanted to practise medicine while 69% would have liked to leave Nigeria, mainly for the United States of America. Financial considerations were a major reason for both groups. CONCLUSION: Surgery, obstetrics and gynaecology continue to attract young doctors to the detriment of other specialties. Financial considerations are also a key determinant of with regard to place of future practice.     

Care-seeking behavioural patterns,awareness and diagnostic processes in patients with smear- and culture-positive pulmonary tuberculosis in Lagos,Nigeria

This study was carried out in 2 chest referral clinics in Lagos, Nigeria, between February 2000 and May 2001 to assess the effects of knowledge, attitude, and practice of 168 newly diagnosed tuberculosis (TB) patients on their care-seeking behaviour. At the onset of symptoms patients sought treatment from one or more of the local private orthodox and traditional health providers, and patent medicine dealers before presenting at a chest clinic. There was a correlation between the level of knowledge and awareness of TB with time of presentation at the chest clinic. Of the 32 patients who presented and were diagnosed at the chest clinics within 4 weeks of onset of symptoms, 50% had knowledge of the aetiological agent of the disease and 60% had some idea of the mode of transmission. Of the 105 patients who presented and were diagnosed 12 weeks after the onset of symptoms, 97% had no knowledge of the aetiological agent and 95% had no idea of the mode of transmission. Overall there was a low level of knowledge and awareness of the disease as well as an apparently high level of improper health care-seeking behaviour amongst the patients studied which probably contributed significantly to the delay in early and accurate diagnosis of most of the cases. These findings indicate an urgent need to educate communities and care providers on the cause and mode of transmission of TB, and the need to attend designated health facilities for early diagnosis and proper treatment.     

Innate resistance to new antimalarial drugs in Plasmodium falciparum from Nigeria.

The rapid dissemination of chloroquine-resistant Plasmodium falciparum in West Africa has been well documented and represents a significant health threat to autochthonous populations. The methodical development of alternative chemotherapeutic agents demands that dispensing new antimalarial drugs (mefloquine, halofantrine, and artemisinine [qinghaosu]) be closely monitored in order to protect their clinical utility. Indeed, mefloquine-resistant strains of P. falciparum have been reported. We present data from experiments in vitro on the innate resistance of P. falciparum isolates to mefloquine as well as a disturbing observation of transient resistance to artemisinine. The implications for the extended efficacy of these new antimalarial drugs are addressed.     

Chloroquine resistance of Plasmodium falciparum in semi-immune children in Zaria, northern Nigeria

Fifty-nine children with Plasmodium falciparum malaria were subjected to the World Health Organization (WHO) extended field test to assess the in vivo sensitivity of the parasite to chloroquine in Zaria urban area, Nigeria. The parasites in 53 children (90%) were positive but those in 6 (10%) were resistant at the RI-RII level. 36 isolates from the patients were successfully cultured in vitro for the WHO standard microtest. 13 (37%) of the isolates underwent schizogony at chloroquine concentrations of 1.6 microM/litre and above. Probit analysis showed that the chloroquine concentrations producing 50% (EC50), 90% (EC90) and 99% (EC99) schizont inhibition were 0.4, 1.6 and 4.9 microM/litre, respectively. The results indicate a rapid decline in the sensitivity of P. falciparum to chloroquine in the study area during the past 3 years.     

The determinants of infant and child morbidity in Lagos,Nigeria

Analysis of the structure of real morbidity among children in Lagos, Nigeria, reveals that the leading diseases were of hygienic, nutritional and perinatal origin. These diseases were highly concentrated in infancy and early childhood; in the case of the former, the concentration was greater among boys than girls. During the 1970s, a decline is noticed in the frequency of infective and parasitic diseases particularly among male infants. Simultaneously, a slightly rising trend of diseases related to birth complications and perinatal nature afflicting predominantly early infancy occurred, off-setting, to some extent, the effect of the diminishing trend in infective diseases. The rising trend of perinatal diseases should be seen in conjunction with a likely increase in gravidity of women and the resultant increase of pregnancies and birth complications, which affected the health of the mother as well as that of the child.The findings seem to suggest that although both medical and non-medical factors contributed to the change in morbidity pattern in the decade 1968–1978, the role of factors of socio-economic nature was significant. The implication is that without socio-economic epidemiology, biomedical epidemiology could make a limited contribution to the reduction of morbidity.     

The epidemiology of breastfeeding cessation in sub-urban Lagos, Nigeria

Two hundred and forty mothers in a sub-urban community in Lagos were studied. Respondents were women who had children 0 -- 24 months of age. They were largely married women of low educational and socioeconomic background. Breastfeeding is commonly practised in this community. Nearly all the mothers (92.4%) breastfed for longer than six months and a large proportion (71.5%) breastfed up to 12 months. The proportion of male infants who were breastfed for longer than 12 months was higher than that of the female infants (75% vs. 67%) although the difference was not statistically significant (X² = 1.77, p=0.279). Older mothers (#lt35 years) tended to breastfeed for slightly longer period than their younger counterparts. There was a significant inverse association between mothers' level of education and the duration of breastfeeding (p = .035). The major reason for stopping breastfeeding as given by 62 percent (149 mothers) was that the child was old enough. The next important reason for stopping breast feeding was that the mother had to resume work. The “insufficient milk syndrome” as reported from many cultures of developed and developing countries of the world has not yet affected the Nigerian suburban women and was not an important reason for stopping breastfeeding.     

Strategies to contain the emergence of antimicrobial resistance: a systematic review of effectiveness and cost-effectiveness

OBJECTIVES: To conduct a systematic review of the literature to describe and critically appraise studies reporting on the cost and/or effectiveness of interventions proposed to control the emergence of antimicrobial resistance (AMR). METHODS: The search for relevant studies encompassed consultation with world experts in AMR, and electronic bibliographic database search of: Medline (1960-2000); ISI (1981-2000); EMBASE (1988-2000); Grey Literature (1999-2000); Database of Reviews of Effectiveness (DARE) and the NHS Health Economic Evaluation Database (HEED) at York University's Centre for Reviews and Dissemination (CRD) (numerous years); OPAC (1975-2000); and the Cochrane Library Online (1990-2000). Only studies that concerned the effectiveness or cost-effectiveness of measures specifically designed to contain the emergence of AMR were reviewed. Standardised data extraction sheets, based on existing checklists for effectiveness and cost-effectiveness, were used to assess the validity of each study using the 'risk of bias criteria' suggested in the Cochrane Handbook. Only studies categorised as being at low or moderate risk of bias were reported fully. The reliability of the data review process was monitored by comparison of several, random, independent assessments by all authors. The mix of study methods (i.e. including studies based on non-randomised controlled trials) meant that formal meta-analysis was not possible, and thus a qualitative review was performed. RESULTS: In total, 43 studies were reviewed, with 21 classed as being at moderate or low risk of bias and therefore reported in the paper. These studies covered policies on: restricting the use of antimicrobials (five studies, suggesting that restriction policies can alter prescriber behaviour, although with limited evidence of subsequent effect on AMR); prescriber education, feedback and use of guidelines (six studies, with no clear conclusion); combination therapies (seven studies, showing the potential to lower drug-specific resistance, although for an indeterminate time period); vaccination (three studies showing cost/effectiveness). Most of these studies were: from the developed world, principally the USA; hospital-based, with few community level interventions; and concerned with effectiveness, not cost-effectiveness. CONCLUSIONS: Overall, there is an absence of good evidence concerning what is effective, and especially cost-effective, in reducing the emergence of AMR. However, in addition to more research concerning these forms of intervention, the paper highlights four specific areas for further investigation: validating intermediate or surrogate outcome measures to enable better use to be made of the literature on intermediate measures; development and evaluation of 'macro' strategies; research into specific aspects of AMR in developing countries; and empirical and methodological research concerning the economic evaluation of interventions.     

Increasing spectrum in antimicrobial resistance of Shigella isolates in Bangladesh: resistance to azithromycin and ceftriaxone and decreased susceptibility to ciprofloxacin

Antimicrobial resistance of Shigella isolates in Bangladesh, during 2001-2002, was studied and compared with that of 1991-1992 to identify the changes in resistance patterns and trends. A significant increase in resistance to trimethoprim-sulphamethoxazole (from 52% to 72%, p < 0.01) and nalidixic acid (from 19% to 51%, p < 0.01) was detected. High, but unchanged, resistance to tetracycline, ampicillin, and chloramphenicol, low resistance to mecillinam (resistance 3%, intermediate 3%), and to emergence of resistance to azithromycin (resistance 16%, intermediate 62%) and ceftriaxone/cefixime (2%) were detected in 2001-2002. Of 266 recent isolates, 63% were resistant to > or =3 anti-Shigella drugs (multidrug-resistant [MDR]) compared to 52% of 369 strains (p < 0.007) in 1991-1992. Of 154 isolates tested by E-test in 2001-2002, 71% were nalidixic acid-resistant (minimum inhibitory concentration [MIC] > or =32 microg/mL) and had 10-fold higher MIC90 (0.25 microg/mL) to ciprofloxacin than that of nalidixic acid-susceptible strains exhibiting decreased ciprofloxacin susceptibility, which were detected as ciprofloxacin-susceptible and nalidixic acid-resistant by the disc-diffusion method. These strains were frequently associated with MDR traits. High modal MICs were observed to azithromycin (MIC 6 microg/mL) and nalidixic acid (MIC 128 micdrog/mL) and low to ceftriaxone (MIC 0.023 microg/mL). Conjugative R-plasmids-encoded extended-spectrum beta-lactamase was responsible for resistance to ceftriaxone/cefixime. The growing antimicrobial resistance of Shigella is worrying and mandates monitoring of resistance. Pivmecillinam or ciprofloxacin might be considered for treating shigellosis with caution.     

Costs and performance of early hearing detection programmes in Lagos, Nigeria

In line with global progress towards early detection of permanent congenital and early-onset hearing loss (PCEHL), the costs and performance of hospital-based and community-based infant hearing screening models were evaluated in Lagos, Nigeria. The protocol consisted of two-stage screening with transient-evoked otoacoustic emissions and automated auditory brainstem response followed by diagnostic evaluation for all infants referred after the second-stage screening. The main outcome measures were referral rates at screening, cost per baby screened, cost per case detected and yield for PCEHL. First-stage referrals were 32.2% for universal and 31.7% for targeted screening in the hospital, compared with 14.3% and 15.2%, respectively for the community-based programme. Second-stage referrals ranged from 3.3% under hospital-based universal screening to 4.9% under community-based targeted screening. The highest yields of 27.4 and 22.5 per 1000 were recorded under community-based targeted and universal screening, respectively. Screening cost per child was lowest (US$7.62) under community-based universal screening and highest (US$73.24) under hospital-based targeted screening. Similarly, cost per child detected with PCEHL was lowest (US$602.49) for community-based universal screening and highest (US$4631.33) for hospital-based targeted screening. Community-based universal screening of infants during routine immunisation clinics appears to be the most cost-effective model for early detection of PCEHL in low-income countries.     

Multidrug resistance in Salmonella enterica serovar typhi isolated from patients with typhoid fever complications in Lagos, Nigeria

OBJECTIVE: The aim of this study was to determine the prevalence of Salmonella enterica serovar typhi in patients with pyrexia of unknown origin (PUO), and antimicrobial resistance in strains isolated from patients with S. typhi in Lagos, Nigeria. STUDY DESIGN: In total, 103 patients were included in this study, subdivided into two categories. Category A comprised 74 patients presenting with PUO, and Category B comprised 29 patients harbouring S. typhi who did not respond to initial treatment. METHODS: Blood samples were cultured for bacterial isolates and identified by standard procedures. Susceptibility testing was performed according to the National Committee for Clinical Laboratory Standards. Plasmid DNA extraction was performed using the alkaline lysis method with Escherichia coli v517 used as the standard. Conjugation and transformation experiments were performed using standard methods. For the latter, E. coli K12 HB 101 (ara-14, galK2, hsd 520, lacyl, leu, mtl-1, Pro A2, rec A13, rps L20, sup E44, thii xyl-5) was used as the recipient and plasmid PBR 322 was used as the positive control. RESULTS: The prevalence of S. typhi in PUO was 16.2% (12/74). In all, 25 of 41 (61.0%) cases were multidrug resistant (MDR) with phenotypic-resistant patterns: ACoCT, ACTCeS, ACTCoCe and ACTS were commonly encountered among the strains. Interestingly, four of the strains harbouring similar plasmid DNA were isolated from patients with hepatosplenomegaly, and a strain harbouring a large transferable plasmid of 81.2MDa was isolated from a psychosis patient. CONCLUSIONS: Our study confirmed the circulation of MDR S. typhi in Lagos, Nigeria. Periodic review of antibiotics used in hospitals is essential as the efficacies of chloramphenicol, ampicillin and cotrimoxazole are now doubtful. Ciprofloxacin and ofloxacin are effective drugs for treatment of typhoid fever, but with current trends of drug abuse in Nigeria, resistance is likely to develop. These results, therefore, provide an early warning signal for the prudent use of fluoroquinolone antimicrobials to preserve their usefulness.     

Dead bugs don't mutate: susceptibility issues in the emergence of bacterial resistance

The global emergence of antibacterial resistance among common and atypical respiratory pathogens in the last decade necessitates the strategic application of antibacterial agents. The use of bactericidal rather than bacteriostatic agents as first-line therapy is recommended because the eradication of microorganisms serves to curtail, although not avoid, the development of bacterial resistance. Bactericidal activity is achieved with specific classes of antimicrobial agents as well as by combination therapy. Newer classes of antibacterial agents, such as the fluoroquinolones and certain members of the macrolide/lincosamine/streptogramin class have increased bactericidal activity compared with traditional agents. More recently, the ketolides (novel, semisynthetic, erythromycin-A derivatives) have demonstrated potent bactericidal activity against key respiratory pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, Chlamydia pneumoniae, and Moraxella catarrhalis. Moreover, the ketolides are associated with a low potential for inducing resistance, making them promising first-line agents for respiratory tract infections.     

Prevalence of Hypertension among Urban Slum Dwellers in Lagos, Nigeria

Urban slum dwellers are not only prone to develop communicable diseases but also to non-communicable disease (NCDs). The extent and magnitude of NCDs among slum dwellers is largely unknown in Nigeria. A total of 964 adults aged 20–81 years (male 330 and female 634) residing in the urban slum of Ajegunle in Lagos State, Nigeria were studied to determine the prevalence of hypertension and associated factors. The overall prevalence of hypertension was 38.2 %. Of the 368 respondents identified as having hypertension, only 50 (5.2 %) respondents were previously aware of their diagnosis. Of the 50 known hypertensive patients, 48(96 %) had poor control of their high blood pressure. The socio-demographic factors significantly associated with hypertension status were age, sex, education, religion, BMI, and marital status. The study concludes a high prevalence of hypertension among urban slums dwellers in Lagos. The need for government to develop policies for the control of hypertension, improve access to early diagnosis and provide an enabling socioeconomic environment while promoting healthy living.     

AIDS: Awareness and blood handling practices of health care workers in Lagos,Nigeria

A questionnaire survey of 260 health care workers from 13 randomly selected health care facilities was undertaken. Their knowledge, attitude, belief and blood handling practices regarding HIV/AIDS were enquired about. Virtually all (99.0%) respondents had heard about AIDS but only 57.0% had seen an AIDS patient before. Although 83.0% knew that AIDS is caused by a virus, a high proportion still confuses mode of transmission with causative agent. Deficient knowledge was exhibited when asked about groups of people who were at a higher risk of contracting HIV and AIDS: Only 54.6% and 51.5% identified homosexuals and IV drug users as being at a higher risk. Almost all (97.0%) of our respondents claimed to have been more careful in their blood handling practices since the emergence of AIDS, 68.5% wore gloves for all procedures involving handling of blood and 28.5% sometimes although as many as 30.4%, 40.4% and 18.1% do not wear gloves for cleaning up blood stained materials, nursing procedures and taking obstetric delivery respectively. It was evident from their responses that not all the health workers knew the correct method for disposing of used bloodstained instruments and left-over blood samples and neither were they all adhering to the safety guidelines recommended for handling these materials. Education of all health care workers in Nigeria on the Universal Precautions Guidelines issued by the Centers for Disease Control (CDC) in 1987 regarding blood, body fluids and contaminated instruments' handling precautions is urgently recommended.     

Molecular characterization of a clinical Haemophilus parainfluenzae isolate with cefotaxime resistance and decreased susceptibility to fluoroquinolones

We report an H. parainfluenzae clinical isolate resistant to cefotaxime and with decreased susceptibility to ciprofloxacin recovered from a patient with cystic fibrosis. The isolate had elevated MICs of ampicillin (256 mg/L), amoxicillin-clavulanate (8 mg/L), cefuroxime (8 mg/L) and cefotaxime (4 mg/L), and showed a β-lactamase-producing amoxicillin-clavulanic acid-resistant (BLPACR) phenotype. A bla_TEM-1 plus five amino acid substitutions in the PBP3 were found: Ser385Thr, Val511Ala, Ile519Val, Asn526Lys and Asp551Leu. MIC of ciprofloxacin was 0.5 mg/L, and substitutions in gyrA (Ser84Tyr) and parC (Ser84Phe) genes were detected.     

Longitudinal trends in antimicrobial susceptibilities across long-term-care facilities: emergence of fluoroquinolone resistance.

BACKGROUND: Antibiotic resistance in the longterm-care facility (LTCF) setting is of increasing concern due to both the increased morbidity and mortality related to infections in this debilitated population and the potential for transfer of resistant organisms to other healthcare settings. Longitudinal trends in antibiotic resistance in LTCFs have not been well described. DESIGN: Correlational longitudinal survey study. SETTING: Four LTCFs in Pennsylvania. SUBJECTS: All clinical cultures of residents of the participating LTCFs (700 total beds) from 1998 through 2003. We assessed the annual prevalence of resistance to various antimicrobials of interest for the following organisms: Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, and enterococcus species. RESULTS: A total of 4,954 clinical isolates were obtained during the study. A high prevalence of antimicrobial resistance was noted for many organism-drug combinations. This was especially true for fluoroquinolone susceptibility among the Enterobacteriaceae (susceptibility range, 51.3% to 92.2%). In addition, the prevalence of resistance to various agents differed significantly across study sites. Finally, significant increasing trends in resistance were noted over time and were most pronounced for fluoroquinolone susceptibility among the Enterobacteriaceae. CONCLUSIONS: The prevalence of antimicrobial resistance has increased significantly in LTCFs, although trends have varied substantially across different institutions. These trends have been particularly pronounced for fluoroquinolone resistance among the Enterobacteriaceae. These findings demonstrate that antimicrobial resistance is widespread and increasing in LTCFs, highlighting the need for future studies to more clearly elucidate the risk factors for, and potential interventions against, emerging resistance in these settings.     

临床菌株耐药性产生和播散的机制

细菌的耐药性一般来源于多种途径，如药物作用靶位被修饰，药物被酶学失活，或同时伴有细菌外膜通透减少和外排泵出增强而使细菌内药物减少。临床菌株耐药往往有多种机制参与，一旦发生，能产生大量的子代耐药株。